ABORTION

PILLS
ABORTION
PILLS
US HISTORY AND
POLITICS
CARRIE N. BAKER
Copyright © 2024 by Carrie N. Baker
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Published in the United States of America by Amherst College Press

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Library of Congress Control Number: 2024933972

DOI: https://​doi.org/​10.3998/​mpub.14469​549

ISBN 978-​1-​943208-​85-​2 (paper)

ISBN 978-​1-​943208-​86-​9 (open access)
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Table of Contents

Acronyms vii

Introduction: Kelly’s Story 1

What Are Abortion Pills? Terms and Definitions 5
Methods and Sources 6
The Story of Abortion Pills in a Nutshell 7
Book Outline 9

1 “Medical McCarthyism”: RU 486 Development and the Fight

for FDA Approval, 1980–​2000 11
Anti-​Abortion Campaign to Block RU 486 from the US Market 17
The Feminist Campaign to Bring RU 486 to the United States 22
FDA Approval of Mifepristone 38

2 “Thankful for Crumbs”: The Fight to Expand Abortion

Pill Access, 2000–​2019 55
FDA Risk Evaluation and Mitigation Strategy (REMS) and
Mifepristone Research 62
Self-​Induced Abortion? 66
Campaign to Remove FDA Restrictions 78
Political Shifts and Movement Mobilization 84

3 “Greased the Wheels”: COVID-​19 Pandemic and the Rise of

Telemedicine Abortion 95
Virtual Abortion Clinics 103
Organizing to Support Increased Access to Abortion Pills Outside of the
Medical System 108
Supreme Court Stops Telemedicine Abortion 110
The Pendulum Swings: Biden Administration Expands Abortion Pill Access 115
vi • Table of Contents

4 “Trying to Shake Abortion Pills Free from the Gatekeepers”:

Eroding Abortion Rights and Expanding Self-​Managed Abortion 121
Texas Bans Abortion: S.B. 8 Spurs Self-​Managed Abortion 121
New Research Supports the Safety of Telemedicine and
Self-​Managed Abortion 128
FDA Loosens REMS Restrictions on Mifepristone 132
Spreading the Word About Abortion Pills 136
Legal Risks of Self-​Managed Abortion 139

5 “Mail Those Pills No Matter What”: The End of Roe Spurs Efforts
to Expand Abortion Pill Access 149
The Immediate Aftermath of Roe’s Fall 150
The Push for Telemedicine Abortion Provider Shield Laws 155
Litigation and Legislation to Expand Abortion Pill Access
at the State Level 161
Federal Initiatives to Expand Abortion Pill Access 167
Expanding Abortion Pill Access Outside of the Medical
System and the Law 172
Reframing Abortion Pills and Early Abortion 179

6 “Putting the Genie Back in the Bottle”: Post-​Dobbs Attempts

to Block Mifepristone 185
Abortion Pill Disinformation 187
Anti-​Abortion Campaign to Remove Mifepristone from the Market 194

Conclusion: “Putting Pills Directly in the Hands of Those Who

Need Them” 215

Appendix A: Abortion Pill Timeline 239

Appendix B: Glossary 241
Appendix C: Interviews 243
Acknowledgments 247
Endnotes 249
Acronyms

AAP Abortion Access Project

ACLU American Civil Liberties Union
ACOG American College of Obstetricians and Gynecologists
ADF Alliance Defending Freedom
AHT Advances in Health Technology
ANSIRH Advancing New Strategies in Reproductive Health
ARM Abortion Rights Mobilization
CPC crisis pregnancy center
CRR Center for Reproductive Rights
EMAA Expanding Medication Abortion Access
ETASU Elements to Assure Safe Use
FDA US Food and Drug Administration
FMF Feminist Majority Foundation
FRC Family Research Council
FTC Federal Trade Commission
GLC Generative Learning Community for self-​managed abortion
HHS Department of Health and Human Services
HIS Indian Health Service
IND Investigational New Drug
M+​A Hotline Miscarriage and Abortion Hotline
NAF National Abortion Federation
NARAL National Abortion Rights Action League
NAWHERC Native American Women’s Health Education Resource Center
NDA New Drug Application
NOW National Organization for Women
NRLC National Right to Life Committee
NWHN National Women’s Health Network
OARS Online Abortion Resource Squad
viii • Acronyms

REMS Risk Evaluation and Mitigation Strategy

RHEDI Reproductive Health Education in Family Medicine
RHTP Reproductive Health Technologies Project
SASS Self-​Managed Abortion. Safe and Supported
SHERo Sisters Helping Every Woman Rise and Organize
SIA Legal Team Self-​Induced Abortion Legal Team
S.T.O.P. Surveillance Technology Oversight Project
WRRAP Women’s Reproductive Rights Assistance Project
 Introduction: Kelly’s Story

In early February of 2022, a young Latina named Kelly living in Texas found out she
was pregnant. The previous September, Texas had banned abortion at six weeks of
pregnancy. At the time she found out she was pregnant, Kelly had just started a new
job, didn’t have health insurance, and couldn’t take time off to travel out of state for an
abortion. She googled “affordable ultrasounds” and found a clinic offering free ultra-
sounds. It had positive reviews, so she gave them a call and made an appointment.
When she got there, they were very friendly. She filled out a form, giving her medical
history and the reason she was there. She checked the box for abortion. Unbeknownst
to Kelly, she was at an anti-​abortion “crisis pregnancy center.” “Being in Texas, I prob-
ably should have been a little more careful,” Kelly later said. “They could have easily
reported me.”1
Kelly believed she was at a medical clinic. “At least that’s how they portrayed them-
selves on Google,” she later reported. A woman gave her a pregnancy test, which was
positive, then asked her if she wanted to go through with the pregnancy. Kelly was hon-
est. “I don’t want this pregnancy, I can’t have this pregnancy,” Kelly told her. “I’ve been
with my partner for only a year. And we’re not ready financially. It’s just out of the ques-
tion. I honestly don’t see myself being ready to be a mother.” The woman asked Kelly
whether she had considered adoption. Kelly responded, “There’s nothing to consider
for me. I’ve thought about it thoroughly. I stand by my decision.” The woman then told
her that abortion could kill her. She said abortion pills were especially dangerous.
After waiting about thirty minutes, Kelly received an ultrasound from another
woman dressed in scrubs, who told her she was eight weeks pregnant. This woman
pressured Kelly not to have an abortion. “I probably told her four or five times as nicely
as I could. ‘No, I do not want to go through with this pregnancy.’ Of course, they don’t
come off as aggressive, but it did seem pushy, like they’re really forcing this down your
throat. But they’re doing it in the nicest way possible. She had a tone in her voice, like,
‘I’m here to take care of you, don’t worry.’ At the end of the ultrasound, they offered to
pray for me.” The woman warned Kelly that abortion could cause breast cancer, infertil-
ity, and depression.
2 • Abortion Pills

Still believing the center was an abortion provider, Kelly made an appointment for
the following week, hoping to get abortion medications. “I was really distracted by the
very motherly, homey feeling from them, the welcoming, ‘It’s okay, we’re here to help
you’ type of vibe I was getting. That’s what really made me think, ‘Okay, they’re here
to help.’ ” At her next visit, the woman told her they did not provide abortion medica-
tions. They insisted on making another appointment for Kelly, but she didn’t return.
She later found out the center she went to was an anti-​abortion organization funded by
a Christian church.
Kelly went on Google again and this time located a real medical clinic with afford-
able ultrasounds. She found out she was ten weeks and three days pregnant, and that
Texas did not allow abortion after six weeks. She was told she would have to travel out
of state for an abortion. “I was just freaking out. I was just trying to find answers,” said
Kelly. She absolutely couldn’t take time off from her new job during the work week
for the eight-​hour drive to a clinic out of state. Desperate, she went on Reddit and
found an abortion forum where women shared information and answered each other’s
questions about abortion. That’s where she read about the organization Plan C, which
shares information about how people can get abortion pills no matter where they live.
“I looked up Texas for telehealth and thankfully they gave a very thorough example of
what to do for a Texas resident,” said Kelly. “I followed every step.”
At the time, she was around eleven weeks pregnant, so she had to move quickly.
On the Plan C website, Kelly read about how to obtain abortion pills from a US-​based
telehealth provider located in another state, using mail forwarding. She rented a box
in a state where the telehealth provider practiced and had the pills sent overnight to
the box, then had the pills forwarded to her home in Texas. The pills arrived in a dis-
creet package within five days of when she first spoke to the telehealth provider. She
took them right away, just one day before she reached twelve weeks of pregnancy—​the
outer limit of what her doctor recommended for the medication dosage that was sent.
“I felt super comfortable with the provider I found. She answered all my questions.
I got thorough answers. I got the help that I truly needed. She lifted a huge weight off
my shoulders,” said Kelly. The abortion process took about four hours and felt like a
heavy period with pain and some nausea. “This was a really positive experience for
me. I felt really safe and I felt assured. I was just so grateful that I was able to succeed
with this,” Kelly later reported.
When Kelly had her abortion, the US Food and Drug Administration (FDA) had
only recently allowed medical providers to offer telehealth abortion with pills. The FDA
first approved a combination of two medications for abortion in 2000—​mifepristone
and misoprostol. Mifepristone, originally known as RU 486, blocks the pregnancy-​
sustaining hormone progesterone, which loosens pregnancy tissue from the uterine
wall. Then misoprostol, taken twenty-​four to forty-​eight hours later, causes uterine
contractions to expel pregnancy tissue. For decades, the FDA only allowed doctors
 Introduction: Kelly’s Story • 3

registered with the drug maker to dispense the medication in person. Reproductive
health advocates campaigned for years to loosen these restrictions. In December of
2021, shortly before Kelly ordered her medications, the FDA permanently removed
the requirement that healthcare providers dispense mifepristone in person, opening
the door to telemedicine abortion. The COVID-​19 pandemic spurred this shift in
policy. As a result, healthcare professionals could consult with their patients by video-
conference, telephone, or online forms, and then mail abortion pills to them for use
at home.
But then in June 2022, just a few months after Kelly got her abortion, the Supreme
Court reversed the constitutional right to abortion established in Roe v. Wade in the
case of Dobbs v. Jackson Women’s Health Organization. States throughout the South
and Midwest quickly banned healthcare professionals from offering abortion services.
As a result, abortion pills and the telehealth infrastructure that advocates had created
during the pandemic became a critical option for people seeking to end a pregnancy.
Reproductive health advocates fought for new telemedicine provider shield laws that
enabled clinicians in states allowing abortion to serve patients in states with bans.
Meanwhile, abortion outside of the formal medical system increased dramatically.
Drawing on knowledge and practices developed in Latin America and used globally
in countries banning abortion, US activists created community networks that mailed
free abortion pills to people in states with bans. Websites selling pills also proliferated
and prices dropped. Finally, activists developed organizations to share information and
provide medical, legal, and emotional support to people using abortion pills outside of
the formal medical system.
The overturn of constitutional abortion rights and state bans on abortion, however,
was not enough for some abortion opponents. In November 2022, a group of anti-​
abortion doctors and a dentist sued the FDA in an attempt to remove mifepristone from
the market nationwide. In April 2023, a lower court judge in Amarillo, Texas, stayed the
FDA’s approval of mifepristone and ordered the medication off the US market nation-
wide. On appeal, the Fifth Circuit reversed in part, allowing mifepristone to stay on the
market, but sustained significant limitations on distribution of the medication, includ-
ing re-​imposing the medically unnecessary in-​person distribution requirement. The
FDA appealed to the Supreme Court. As America waited on pins and needles for a deci-
sion, Plan C posted on social media, “No matter how the ruling comes down, people
who want to self-​manage their abortions will continue to have options through the
robust alternative supply systems that now exist in the U.S.” They recommended that
people order abortion pills in advance to have on hand just in case. “The ecosystem of
support—​ways people are accessing pills, free hotlines, and community networks—​is
crucial info to know and repost right now,” said Plan C on Instagram the evening before
the Supreme Court stayed the Texas court’s ruling until a final resolution of the case.2
Meanwhile, pills kept flowing through legal and extralegal channels.
4 • Abortion Pills

To fully understand what led to Kelly’s ultimately successful journey to abor-

tion and what future “Kellys” may face, this book examines the battle to establish,
expand, and maintain legal access to abortion pills in the United States over the last
thirty-​five years, as well as the story of activists’ campaigns to support people using
abortion pills outside of the formal medical system. Scholars have documented a
long history of abortion practice, politics, and law in the United States, including
pre-​Roe practices of abortion outside of the formal medical system,3 and scholar-
ship has documented the global feminist movement for self-​managed abortion and
the global politics of abortion pills,4 but no one has told the full story of abortion
pills in the United States. Scholarship on the Roe period has focused primarily on
abortion within the formal medical system and the legal regulation and restriction
of access to this form of abortion, which has obscured the continued existence of
self-​managed abortion after Roe v. Wade legalized abortion in all fifty states in 1973
and the growing importance of abortion pills, especially for self-​managed abortion
as reproductive freedom has diminished in recent years.
The goal of this book is to tell the story of abortion pills in the United States
and how increasing access to these medications has been a key strategy of women’s
resistance to attempts by politicians, religious leaders, medical professionals, intimate
partners, and others to control women’s bodies and lives. I tell this story from my
position not only as a feminist legal scholar, but also as a journalist who has closely
covered this issue for Ms. magazine since 2018, and as a participant in the movement
to increase access to abortion pills. As a result, I will focus on the story of abortion
pills rather than on abortion historiography or scholarly debates on abortion. I will
focus on what happened in the political campaigns for and against access to abortion
pills, the laws and policies restricting or promoting access to these medications, and
the ways activists expanded access both within the formal medical system and extra-
legally outside of it.
In telling this story, I will explore the role science played in abortion politics, the
varied strategies and tactics used by abortion pill advocates, disagreements among
these advocates, and how the intersections of sex, race, and class impacted abortion
pill access and politics. In this book, I will examine how resistance to increasing abor-
tion pill access not only came from the anti-​abortion movement and Republican politi-
cians, but also resulted from a combination of FDA conservativism and cautiousness,
the market-​oriented pharmaceutical, health care, and insurance industries, mainstream
medicine’s abandonment of abortion care, physician gatekeeping, Democrats’ luke-
warm support for abortion, the influence of philanthropy in abortion health care and
activism, and the cautious approaches of some abortion rights supporters.
In the rest of this introduction, I will first define important terms and concepts used
throughout the book, then describe my methods and sources, provide a short summary
of the story of abortion pills, and then provide an outline of the chapters.
 Introduction: Kelly’s Story • 5

What Are Abortion Pills? Terms and Definitions5

Abortion pills are not common knowledge to most people, so this section will explain
what they are and how they are used. The FDA has approved the use of two medica-
tions to end an early pregnancy: mifepristone and misoprostol. The recommended
regimen is to take one 200-​milligram mifepristone pill followed twenty-​four to forty-​
eight hours later with four 200-​microgram misoprostol pills through ten weeks of
pregnancy (counting from the first day of the last menstrual period).6 The World
Health Organization has approved this regimen for up to twelve weeks after the last
menstrual period, including self-​ administration with no clinician involvement.7
Abortion pills are effective later in pregnancy under different regimens.8 Misoprostol
taken alone can also end a pregnancy. The World Health Administration recommends
three 800-​microgram doses taken vaginally, under the tongue, or in the cheek pouch
(buccally), three hours apart, with repeat doses if necessary.9 Mifepristone and miso-
prostol are commonly referred to as “abortion pills,” although both medications have
other uses. Mifepristone was called RU 486 when it was first developed in the 1980s
by the French pharmaceutical company Roussel Uclaf for the initials of the company
and the number assigned to the substance developed. The FDA-​approved cancer drug
methotrexate is also used off label in combination with misoprostol for treatment of
ectopic pregnancies.
People choose medication abortion for a number of reasons, including because
they think it is more natural (more like a miscarriage), more private (done at home),
more convenient and accessible, more affordable, and less invasive than procedural
abortion. Telemedicine abortion is when a clinician screens a patient by videocon-
ference, telephone, or online form, then prescribes abortion pills to be mailed to the
patient. Telemedicine abortion is more private, convenient, and accessible than in-​
clinic abortion for many people.10
Abortion pills are safe and effective. Serious adverse events occur in less than one-​
third of one percent of medication abortions and abortion pills are over 95 percent
effective when used within the first ten weeks of pregnancy.11 They are slightly less
effective later in pregnancy. Using these pills in combination is preferable, but misopro-
stol alone is also safe and effective to end a pregnancy.12
Abortion pills are prescription medications in the United States. Misoprostol is a
widely available ulcer medication, but mifepristone is tightly controlled by the FDA,
which allows only certified healthcare professionals to prescribe the medication and
only certified providers and pharmacies to dispense it. As states adopted burdensome
restrictions or bans on abortion, and as a result of the high cost of abortion care in states
that allowed it, people began buying abortion pills from websites without a prescrip-
tion or found other ways to access these pills. Finding and using pills without consult-
ing a medical provider is one form of self-​managed abortion (also called self-​induced
6 • Abortion Pills

abortion). Other forms involve manual vacuum aspiration of the contents of the uterus,
or other substances to cause a miscarriage such as herbs.13
As of 2020, medication abortion comprised over half of abortions in the United
States. The alternative is procedural abortion (often called surgical abortion), which
involves the removal of the contents of the uterus either by suction (called aspiration
abortion) or manually removing fetal tissue. Procedural abortion in the first trimes-
ter takes five to ten minutes and is very safe and effective. Abortion pills are different
than Plan B, which is an emergency contraceptive pill used to prevent pregnancy up to
five days after intercourse. Abortion pills end a pregnancy and are used after a missed
period and/​or pregnancy confirmation.
Mifepristone has uses beyond elective abortion. Some physicians use mifepristone
off label for miscarriage treatment and during childbirth to soften the cervix. The FDA
has approved mifepristone to treat Cushing syndrome. The agency has also approved
the use of mifepristone for treating meningioma (a non-​cancerous tumor in the mem-
branes around the brain and spinal cord) through a compassionate use program admin-
istered by the nonprofit Feminist Majority Foundation. Research has demonstrated
that mifepristone is effective at treating a range of other conditions, including fibroids,
endometriosis, postpartum depression, and breast cancer, and can act as a contracep-
tive, but the FDA has not approved the medication for these uses.14

Methods and Sources

This book draws on interviews with over eighty people, including activists, abortion
providers, researchers, and people who have used abortion pills (see Appendix C for
a list of people interviewed). I quote my sources generously throughout the book in
order to give readers a sense of the range of perspectives, contributions, and expe-
riences in the movement to expand access to abortion pills over the last thirty-​five
years. While many people and organizations have talked about abortion pills over
the years, in this book I focus on the people and organizations that took actions to
increase access to abortion pills. I also conducted research in several archives, includ-
ing the papers of Lawrence Lader, Planned Parenthood, and the National Women’s
Health Network at Smith College, the papers of the Reproductive Health Technologies
Project at Schlesinger Library at Harvard University, and the private collections of
several activists, including Marie Bass, Francine Coeytaux, and others. This book pays
particular attention to the medical research conducted on mifepristone—​and how
advocates used this research to achieve FDA approval of mifepristone and to push the
FDA to lift its restrictions on the medication. This research also advanced the move-
ment toward self-​managed abortion by reassuring advocates of the safety of medica-
tion abortion outside of a clinical setting. Finally, I have conducted research into the
government records and legal cases relating to RU 486/​mifepristone. As a legal and
 Introduction: Kelly’s Story • 7

social movement scholar, I focus on how activists have shaped the evolution of law
and policy, as well as opportunities for extralegal access to abortion pills in the United
States. The bulk of the book (Chapters 3 to 6) focuses on the critical period between
2020 and 2024 when activists revolutionized abortion in America by shifting people’s
understanding of and access to abortion pills and removing and/​or bypassing years of
political and medical barriers to mifepristone.
While most people seeking abortion are cisgender women, nonbinary people and
trans men also become pregnant and need abortions. This book will at times use gen-
dered language to emphasize the gendered dynamics of abortion pill politics.15

The Story of Abortion Pills in a Nutshell

The French pharmaceutical company Roussel Uclaf developed mifepristone in 1980
and the French government approved use of mifepristone for abortion in 1988, but the
battle for FDA approval in the United States lasted decades. Beginning in the 1980s,
US women’s health advocates collaborated with researchers, healthcare providers, and
public health experts to push for FDA approval of mifepristone. When Roussel Uclaf
and other drug companies refused to develop the medication for the US market for
fear of boycotts and threats of violence from abortion opponents, reproductive health
advocates did it themselves, as their predecessors had done with birth control pills
in the 1950s.16 They raised money from wealthy individuals and foundations to con-
duct the necessary research, found investors willing to create a company to market
mifepristone in the United States, and applied for and finally achieved FDA approval
of mifepristone. But the FDA placed severe restrictions on mifepristone and doc-
tors required expensive medical tests for people to obtain the medication, making it
inaccessible to many people. Meanwhile, women in immigrant communities were shar-
ing knowledge about how to use misoprostol, bringing to the United States grassroots
self-​managed abortion accompaniment practices that were widespread throughout
Latin America, and later elsewhere, after women in Brazil figured out that the widely
available and low-​cost ulcer medication misoprostol could be used for abortion.17
After the FDA approved mifepristone in 2000, reproductive rights advocates urged
a wide range of healthcare providers to offer abortion pills, conducted ongoing research
to support a less burdensome medical protocol for accessing pills, and worked to remove
the FDA restrictions on the medication. The approval of a generic version of mifepris-
tone in 2019 increased access by bringing down the price of the medication. But as
abortion restrictions increased over time, particularly in the 2010s, advocates began
meeting to discuss the use of misoprostol alone for people who could not access abor-
tion within the medical system. Later, anticipating the fall of constitutional abortion
rights established in Roe v. Wade, advocates and entrepreneurs built “alternative supply
systems” to provide abortion pills to people living in states banning medical providers
8 • Abortion Pills

from offering abortion services. Meanwhile, all along the way, abortion opponents
worked to block access to abortion pills, challenging the FDA approval of mifepristone
with false claims about the dangers of what they called “chemical abortion,” and spread-
ing misinformation about abortion pills through a nationwide network of anti-​abortion
“crisis pregnancy centers” like the one that obstructed Kelly’s access to abortion.
After Dobbs, abortion pills meant that women faced a very different set of options
when seeking to end a pregnancy than they had experienced before the Supreme
Court decided Roe in 1973. Whereas before Roe, illegal abortion posed significant
health risks, post-​Roe, abortion pills provided a safe and accessible way to end an
early pregnancy outside of the formal medical system. Before Roe, women often had
difficulty finding information about how to obtain a safe abortion. By the time Roe
was overturned, information about abortion pills was widely available on the inter-
net. Before Roe, the legal risks of providing and receiving abortion varied over time,
but illegal abortion was often tolerated by authorities.18 Post-​Roe, concerns about the
legal risks of abortion in states with restrictions were high in the context of a vastly
expanded prison-​industrial complex. Some anti-​abortion prosecutors targeted people
using abortion pills and those supporting them.19 Despite these risks, telemedicine
abortion providers offered medication abortion to people in all fifty states, operating
both from within the country and from abroad, despite the law. Moreover, activists
operated alternative supply networks for people to access abortion medications for
free through grassroots accompaniment networks or for low prices through online
websites in all fifty states, with free medical, emotional, and legal support services
available via hotlines as well. In this way, abortion pills have played a critical role in
maintaining access to abortion for many people living in America after the Dobbs
decision in June 2022. In fact, the year after Dobbs, the number of abortions in the
United States increased, which experts attributed in part to increased abortion access
in states maintaining legal abortion, including telemedicine abortion.20
Not everyone was unanimous in their support for creating these alternative path-
ways for accessing abortion pills, however. Some brick-​and-​mortar abortion clinic
owners expressed the fear that telemedicine abortion providers would drive them out
of business by offering a less expensive alternative to patients seeking abortion pills.
Some providers didn’t believe that women could use abortion pills safely on their own
or did not want other providers taking any legal risks. Reproductive justice advocates,
whose activism centered the lives and experiences of women of color,21 warned about
state surveillance and criminal prosecution of people ordering and using abortion pills
outside of the formal medical system, fearing police would target low-​income women
and women of color in particular. Some advocates focused on fighting to keep abortion
legal, while many worked to transport women to states where abortion health care was
still legal. But a small and determined group of reproductive healthcare advocates and
clinicians believed that abortion pills were safe and that women were fully capable of
 Introduction: Kelly’s Story • 9

using these pills outside of the formal medical system. These advocates believed people
should be able to make their own decisions about the risks and benefits of using abor-
tion pills outside of the formal medical system. They also believed that clinicians should
be able to make their own risk assessments and provide these services if they chose to as
a matter of conscientious provision, the opposite of conscientious objection. This book
explores these conflicts, as well as the broader politics of abortion pills in the United
States over the last several decades, to understand how the anti-​abortion movement,
the FDA, the medical system, and the incrementalism of many reproductive health
advocates limited access to mifepristone for over two decades, but how COVID-​19 and
Dobbs drove some activists to break through longstanding political and medical bar-
riers and finally place abortion pills directly in the hands of people who needed them.

Book Outline
This book is arranged chronologically.22 Chapter 1 explains the development of RU
486 in 1980 in France and the years-​long battle to win FDA approval in the United
States. Chapter 2 traces how reproductive rights advocates worked to increase access
to mifepristone and misoprostol over the first two decades of the twenty-​first century,
and anti-​abortion attempts to block access. Chapter 3 describes the development of
telemedicine abortion during 2020 and 2021, spurred by the COVID-​19 pandemic.
Chapter 4 documents the erosion of abortion rights and the rise of self-​managed abor-
tion in the second half of 2021, including the development of support systems for
people self-​managing their abortions. Chapter 5 recounts how reproductive rights
advocates organized before and after the overturning of Roe in June 2022 to make
abortion pills accessible to more people by increasing access to telemedicine abortion
providers and developing alternative supply networks for abortion pills. Chapter 6
chronicles anti-​abortion strategies to restrict abortion pills and discourage people from
using them post-​Dobbs, including criminal prosecution of people for self-​managing
their abortions, the spread of disinformation about the safety of abortion pills through
“crisis pregnancy centers,” and a lawsuit filed in a Texas federal court attempting to
remove mifepristone from the market nationwide and revive the nineteenth-​century
Comstock Act prohibiting mailing abortifacients. The conclusion will reflect on the
factors that have influenced the expansion or contraction of access to abortion pills at
different points in time, as well as what this past means for the future of abortion pill
access in the United States.
Understanding the history of abortion medications as well as the ongoing political
and legal battles over abortion pills in the United States is important for understand-
ing the future of abortion access in the United States. With the rise of telemedicine
abortion in 2020, abortion pills posed a fundamental threat to the longstanding anti-​
abortion strategy of limiting abortion to brick-​and-​mortar clinics and then targeting
10 • Abortion Pills

these clinics with excessive regulation as well as protests, blockades, and violence. Post-​
Dobbs, abortion pills became a critical avenue for ending unwanted pregnancies for
people living in states banning abortion.
Medication abortion advocates imagined a world of increasing access to abortion
pills, including outside of the formal medical system. They imagined a world where
women could access safe and supported abortion health care without ever leaving
their homes. In this world, after completing an online form or a video conference with
a healthcare professional, women could promptly receive abortion pills in the mail,
which they could take safely in the privacy of their own homes under the supervision of
a clinician, if they so chose. No invasive, time-​consuming pelvic exams or blood tests.
No state-​mandated ultrasounds or waiting periods requiring multiple clinic visits. No
walking past lines of screaming anti-​abortion protesters. No driving long distances,
having to find and pay for childcare, or taking time off from work. No exposure to
COVID-​19.23 But some advocates had even more ambitious dreams. The co-​founders
of Plan C, Francine Coeytaux and Elisa Wells, who advocated for increased access to
abortion pills, imagined a world where abortion pills were available on the pharmacy
or grocery store shelf next to condoms and pregnancy tests and available without a pre-
scription. They imagined a world where these medications cost very little, and women
could buy them to put in their underwear drawer in case they missed a period and did
not want to be pregnant. In 2014, Coeytaux and Wells traveled to Ethiopia and saw that
abortion pills were available from pharmacies over the counter for just a few dollars.24
“The discrepancy between what I knew was possible and what was happening here in
the U.S. motivated us to found Plan C,” said Coeytaux.25
The United States is still a long way from over-​the-​counter abortion pills, and abor-
tion opponents are dead set on banning these medications altogether and criminaliz-
ing anyone who uses them. The future is uncertain, but understanding the past is an
important step toward building a world where women can control their fertility and
their lives.
 CHAPTER 1

“Medical McCarthyism”: RU 486

Development and the Fight for
FDA Approval, 1980–​2000

RU-​486 will make its American entrance: science, good sense, and freedom will
triumph.
Étienne-​Émile Baulieu, 19911

In November 2022, a group of anti-​abortion doctors and a dentist calling themselves

the Alliance for Hippocratic Medicine filed a lawsuit challenging the FDA’s approval of
mifepristone that had happened over two decades before. They argued that approval
of mifepristone was rushed and that the FDA did not have adequate clinical evidence
to support the drug’s approval. This chapter goes back to the beginning to trace the
development of mifepristone, the years of scientific research showing its safety and
effectiveness, and the political wrangling that delayed FDA approval of mifepristone.
This chapter will show that, contrary to the claims of the Alliance for Hippocratic
Medicine, the FDA took years to approve mifepristone and the approval was based on
plenty of scientific evidence to support its safety and effectiveness. This chapter will
show that the FDA, in fact, placed unusual restrictions on access to mifepristone, not
for scientific reasons, but because of anti-​abortion political pressure, harassment, and
threats of violence that made the FDA overly cautious. This chapter also shows how the
profit-​driven pharmaceutical industry refused to take on mifepristone to develop it for
the market, leaving this task to a nonprofit reliant on foundation and private money
to fund clinical trials and a small startup to take on distributing the medication in the
United States, which also contributed to delays in bringing the medication to market.
The story of abortion pills begins with a young French doctor, Étienne-​Émile
Baulieu, who helped develop mifepristone and would become a tireless advocate for
increasing access to abortion pills. In 1962, while pursuing a PhD in biochemistry at
Lycée Pasteur in Paris, Baulieu worked with the US researcher Dr. Gregory Pincus,
12 • Abortion Pills

who had helped develop the birth control pill in the 1950s. Pincus first envisioned
a molecule that could block the action of the hormone progesterone. Baulieu—​later
known as the “father of the abortion pill”—​took Pincus’s idea back to France and
helped to develop it into a medication that could end an unwanted pregnancy or
complete a miscarriage.
After graduating in 1963, Baulieu was named director of the French National
Institute of Health and Medical Research in Paris. He studied hormones and began
brainstorming a way to block the hormone progesterone, which prepares the uterus
to receive a fertilized egg and then signals the uterus to hold the fertilized egg
and sustain the pregnancy after implantation. In 1970, while conducting research
on guinea pigs, Baulieu and his team of researchers at the National Institute iden-
tified the receptor molecules within uterine cells that receive messages from the
hormone progesterone.
Baulieu and other scientists then began searching for a substance—​ an
antiprogesterone—​that would latch onto the receptor molecules, occupy them, and
block progesterone from delivering its message that enables the uterus to retain the
pregnancy. In a 1989 New York Times article, Baulieu explained: “The receptors are like
a keyhole, and we were trying to produce a false key.”2 He characterized the process as
“jamming a radio signal.”3
Baulieu later said he wanted to find an alternative to the abortion procedures that
were available at that time, which were removing a pregnancy by either scraping or suc-
tioning out the contents of the uterus. “Rather than disrupt a pregnancy with a sharp-
ened spoon or a suction tube, why couldn’t the natural process be reversed by altering
the balance of the same hormone that caused it to begin? My intention was to give
women a choice that, through a pill, respects their privacy and physical integrity and
allows them to totally avoid the aggression of surgery.”4 He called it an “unpregnancy
pill” and a “contragestive” because it countered gestation.5
At the time, Baulieu was a part-​time consultant at the French pharmaceutical com-
pany Roussel Uclaf. Baulieu worked with chemists at the company to develop a com-
pound to block progesterone by grafting a complex atom cluster onto a progesterone-​like
molecule to make it chemically different from progesterone but similar enough to bond
with the receptor molecule. Roussel Uclaf ’s chief chemist, George Teutsch, led a team of
researchers that tried over nine hundred substances to find one with the highest bind-
ing qualities.6 “Whereas Teutsch and his group were making a fake key that would fit
the lock, Baulieu’s work was defining the shape of the lock,” National Abortion Rights
Action League (NARAL) founder Lawrence Lader later explained.7 Lader described
how the medication worked in his 1995 book: “by occupying the space in the proges-
terone receptor without activating it, RU 486 impedes progesterone from entering the
receptor. Instead of inducing the usual hormone responses, RU 486 stops them.”8 In
1980, Teutsch’s team synthesized a compound that worked. The company named the
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 13

compound RU 486 for the initials of Roussel Uclaf and the lab serial number of the
compound—​it was the 38,486th compound synthesized by Roussel Uclaf. The com-
pany applied for a patent for RU 486 in 1980 and received it the next year.
Baulieu then recruited an old friend, the Swiss doctor Walter Hermann at Geneva’s
University Hospital, to test the compound. In the first human trial, RU 486 ended
early pregnancies in nine of eleven patients. Baulieu joined with Roussel Uclaf ’s CEO
Dr. Edouard Sakiz to publish these results in 1982. In a larger trial in 1986, Hermann
found that RU 486 ended pregnancies in eighty-​five out of one hundred women.
Other scientists began running tests of RU 486’s safety and effectiveness. A doctor in
Stockholm, Marc Bygdeman, tested RU 486 in combination with a synthetic prosta-
glandin, which stimulated uterine contractions, decreased bleeding, and sped up the
pregnancy termination.9 This combination of medications proved to be more than
96 percent effective.10 Scientists at the World Health Organization and elsewhere began
extensively testing RU 486’s safety and effectiveness. In 1985, the National Institutes of
Health in the United States began to support research on RU 486 for non-​abortifacient
applications, including contraception and as a treatment for breast cancer, endome-
triosis, glaucoma, Cushing syndrome, and other disorders.11 Roussel Uclaf ran clinical
trials consisting of two multicenter studies, with twenty-​four locations and over two
thousand participants. These studies showed a 95.5 percent success rate in the first
seven weeks of gestation.12 After worldwide clinical trials involving twenty thousand
women, Roussel Uclaf applied to the French government for approval to market the
drug for abortion in October 1987.
In response, Catholic fundamentalists in France led by the president of the French
Bishops Conference Msgr. Albert Decourtray organized a campaign to pressure
Roussel Uclaf and one of its major shareholders Hoechst AG in Frankfurt, Germany
to withdraw the application.13 They attended shareholders’ meetings in large numbers
and made inflammatory parallels between RU 486 and cyanide gas used in Nazi con-
centration camps. Baulieu, who is Jewish, was accused of being a Nazi. At one meeting,
an anti-​abortion protester yelled, “You are turning the uterus into a crematory oven,”
reported Dr. Baulieu.14 US anti-​abortion activists such as Judie Brown of the American
Life League and John Willke of the National Right to Life Committee (NRLC) sup-
ported the protests. In an attempt to pressure Hoechst, they published a story in the
National Right to Life News inaccurately claiming that a predecessor of Hoechst had
manufactured the poison gas used by the Germans during World War II.15
Abortion opponents targeted much of their ire at Dr. Edouard Sakiz, the CEO of
Roussel Uclaf. At the time, Sakiz received as many as twenty-​five threatening letters a
day and had to endure protesters yelling outside his office. “Your pill kills babies, and
you will suffer the consequences,” wrote one letter. Another charged, “Assassins, stop
your work of death!”16 Hundreds of anti-​abortion protesters showed up at the company’s
annual meeting on June 23, 1988, where one protester, anatomy professor and abortion
14 • Abortion Pills

opponent Xavier Dor, screamed at Sakiz for twenty minutes straight.17 In a New York
Times article, Sakiz said, “It’s impossible to discuss things with these people. When you
try arguments, all they say is you’re killing babies.”18
Under anti-​abortion pressure, Roussel Uclaf almost withdrew its application, but
Sakiz had personal and professional reasons for staying the course. On the personal
side, Sakiz was indebted to Baulieu, who helped him get his initial position as direc-
tor of biological research at Roussel Uclaf in 1966. Baulieu pressed Sakiz and others
at the company not to withdraw the application for RU 486 approval. Professionally,
Sakiz did not want to repeat the mistake made by Roussel Uclaf in the 1960s of
declining to produce the contraceptive pill for fear of offending the Catholic Church
in France. “We lost the market for contraceptives even though we were the most
important steroid company in the world. And now contraceptives are considered
natural; they aren’t controversial at all,” Sakiz later explained.19
In addition to targeting Roussel Uclaf and Hoechst AG, abortion opponents put
pressure on the French government to deny the companies’ RU 486 application, writing
letters to French embassies around the world, threatening to boycott French wine and
other products if the government approved RU 486. Despite this pressure, the French
government approved the medication under the brand name Mifegyne in September
1988. The protocol they approved was 600 milligrams of RU 486 administered in person,
followed within two days with the injectable prostaglandin sulprostone administered
in person, and then a follow-​up visit two weeks later to confirm successful completion
of the abortion. The government approved this regimen through forty-​nine days of
pregnancy and limited the procedure to hospitals and clinics.20 The same month, China
also approved RU 486.21
To protest the approvals, Catholic bishops organized a march through Paris, draw-
ing around two thousand people, and anti-​abortion protesters picketed both Roussel
Uclaf offices and the French Ministry of Health. US-​based NRLC threatened a boycott
of Roussel Uclaf in the United States.22 In the early 1980s, NRLC had threatened to
boycott the pharmaceutical company Upjohn for researching the prostaglandin mete-
neprost, which Upjohn later discontinued.23 Roussel Uclaf had only 7 percent of its $1.7
billion of sales in the United States, but the company hoped to expand there. Hoechst
AG, on the other hand, had 25 percent of its $23 billion in sales in the United States. The
company’s CEO, Wolfgang Hilger, was Catholic and opposed abortion.24 Hoechst AG,
which owned 54.5 percent of Roussel Uclaf shares, reportedly put pressure on Roussel
Uclaf to withdraw the medication from the market.25 Roussel Uclaf ’s five-​person execu-
tive committee was divided, with two older members wanting to withdraw the medica-
tion. When an ambitious young vice-​president, Alain Madec, announced he was against
RU 486, Sakiz worried that Madec might be trying to get Hoechst AG to appoint him
CEO.26 Meanwhile, personal threats by abortion opponents to Roussel Uclaf officials
continued unabated and expanded to their spouses and children as well.27
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 15

Then anti-​abortion extremists turned violent. In October of 1988, extremists tear-​

gassed a theater screening the Claude Chabrol film Une Affaire de Femmes, about the
1943 guillotining of Marie-​Louise Giraud for performing twenty-​seven abortions.
Shortly after, Catholic extremists firebombed a Paris movie theater showing Martin
Scorsese’s film The Last Temptation of Christ, purportedly because of a scene depict-
ing Jesus and Mary Magdalene having sex.28 Three days later, under the pall of reli-
gious extremists’ violence, Roussel Uclaf ’s board of directors voted sixteen to four to
withdraw RU 486 from the market—​just one month after its approval. The company
announced they were withdrawing the drug not because of any side effects, but because
of anti-​abortion protests and threats of violence.29 Baulieu confronted Sakiz, who told
him, “You’re independent. You can go out and speak freely.”30
Within days, Baulieu showed up at the World Congress of Gynecology and Obstetrics
in Rio de Janeiro, Brazil,31 where nearly ten thousand physicians and researchers were
gathered. Baulieu and others at the conference spoke out about the withdrawal of RU
486 from the market, generating widespread condemnation. Baulieu called for a “pub-
lic mobilization to demand RU 486 be made available.”32 Attendees at the conference
denounced Roussel Uclaf ’s decision to withdraw RU 486 from the market. Baulieu
called it “morally scandalous,” while the dean of Columbia University School of Public
Health Allan G. Rosenfeld called it “a tragic decision.”33 Over two thousand attendees
signed a petition organized by Rebecca Cook, a professor and attorney for women’s
rights, objecting to Roussel Uclaf ’s actions.34 A Paris gynecologist, Elisabeth Aubény,
delivered the petition to Roussel Uclaf. According to surveys at the time, 64 percent of
French people supported legal access to RU 486.35
Many others protested the withdrawal as well. University professors from the United
States and Europe asked physicians to boycott Roussel Uclaf ’s products and placed
advertisements in newspapers calling for people to contact Hoechst AG to protest the
withdrawal. The French Family Planning Association national coordinator, Catherine
Lesterpet, stated, “we’re worried about the rise of Catholic fundamentalism and the black-
mail exercised against Roussel.”36 US-​based pro-​choice groups, including NARAL and
Planned Parenthood Federation, denounced Roussel Uclaf ’s decision to withdraw RU 486
from the market as well.
But the decisive push came when the French government, which owned 36 per-
cent of Roussel Uclaf stock, threatened to transfer the patent to another company in
the interest of public health. French Health Minister Claude Évin famously explained
at the time, “I could not permit the abortion debate to deprive women of a product
that represents medical progress. From the moment government approval for the drug
was granted, RU 486 became the moral property of women, not just the property of
a drug company.”37 Later, Évin said, “I was doing what I could to make sure France
did not surrender to pressure groups animated by archaic ideologies.”38 In response,
Roussel Uclaf reversed its decision and put RU 486 back on the market. The company’s
16 • Abortion Pills

vice-​chairman, Pierre Joly, stated, “We are relieved of the moral burden weighing on
our group. For us, the problem is now solved.”39 Since that decision in the fall of 1988,
French women have had access to the abortion pill mifepristone.
The initial medical protocol for medication abortion in France involved three
appointments. At the first appointment, patients took 600 milligrams of RU 486. At
the second appointment two days later, patients received the injectable prostaglandin
sulprostone and remained in the clinic in their own clothes the entire time, wearing
a sanitary napkin, until they completed the abortion. If the medication did not work,
then patients received an aspiration abortion. A follow-​up exam was required two
weeks later. In 1992, France approved the use of the prostaglandin Cytotec—​the brand
name for misoprostol—​for use with RU 486 and French doctors substituted a 400-​
microgram oral dose of Cytotec at the second appointment.40 Cytotec was preferable to
the injectable prostaglandin because it came in tablet form to be taken orally, did not
need refrigeration, and was much less expensive.41 To control RU 486 and prevent the
development of a black market, each package of RU 486 was labeled with three stick-
ers: one for factory records, one for the hospital or pharmacy records, and the third for
the patient’s medical charts.42
In December 1988, under pressure from Hoechst AG, Roussel Uclaf suspended all
other plans to market the drug themselves in other countries, halting distribution of RU
486 in China and stopping plans to distribute the medication in Great Britain, Sweden,
and the Netherlands, which were in the process of approving the drug. China, which
did not recognize international patent law, synthesized its own version of RU 486 in
1988 and began manufacturing the medication.
In early 1989, leaders at Roussel Uclaf met with the executive director of Planned
Parenthood of America, Faye Wattleton, to discuss granting them an exclusive license
to distribute RU 486 in the United States. Wattleton traveled to Paris three times to
discuss this possibility, but the company eventually declined to move ahead with
Planned Parenthood.43 The same year, the Supreme Court issued a decision in Webster
v. Reproductive Health Services, which upheld a Missouri law that imposed restrictions
on abortion and barred the use of public hospitals or clinics for abortion services.44
This case, along with anti-​abortion actions of the Bush administration and conserva-
tive members of Congress, alerted Roussel Uclaf to the hostile political environment for
abortion in the United States.
In 1991, Roussel Uclaf and Hoechst issued a joint statement that they would only
consider licensing RU 486 to companies in countries “where abortion is tolerated by
society,” where there was an “advanced medical infrastructure,” and where the govern-
ment had made a written request for the licensing of the medication.45 In the United
States, such an invitation was not forthcoming under Republican President George
H.W. Bush. Other countries, however, moved forward. In 1990, Roussel Uclaf resumed
marketing the drug in Great Britain, which approved the medication in 1991, and in
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 17

Sweden, which approved the medication in 1992.46 Despite concerns about the United
States, Roussel Uclaf ’s CEO Edouard Sakiz met with the Population Council’s president
George Zeidenstein in 1991 to discuss the distribution of the medication in the United
States.47
Meanwhile, anti-​abortion extremists continued to stalk and harass Baulieu. When
he gave a talk on RU 486 in Toronto in 1991, abortion opponents plastered the streets
with posters saying “Wanted, Etienne Baulieu for Genocide” with his photograph.48

Anti-​Abortion Campaign to Block RU 486 from the US Market49

By the late 1980s, the FDA had already approved two medications with abortifacient
effects. In 1961, Wyeth Labs obtained approval for methotrexate as an anti-​cancer
drug, but the medication also stopped fetal cells from growing by blocking the folic
acid needed to maintain an early pregnancy.50 In 1988, over the objections of abor-
tion opponents, the FDA approved an application, from the pharmaceutical company
Searle, for a new prostaglandin called misoprostol under the brand name Cytotec to
treat ulcers, but the medication also induced labor and could safely end a pregnancy
in the first twelve weeks.51 Methotrexate used in conjunction with misoprostol became
commonly used to end ectopic pregnancies, a life-​threatening condition where a fer-
tilized egg grows outside the uterus. These medications were not labeled for this use,
but doctors used them off label, a common practice for many drugs.
US scientists began studying RU 486 in the early 1980s. In 1983, Roussel Uclaf agreed
to provide the US-​based Population Council with the right to import RU 486 into the
United States for testing.52 The Population Council, a nonprofit research institution that
developed new forms of contraception, obtained an Investigational New Drug (IND)
permit from the FDA in 1983 to test the safety and efficacy of RU 486. Between 1984
and 1990, University of Southern California professor of obstetrics and gynecology
Dr. David Grimes conducted studies to determine the safety and efficacy of RU 486 for
early abortion, finding in one study a 90 percent success rate after administration of 600
milligrams of RU 486 alone.53 The FDA also issued IND permits to ten research groups
to investigate other clinical applications of RU 486, including for Cushing syndrome,
meningioma, contraception, breast cancer, and endometriosis.
Abortion opponents mobilized to block RU 486 in the United States in 1988, even
before France approved it. NRLC, the United States Conference of Catholic Bishops,
the Fundamentalist Crusade Against Abortion, and Robins Carbide Reynolds Fund led
the campaign against RU 486 in the United States, calling it a “death drug,” a “human
pesticide,” and a form of “chemical warfare against unborn babies.”54 NRLC’s education
director Richard Glasow argued that RU 486 “kills an unborn baby whose heart has
started to beat and kills and injures women.”55 Other groups organizing against RU 486
included Phyllis Schlafly’s Eagle Forum, Focus on the Family, Knights of Columbus,
18 • Abortion Pills

Concerned Women for America, the Southern Baptist Convention, the International
Right to Life Federation, and the Family Research Council. Abortion opponents argued
that abortion pills might encourage sexual irresponsibility, teen pregnancy, and infidel-
ity.56 The anti-​abortion movement used two primary strategies to block RU 486 from
coming to the United States: boycott threats against drug companies that might market
the medication, and calls for the government to stop research on RU 486 and impose
an import ban—​both of which occurred in a context of increasing violence directed
toward abortion clinics and providers.
RU 486 threatened the anti-​abortion movement’s central strategy of symbolically
framing abortion as ending a human life. By enabling people to obtain very early
abortions, RU 486 undercut the anti-​abortion movement’s use of graphic fetal imag-
ery. In a 1986 Washington Post article, NRLC’s president John Willke explained how
RU 486 could undermine efforts to ban abortion: “If what [abortions] destroy in there
doesn’t look human, then it will make our job more difficult.”57 In 1988, Glasow said,
“It’s more difficult to make the case that this is a developing baby if you don’t have
pictures of the fetus. If you can show people fingers and toes, it’s dynamite…the abor-
tion debate won’t go away, but we’d lose some of our best arguments.”58 Polls at the
time showed that Americans looked significantly more favorably on abortion early
in pregnancy than in later pregnancy.59 NRLC also feared they would lose credibility
if they were seen as opposing contraception. Glasow warned, “if RU 486 becomes
identified in the public’s mind with contraception, then right-​to-​life opposition to
the drug could be portrayed as ‘reactionary’ and ‘out of touch’ with the mainstream
of Americans.”60
RU 486 also had the potential to undermine one of the anti-​abortion movement’s
primary tactics: protesters blocking clinic access. The medication could allow an
increasing number of doctors to offer abortion services, thereby decentralizing abor-
tion care and making it harder for protesters to target doctors and interfere with
patient access to clinics by using intimidation and threats of violence.61 Abortion sup-
porters, on the other hand, argued that, in addition to its other virtues, RU 486 could
de-​escalate clinic violence by dispersing abortion health care to a wider number of
clinicians and locations.62
Anti-​abortion terrorism played a central role in French RU 486 politics, but it
played an even greater role in the United States, where extremists regularly vandalized
and destroyed clinics, and harassed, assaulted, and sometimes even murdered clinic
employees. In France, England, and Sweden, abortion services were integrated into the
public healthcare systems, but in the United States, the medical system had refused to
integrate abortion health care into the mainstream. Therefore, abortion services were
primarily offered at stand-​alone clinics where abortion was the main service provided.
As a result, the anti-​abortion movement could more easily target abortion health care
with protests and violence. Between 1977 and 1988, anti-​abortion extremists committed
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 19

110 cases of arson, firebombing, and bombing at abortion clinics, involving facilities in
twenty-​eight states and the District of Columbia. Authorities convicted thirty-​three
people for this violence.63
Anti-​abortion violence escalated in the 1990s. Thousands of incidents occurred,
including blockades, invasions, chemical attacks, arsons, bombings, death threats,
shootings, sniper attacks, and cold-​blooded murder. In 1991, a masked gunman shot
and paralyzed a clinic worker and wounded a second person in Springfield, Missouri,
and a doctor was shot and wounded in Houston, Texas. In 1993, anti-​abortion extrem-
ist Michael Griffin shot and killed Dr. David Gunn in Pensacola, Florida; Rachelle
“Shelley” Shannon shot Dr. George Tiller at point-​blank range in Wichita, Kansas; and
Dr. George Patterson was shot to death in Mobile, Alabama. In 1994 in Pensacola, Paul
Hill shot and killed Dr. John Bayard Britton and a volunteer clinic escort, Lt. Col. James
Barrett, injuring another volunteer escort as well. Then in December of that year, John
Salvi shot and killed Planned Parenthood receptionist Shannon Lowney in Brookline,
Massachusetts, and then shot and killed receptionist Leanne Nicholas at a second clinic,
wounding five other people in the attacks. In addition to extreme violence, tens of thou-
sands of protesters blocked access to abortion clinics.64
In response, Congress passed the Freedom of Access to Clinic Entrances Act in
1994, creating civil and criminal penalties for blocking access to abortion clinics.65
But the violence continued. In 1995 in St. Louis, Missouri, Dr. C. Jackson was brutally
stabbed fifteen times outside his clinic, then the next year Eric Robert Rudolph deto-
nated two bombs at the Northside Family Planning clinic in Atlanta, Georgia, destroy-
ing the clinic and injuring seven people. In Rochester, New York, Dr. David Gandell
was wounded by flying glass when a sniper with a high-​powered rifle shot into his
home. In 1998 in Birmingham, Alabama, Eric Rudolph detonated a bomb packed with
nails at the New Woman, All Woman clinic, killing a security guard and maiming a
nurse. In Amherst, New York, in 1998, James Charles Kopp shot and killed Dr. Barnett
Slepian with a high-​powered rifle while he stood with his wife and children in the
kitchen of his home.66
Anti-​abortion violence negatively impacted the willingness of drug companies to
market mifepristone in the United States. Anti-​abortion extremist groups Operation
Rescue, Pro-​Life Action League, Rescue America, and Advocates for Life Ministries
organized protests at French consulates and embassies as well as at the offices of
Hoechst subsidiaries, and threatened violence against Roussel Uclaf officials and physi-
cians conducting trials of the drug. The threats of violence dissuaded researchers from
studying RU 486, even for non-​abortion applications, and created concern at the FDA
about the safety of employees involved in the approval process. Abortion rights sup-
porters argued that anti-​abortion violence was a reason to approve RU 486 so that it
could be offered in any doctor’s office, making abortion services less concentrated in
discrete, easily targetable clinics.
20 • Abortion Pills

In addition to violence, harassment, and threats, abortion opponents found politi-

cal support in the administration of Republican President George H.W. Bush and in
members of Congress, who took steps to block US scientists from studying RU 486. In
1986, Senator Robert Dornan (R-​CA) circulated a “Dear Colleague” letter about the
French “death pill” and threatened to wage a fight against federal research. Dornan
warned that RU 486 could mean “taking of a pre-​born life will be as easy and trivial as
taking aspirin.”67 In March of 1987, Senator Gordon Humphrey (R-​NH) wrote a letter
to the director of the National Institutes of Health requesting a detailed report of how
the drug was being tested and expressing concern that RU 486 was being tested as a
contraceptive that might take effect post-​fertilization.68 In 1987 and every year after,
Dornan introduced legislation to block federal funds for research on RU 486 and deny
FDA authority to permit testing of the drug.69 In response, the American Public Health
Association adopted a resolution to support research on RU 486 in 1988.70
Anti-​abortion conservatives in Congress also pressed the FDA for an import ban.
The FDA had authority under the Food, Drug and Cosmetic Act to permit importa-
tion of unapproved drugs for personal use on a discretionary basis and in the interest
of compassion.71 On June 6, 1989, at the request of anti-​abortion members of Congress,
including Representatives (Reps.) Jesse Helms (R-​NC) and Henry Hyde (R-​IL), Bush’s
FDA Commissioner Frank Young imposed Import Alert 66–​47 on RU 486, direct-
ing customs officials to “automatically detain all shipments of unapproved abortifa-
cient drugs.” Without evidence, Young stated RU 486 could present an unreasonable
safety risk. The alert prohibited people from bringing RU 486 into the country and
had the effect of halting all clinical trials on RU 486 in the United States.72 After the
Bush administration imposed an import alert on RU 486, Roussel Uclaf stopped sup-
plying the medication to the Population Council. Their tests ended in 1990 when the
Council ran out of medication. The import alert stymied research on use of RU 486 for
other medical conditions as well.73 In 1991, Bush appointed the first woman to head
the National Institutes of Health, Dr. Bernadine Healey, who opposed RU 486 research.
At the time the import ban was imposed, women were a small minority in
Congress—​only twenty-​five women in the House and two in the Senate in 1989, and
none occupied positions of leadership—​but they spoke out in support of RU 486.
Supporters asked the Congressional Caucus on Women’s Issues to press for ending
the import alert. The Caucus Chair, Representative (Rep.) Patricia Schroeder (D-​CO),
urged members to send letters to the president and the FDA asking them to recon-
sider the import alert. They asked to meet with President Bush about the issue, but
he refused.74 In July of 1990, Rep. Barbara Boxer (D-​CA) organized seventy members
of the House of Representatives to sign a joint letter to the president of Roussel Uclaf
requesting the company to market RU 486 in the United States.75
Outside the halls of Congress, abortion opponents threatened drug companies
with economic harms. Virginia minister Kevin Dubin created the Robins Carbide
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 21

Reynolds Fund—​named after three pharmaceutical companies sued by patients for

harmful drugs. Dubin threatened to organize national boycotts and block invest-
ment in companies involved with RU 486. He encouraged product liability lawsuits
against Roussel Uclaf and Hoechst, called for legislation to ban the companies from
bidding on government contracts, and delivered a twenty-​page declaration threaten-
ing to boycott Hoechst AG.76 In 1991, NRLC called for a boycott of the US-​based
subsidiary of Hoechst AG called Hoechst Celanese. In early 1992, the president of
Hoechst Celanese, Ernest Drew, reportedly persuaded Hoechst AG to halt plans to
allow the Population Council to renew its clinical testing of RU 486 in the United
States.77 Nevertheless, in 1993, NRLC picketed Hoechst Celanese in several states and
later threatened to boycott Copley Pharmaceuticals in Massachusetts after Hoechst
Celanese purchased the company. Following NRLC’s lead, Catholic hospitals, which
controlled one-​third of hospital beds in the United States at the time, threatened
to boycott pharmaceuticals produced by Roussel Uclaf and Hoechst AG.78 Abortion
opponents also tried to mobilize women against Hoechst by stoking safety fears about
RU 486 and calling attention to the absence of women in senior management posi-
tions at the company.
In response to these political pressures, Roussel Uclaf set out five criteria for intro-
ducing RU 486 to a new country: 1) abortion must be legal; 2) the political climate
must be accepting of abortion; 3) an appropriate prostaglandin must be available; 4) the
medical services system must be able to carefully monitor patients and the drug supply;
and 5) informed consent procedures must be strictly followed.79 Due to anti-​abortion
pressure, Roussel Uclaf did not seek FDA approval to market RU 486 in the United
States. Newspapers at the time attributed their reluctance to fear of anti-​abortion boy-
cotts and violence, as well as the Bush administration’s hostility to abortion. Roussel
Uclaf also feared the United States Supreme Court would overturn or weaken Roe
v. Wade, leading to abortion restrictions and bans.80 They also attributed this decision
to economic factors, including the unlikely profitability of the medication along with
the difficulty and expense of obtaining FDA approval (which can take five to ten years
and cost $70–​100 million or more), the potential cost of product liability claims, and
the potential loss of public good will.81
Some leaders at Roussel Uclaf, however, supported bringing RU 486 to the US
market, including former CEO Edouard Sakiz and the Director of Communications
and Scientific Relations, Catherine Euvrard, who both supported women’s rights. But
Hoechst AG’s CEO, Wolfgang Hilger, opposed bringing RU 486 to market in the United
States. In a San Francisco Examiner article, Euvrard criticized the men in power at
Hoechst AG for being “afraid of controversy, afraid to fight” and for always seeing RU
486 as a problem of “politics, money and corporate image” rather than a women’s health
issue. In the same article, Roussel Uclaf ’s medical director, André Ulmann, described
Hoechst’s leadership as “men who are often aged men, elderly men who know nothing
22 • Abortion Pills

about birth control and abortion” and “are convinced it is going to bring a lot of trouble”
and “jeopardize their market if there is a boycott.”82

The Feminist Campaign to Bring RU 486 to the United States

In response to the reluctance of Roussel Uclaf and Hoechst AG to market the medi-
cation in the United States, a range of feminist organizations organized campaigns to
bring RU 486 to the United States, including the Reproductive Health Technologies
Project (RHTP), Feminist Majority Foundation (FMF), Abortion Rights Mobilization
(ARM), Planned Parenthood Federation of America, the Population Council, and
NARAL. Beginning in 1988, these groups worked to generate public understanding
and support for RU 486, as well as support from the scientific and medical commu-
nities in order to pressure Roussel Uclaf and Hoechst AG to release the patent rights
to RU 486 so it could be sold in the United States. “Roussel Uclaf is not convinced
that there is public support for RU 486 in the United States,” said FMF’s Jennifer
Jackman in 1991. “The sense we got from them is that the more public support we
could demonstrate, the more willing Roussel Uclaf would be to make it available in
the United States.”83
Abortion opponents weren’t the only ones wary of RU 486. Some in the femi-
nist health community were hesitant about RU 486 due to the history of medical
and pharmaceutical companies promoting medications without adequate testing
and warnings. The “father of modern gynecology,” J. Marion Sims, performed brutal
experimental surgeries on enslaved women without anesthesia in the mid-​nineteenth
century.84 A century later, Gregory Pincus and John Rock tested birth control pills
on women in Puerto Rico without allowing them to make an informed decision on
whether they wanted to serve in the trials.85 The long history of coercive sterilization
and imposition of dangerous contraceptives on women of color made many skeptical
toward new technologies.86
In 1991, University of Massachusetts Women’s Studies professor Janice
G. Raymond, along with Renate Klein and Lynette J. Dumble, published a book, RU
486: Misconceptions, Myths and Morals, arguing that RU 486 and prostaglandins were
“fraught with risk and problems” and endangered women’s lives and health.87 They
questioned the women’s groups who worked alongside population control groups and
pharmaceutical and medical researchers to promote RU 486, noting the contradiction
of arguing that medication abortion protects women’s privacy while also requiring that
the drug be used only under close medical supervision. They warned that Margaret
Sanger and others in the early twentieth century had “succumbed to the pressure of
promoting physician control and the strict medicalization of birth control” to obtain
legalization. Instead, they proposed the de-​medicalization of women’s health. They
pointed to the Jane Collective, which offered safe abortion before Roe v. Wade, and to
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 23

the self-​help menstrual extraction movement in the 1960s.88 They argued, “the femi-
nist critique knew the difference between a procedure which gave women real control
of their bodies and a chemical cocktail attended by all the accoutrements of exten-
sive medical-​technical intervention.”89 Further, they questioned the impact of abor-
tion medications on the sexual politics of women’s lives and their right to refuse sex.
They expressed concern that “RU 486 may absolve men of any future contraceptive
commitment since the drug has been promoted as ‘safe and easy’ for women.”90 They
concluded, “no procedure requiring medical supervision and involving a host of risks
and complications will help provide sexual and reproductive self-​determination for
women.”91 These concerns seemed to be confirmed when the Population Council—​an
organization founded in 1952 by prominent eugenicists—​was later chosen to conduct
the clinical trials of RU 486. The leader of the American Eugenics Society, Frederick
Osborn, served as both vice-​president and president of the Population Council until
1959.92 Anti-​abortion groups stoked fears about potential dangers of RU 486 by claim-
ing the drug had been inadequately tested, and making parallels to previous contro-
versial products, such as the injectable contraceptive Depo-​Provera and the Dalkon
Shield, which caused bacterial infections and severe injuries to many women. They also
claimed RU 486 would be used to exploit women in developing countries by tricking
or coercing them into abortion.93 In 1993, Ms. magazine published side-​by-​side articles
on RU 486 arguing for and against it. Raymond, Klein, and Dumble argued against it,94
while Janet Callum and Rebecca Chalker argued in favor of RU 486.95
To build consensus and support for RU 486, reproductive health advocates Marie
Bass and Joanne Howes, who ran a public policy and public affairs consulting firm
focused on health issues, formed the Reproductive Health Technologies Project.
Bass had worked with NARAL’s Political Action Committee in 1982 and 1984, where
she had heard about RU 486. Howes had been a Washington lobbyist for Planned
Parenthood. In 1986, Bass met in Paris with Dr. André Ulmann, the medical director
at Roussel Uclaf, and Étienne-​Émile Baulieu to learn about RU 486. Bass and Howes
then decided to conduct research on what it would take to bring RU 486 to the United
States. They interviewed researchers, medical professionals, and women’s health advo-
cates about their views on RU 486 and the possibilities for bringing the medication to
the US market. In 1987, with the support of a grant from the Sunnen Foundation in
St. Louis, Bass, Howes, and Nanette Falkenberg published “A Report on RU 486 and
Its Prospects for Use in the United States.” The authors recommended a three-​part
strategy: increase medical research, find a drug company to distribute the drug, and
run a public education campaign to increase awareness of, and demand for, RU 486.
“Growing public support will be necessary to convince drug companies to invest their
financial resources, and the research community to continue its quest for a safe and
effective progesterone antagonist,” they argued.96 They emphasized the potential dif-
ficulties of finding a drug company willing to develop and market RU 486, especially
24 • Abortion Pills

in light of the “politicized environment surrounding the rejection of Depo-​Provera,

and the criticism of the approval and m ­ arketing of oral contraceptives before they had
been fully tested and understood.” 97
They reported that doctors, drug companies, and
researchers perceived that feminist women’s health groups had blocked FDA approval
of Depo-​Provera and therefore were hesitant to invest in another reproductive drug.
Women’s health groups, they found, preferred independent research to drug-​company-​
sponsored research, and were likely to oppose any type of “chemical contraception.”98
The report rejected Baulieu’s strategy of framing RU 486 as a “contragestin” rather
than an abortifacient because of the “complexity of trying to change the popular under-
standing and definition of ‘birth control,’ abortion and pregnancy.”99 It did, however,
note that the National Institutes of Health was testing RU 486 as a contraceptive. They
also noted that Roussel Uclaf at the time had an international marketing plan that
included the United States and that they were willing to invest significant money to
market the drug in the United States. The report predicted that many companies may
be interested in developing the drug and recommended “in-​depth discussions with the
Population Council and Roussel.” It concluded, “the potential of RU 486 or a similar
drug is very exciting, but it will become a reality only if a concerted effort is organized
to make it happen.”100 Bass, Howes, and Falkenberg expressed hope that RU 486 “could
fundamentally alter the politics of the abortion issue as we know it today—​perhaps
even end the issue.”101
Bass and Howes distributed the report widely to their political contacts, drawing
significant attention to the issue. When Planned Parenthood hired Bass and Howes to
coordinate a series of ten conferences around the country on new birth control tech-
nologies, they included RU 486 in the program, which generated more awareness of the
medication. They also worked with Kathy Bonk at the Communications Consortium
Media Center to generate media coverage of RU 486. When Roussel Uclaf withdrew
the medication from the market in France in 1988, Howes traveled to Brazil to attend
the global conference of obstetricians and gynecologists, meeting people and making
contacts in the United States and abroad. But Howes and Bass were not able to get
mainstream women’s organizations interested. “At the end of 1987 and during 1988,
pro-​choice and women’s rights groups were consumed by their efforts to defeat the
nomination of Robert Bork to the Supreme Court and, following that victory, by the
coming November elections,” said Bass. “Their agenda was overcrowded as it was, and
their resources were limited. RU 486 was not a priority.”102
After the fall elections in 1988, Bass and Howes convened a group of about forty
representatives of women’s health, family planning, pro-​choice, and international pop-
ulation organizations on November 21. They shared the science of RU 486 and created
space for people to discuss their concerns about the safety of the medication. Judith
Norsigian of the Boston Women’s Health Book Collective expressed concerns about
the effect of the drug on women of color and about access to hospital care in the case
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 25

of emergencies. Several people recalled that “drugs and devices that were once highly
touted had turned into disasters for women—​diethylstilbestrol (DES), thalidomide, the
Dalkon Shield.”103 Norsigian later said: “We wanted to tread carefully because we had
seen so many medical advances that did not pan out well for women. We were cau-
tious and wanted to wait till better research was in before we embraced it completely.
But we also recognized that in countries where abortion was illegal, this might be like
exactly what was needed, because it could come under the radar screen.”104 Cynthia
Pearson of the National Women’s Health Network remembered that she wondered why
anyone would want to go through a medication-​induced miscarriage when they could
get an aspiration abortion. “Who would want to go through hours or days of cramps
and bleeding?” asked Pearson.105 Pearson also wanted assurances about the safety of
mifepristone before supporting it. After seeing the research from France, and hear-
ing reports from French women who had used the medication, Pearson was reassured
about the safety and acceptability of mifepristone. These conversations helped build
trust among different constituencies and were critical to achieving strong support for
RU 486 in the women’s health community, which later facilitated FDA approval of the
medication and acceptance of medication abortion, particularly among communities
of color. By the end of the daylong meeting, most participants agreed to a special proj-
ect on RU 486 managed by Bass and Howes.
For the next two years, Bass and Howes convened periodic meetings to keep people
informed about the progress of RU 486 around the world and “develop common mes-
sages and themes.”106 According to Bass, the meetings became a “forum for listening and
learning, for establishing consensus, painstakingly but genuinely.”107 This hard work
“defanged a lot of the skeptics who might have said, ‘Why do we need a drug? We’ve got
other ways to have an abortion,’ ” said Amy Allina, who was at the National Women’s
Health Network (NWHN), which was founded by people who raised questions about
the safety of birth control pills. “They looked at the data and they were like, yeah, this
is safe. The research has been done in a rigorous way. We’ve looked for the problems we
might worry about, and we think this is an important new option.”108
Many feminists distrusted mainstream, male-​ controlled medicine because
researchers had ignored women’s reports of dangerous side effects of the birth con-
trol pill.109 They preferred what they saw as more natural methods for abortion,
such as manual vacuum aspiration controlled by women themselves.110 In 1989, the
Feminist Women’s Health Center federation raised funds to send self-​help advo-
cate Carol Downer to France to speak with clinic directors, staff, and women who
had used the pill. The visits were arranged by another self-​help advocate Claudine
Serre. “We were very skeptical. We left no stone unturned. We asked every question,”
recalled Downer. “The thing that jumped out was that all of them had a very positive
reaction to experiencing this process.” The women said the process felt very natural,
similar to a spontaneous miscarriage. “We realized this was a momentous discovery,
26 • Abortion Pills

and once unleashed into the world at large, it would affect millions of women’s lives,”
said Downer. Back in the United States, Downer authored a report, gave press inter-
views, talked to people in government, and held workshops with clinicians about her
findings.111 In July of 1990, RHTP invited two pro-​choice leaders from England and
a prominent French physician who ran a clinic offering RU 486 to the United States
for a series of meetings and press briefings, where they shared their experiences with
the medication.112
In 1992, Bass and Howes founded Reproductive Health Technologies Project in
Washington DC as an independent nonprofit, funded mostly by The Tides Foundation
and led by reproductive health advocate Kirsten Moore, who served as president and
CEO. According to Bass, RHTP acted as a clearinghouse for information on RU 486,
“distributing thousands of information kits to organizations, public officials, and the
media. We fielded press calls and put journalists in touch with doctors and researchers
who could speak authoritatively about the drug. We assisted organizations that were
writing resolutions of support, legislators who wanted to introduce resolutions or hold
meetings, and academics who were putting together conferences.”113 RHTP served as
a forum to discuss concerns among a diverse range of constituencies, including main-
stream abortion rights groups, population control groups, and emerging reproductive
justice groups formed by women of color.
RHTP recruited a diverse board of advocates to lead the organization. The twenty-​
three members of the board included the executive director of the National Asian
Women’s Health Organization, Mary Chung; director of the Native American Cultural
Center at North Dakota State Hospital, Mary Louise Defender-​Wilson; a National
Welfare Rights Union organizer, Cheri Honkala; director of the National Latina
Health Organization, Luz Alvarez Martinez; president of the National Black Women’s
Health Project, Julia R. Scott; and Dr. Helen Rodríguez-​Trías, who was president of the
American Public Health Association.114 Marie Bass explained the importance of this
diverse group:

The project’s members have learned from each other, the scientist teaching the nonscien-
tist and the nonscientist teaching the scientist. White women learn from Black and Latina
women, who explain why they recoil almost instinctively from the introduction of any new,
highly touted birth control technology; why they may view it as an attempt to coerce and
control rather than liberate them. Middle-​class participants learn from poor women about
the harsh realities of these women’s lives, which overrule the moral or ideological soapboxes
that others are privileged enough to speak from.115

Martinez, who remembers urging RHTP to expand the board to include more women
of color, recalled her excitement about RU 486: “It was something new and I was excited
about it because it was another option that women didn’t have at that time.”116
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 27

Kimberly Inez McGuire, who was a senior programs and policy associate with RHTP
between 2009 and 2011, described how RHTP developed trust among advocates:

The early work on medication abortion established this integrity and this sense within the
community that RHTP could be trusted both to be an honest broker of the science, the facts,
the information, but also of bringing people together in a way that allowed them to have
their own priorities, their own values…I think about some of those early meetings where
it was the first time that you had women-​of-​color-​led reproductive justice organizations
alongside researchers, and really treating all the advocates with the respect of giving them
all the facts and not just pushing an agenda the way that unfortunately many of those groups
have been subjected to, that forceful coalition management, where someone comes to a table
and says this is what we’re doing and you better get on board. RHTP wasn’t like that. For
RHTP, it was, “we’re going to bring this to the table, here’s the information, and ultimately
you make your own decision.” There was a sort of informed consent to coalition building
that I think is really rare and is still really rare.117

Reproductive health advocate Francine Coeytaux,118 who was with the Population
Council at the time, explained the importance of RHTP:

The brilliance of RHTP was the model of bringing together a working network of really key
individuals in many sectors to discuss new reproductive health technologies. The reason it
had so much impact was because of the importance of involving every sector at the table as
you’re trying to move a new contraceptive idea forward. Somebody who is a legislator and
knows how to work the legislation, somebody who is a chemist and knows how to deal with
the FDA, somebody who is an MD—​all these really top thinkers with a commitment to
working together to think through what it would take, what are the obstacles.119

This diverse network of people enabled collaboration among various sectors, thereby
playing a critical role in eventually achieving FDA approval of RU 486.
RHTP published a widely distributed handbook, titled The Case for Antiprogestins,
on the science and politics of RU 486, which became a key informational source on
the medication.120 They conducted educational sessions on RU 486 for conferences,
workshops, and community meetings for local, regional, and national groups, includ-
ing major professional associations and outreach to low-​income women and women of
color. They also provided technical assistance and expertise to national, state, and local
policymakers121 and encouraged medical organizations such as the American Public
Health Organization and the American College of Obstetricians and Gynecologists
(ACOG) to pass resolutions in support of RU 486, many of which did.122
On December 6–​7, 1991, the American Society of Law and Medicine convened
a landmark conference to assess the medical, ethical, and legal issues surrounding
28 • Abortion Pills

antiprogestins. At the conference, speakers included doctors, attorneys, ethicists, wom-

en’s health advocates, and others. According to an RHTP report on the 1991 hearing
and the conference, “speaker after speaker at both events…argued that antiprogestins
are a safe, effective and highly desirable alternative to surgical abortion for the termi-
nation of very early pregnancy…and hold tremendous value for the treatment or cure
of many other conditions and diseases.”123 Director of the Atlanta Feminist Women’s
Health Center Janet Callum reported on speaking to French women who had used RU
486: “some women felt that because there was no instrumentation, RU 486 was gentler
and less intrusive, and they also appreciated not having to disrobe and lie down before
a stranger.”124 At the end of the conference, 137 participants wrote a letter to the presi-
dent of Hoechst Celanese Ernest Drew, demanding the company market RU 486 in the
United States.125
Another key advocate for RU 486 was the Feminist Majority Foundation, which
launched a campaign for RU 486 in June 1989. Former National Organization for
Women (NOW) president Eleanor Smeal and feminist Peg Yorkin, who chaired the
FMF board, led the campaign.126 Yorkin later donated $5 million toward bringing the
abortion pill to the country.127 Smeal said at the time, “We intend to visit the pharma-
ceutical leaders, the medical health leaders to urge them to rise up against this move-
ment that is denying the best of medical research, and the best that modern medicine
can provide for the modern woman.”128 Her plan gained urgency a month later when the
Supreme Court ruled in Webster v. Reproductive Health Services to expand state pow-
ers to restrict privately funded abortion services in state facilities. FMF hired Jennifer
Jackman to head the Campaign for RU 486 and Contraceptive Research, which was
based in Boston. “The first thing we did was put together a scientific team, and they
explained to us exactly how it worked and its safety,” said Smeal. “We talked to the most
preeminent doctors in the field.”129 Smeal recruited Carl Djerassi, who helped develop
the oral contraceptive pill. “I just called him. His wife was a feminist. He then helped
me put together a team of scientists. He said he’d serve on it, and he’d help get some
other scientists,” said Smeal.130 FMF then sought to educate the public about RU 486
and convince Roussel Uclaf and Hoechst AG that there was widespread support for the
medication in the United States. They also sought to neutralize anti-​abortion threats to
organize economic boycotts of the companies by showing widespread support for RU
486 in the United States. Smeal said most people were supportive of the campaign, but
that some abortion providers worried that RU 486 might undermine the clinic system
because any doctor could offer it.131
FMF ran a direct mail campaign, sending eight million letters to women’s rights
supporters with information about RU 486 and petitions to Hoechst AG and Roussel
Uclaf, which they asked recipients to complete and mail back in. To support the
petition, NOW organized a “Freedom Caravan” to collect petition signatures, which
traveled to New Jersey, Pennsylvania, Massachusetts, Nevada, Oregon, and other
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 29

states, collecting signatures along the way.132 In less than four years, they collected
700,000 petitions. FMF also collected petitions from scientists by mailing and fax-
ing various lists of scientists, Nobel laureates, and faculty, as well as distributing the
petitions at conferences.
On July 23, 1990, an FMF delegation met with Roussel Uclaf officials, bringing
petitions signed by 115,000 Americans and weighing 800 pounds!133 The delega-
tion included Smeal, Yorkin, NOW president Patricia Ireland, and FMF Director of
Policy and Research Jennifer Jackman, as well as prominent scientific and medical
leaders, including Djerassi, the Dean of Columbia School of Public Health Dr. Allen
Rosenfield, and president of the American Public Health Association Dr. Myron
Allukian (see Figure 1.1). When they arrived at the office of Roussel Uclaf ’s CEO
Edouard Sakiz, Smeal was surprised to find out that Sakiz and Djerassi already knew
each other. “They were buddies,” said Smeal. “I just knew [Djerassi] was one of the
best scientists in this field in our country. As things happen worldwide, people who

Figure 1.1: FMF delegation visits Roussel Uclaf in Paris, France, in 1991 to deliver thousands of
petitions asking the company to release RU 486 to the US market. Those pictured from left to right
include Dr. Catherine Euvrard (Roussel Uclaf), Dr. Myron Allukian (President, American Public
Health Association), Dr. Judith Resnick, Peg Yorkin (FMF), Patricia Ireland (NOW), Dr. Eduoard Sakiz
(Roussel Uclaf), Eleanor Smeal (FMF), Ariel Mouttet (Roussel Uclaf), Allan Rosenfield (Dean, Columbia
University Mailman School of Public Health), Dr. Carl Djerrasi (Stanford University), who has been
credited with developing the birth control pill, and Dr. Diane Robins (photo credit: Jennifer Jackman).134
30 • Abortion Pills

are doing something in the avant-​garde, they know each other. As it turned out, they
had worked together on research, so that was helpful.”135
The first thing that happened was that Sakiz said he thought it was very important
that RU 486 obtain FDA approval in the United States because the FDA had a “gold
seal of approval,” and if the FDA approved a drug, then it would become a drug that
would be used widely around the world. Smeal described Sakiz’s motivations: “He
made it very clear that the reasons he had worked on this so hard was he thought
that it would save women’s lives throughout the developing world and it would create
healthier babies when they did come because the mother herself would be in better
condition.”136 To publicize the life-​saving benefits of mifepristone, FMF made a brace-
let saying how many women die from botched, illegal abortions each year. Jennifer
Jackman explained the important role that these meetings played:

That meeting was really critical because it’s how we got to know the senior people at Roussel,
especially Dr. Sakiz and his right-​hand person, Catherine Euvrard. We got to know them and
realized that these are people who support women’s reproductive rights. They’re in this for
the right reason. They were constrained institutionally because they were owned by Hoechst
AG, a parent company that was quite conservative, based in Frankfurt. They wanted us to
generate pressure on them to counter the anti-​abortion pressure. They welcomed a cam-
paign that would demonstrate that there was support for the drug. So we were trying to do
that through showing public scientific support.137

After meeting with officials at Roussel Uclaf, the delegation flew to Frankfurt,
Germany to meet with Hoechst AG officials, shipping the petitions to arrive for the
meeting as well.
FMF returned to meet with company executives on February 20, 1991, and again
in 1992, delivering an additional 110,000 petitions, including more than three thou-
sand petitions from medical experts. During the 1992 trip, Smeal, Yorkin, and Jackman
met with women in the Bundestag, German federal parliament, to discuss the RU 486
campaign (see Figure 1.2). Catherine Euvrard said later that the petitions were “very
important” in convincing the companies to find a way for RU 486 to be marketed in the
United States. “It was concrete because you have all those petitions. It was fifty/​fifty so
why choose one over the other. Our position was just to put the drug on the market and
to let women decide. It’s a personal decision of a woman,” said Euvrard later. “Thanks to
FMF and other groups, we had proof that such a medicine was necessary and good.”138
To put peer pressure on Roussel Uclaf, FMF also urged scientific and medical asso-
ciations to pass resolutions supporting RU 486 research and condemning the import
alert. On June 27, 1990, the American Medical Association policy committee voted
unanimously to support the testing of RU 486. Eight months later, the American
Association for Advancement of Science followed suit. Advocates eventually secured
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 31

Figure 1.2: During the 1992 trip to Frankfurt, Germany to meet with Hoechst, Smeal, Yorkin, and
Jackman (on the right) meet with German Medical Women’s Association Vice President Gertrude
Zickgras, Medical Women’s International Association General Secretary Carolyn Motzel, and State of
Hessen Minister of Health Iris Blaul to discuss the RU 486 campaign (photo credit: Jennifer Jackman).

RU 486 endorsements from almost every scientific and medical organization in the
country.139 FMF also had a campaign to collect petitions from individual scientists.
Jackman explained, “the whole idea behind the scientific outreach was to put pressure
on Roussel Uclaf from the community that mattered to them, those they would see as
their peers, because Roussel really was a first-​rate kind of pharmaceutical company that
valued scientific research.”140
FMF organized direct actions as well, such as attending stockholder meetings and
holding demonstrations at public events. In April of 1992, FMF announced a “Web of
Influence” campaign, publicizing the names of companies doing business with Roussel
Uclaf and Hoechst, and urging people to contact these companies to tell them to ask
Roussel Uclaf and Hoechst to make RU 486 available in the United States. In April 1992,
FMF held an RU 486 picket at Trevira Twosome race in New York City, sponsored by
Hoechst Celanese and Nike (see Figure 1.3). At the time, Hoechst Celanese was the
100 percent-​owned subsidiary of Hoechst AG and Nike used Hoechst-​produced fibers
in its sports attire. RU 486 was also a major focus of massive abortion rights rallies in
Washington, DC, in April 1989 and April 1992. FMF and NOW pledged to boycott the
pharmaceutical companies if they did not bring the medication to the United States.
At the state government level, FMF worked to persuade legislators to pass resolu-
tions in favor of making RU 486 available in the United States. New Hampshire passed
a resolution in 1991, followed by California, Maine, and Hawaii. Lawmakers in at least
Figure 1.3: As a part of the Web of Influence Campaign to bring RU 486 to the United States, FMF held
a demonstration in April 1992 at the Trevira Twosome Race in New York City, which was sponsored
by Hoechst Celanese and Nike. Protesters held signs saying, “Fight Breast Cancer” and “Say No to
Brain Tumors, Say Yes to RU 486,” referring to research suggesting other uses for RU 486 (photo
credit: Jennifer Jackman).
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 33

eight other states introduced resolutions to support RU 486. Local lawmakers also
acted. New York City Mayor David Dinkins organized thirty mayors to urge the Bush
administration to reverse its opposition to RU 486 and support testing of RU 486 in the
United States.141 New York City Comptroller Elizabeth Holtzman threatened to have
the city’s hospital system stop buying products from companies affiliated with Roussel
Uclaf and Hoechst AG.
Another organization—​ Abortion Rights Mobilization (ARM), formed by the
founding chair of NARAL Lawrence Lader—​also helped raise public awareness of RU
486. Lader published two books—​RU 486: The Pill That Could End the Abortion Wars
and Why American Women Don’t Have It (1991) and A Private Matter: RU486 and the
Abortion Crisis (1995). In his 1991 book, Lader characterized RU 486 as revolutionary,
with the potential to give a woman “full control over her abortion in the surroundings
of her choice,” allowing women to obtain abortions in their doctor’s office rather than
an abortion clinic and avoid the “physical invasion of the body” required by proce-
dural abortion.142 Lader argued that fundamentalist opposition to abortion was rooted
in men’s anger at “the women’s movement and the sexual revolution, which have tested
and eroded male dominance.” He explained:

Their recourse is to keep women cloistered at home as the bedrock of family values. The
most obvious restriction on women is to force them to bear a child against their will. The
war on abortion and birth control thus protects and reinforces the sentence to bear children.
By contrast, RU 486 guarantees women freedom of choice through a private, simple, and
almost painless abortion—​no punishment for women, no control for men.143

Lader tirelessly promoted the books, traveling around the country giving talks and
regularly speaking with media outlets about RU 486.
Lader was very effective at increasing public awareness about RU 486. “Larry was one
of a kind. He was a character,” said Smeal. “He felt that we had to get a lot of press to win
this one. He would always come up with ideas, and we frequently would be responsive
to it.”144 Lader heard about a law empowering the US government to take a patent for an
essential drug that was being withheld from the US market. He had the idea to use this
law to pressure Roussel Uclaf and Hoechst AG to allow RU 486 into the United States.
“That was Larry’s idea, and he took it to Ron Wyden,” said Smeal. At that time, Ron
Wyden was a young member of the House of Representatives from Oregon. “Wyden
took us all seriously and had hearings. Those hearings were very important because
Eduard Sakiz at Roussel Uclaf could use them in his bargaining with Hoechst AG. In
other words, ‘you guys are going to lose this patent because the United States isn’t going
to take this.’ They thought that the Congress was going to act. That was important.”145
Rep. Wyden held congressional hearings in 1990, 1991, and 1992 on the Bush
administration’s import alert on RU 486 before the Small Business Subcommittee on
34 • Abortion Pills

Regulation, Business Opportunities, and Energy.146 On November 19, 1990, the first hear-
ing examined the import ban’s effect on medical research. Scientists testified about how
the import alert interfered with research into potential uses of RU 486 to treat illnesses,
including Cushing syndrome, breast cancer, and meningioma. Wyden accused the FDA
of “arbitrary, political, and unscientific RU 486 policies.”147 At the end of the hearing,
Wyden introduced a bill to remove the import ban, which died in committee.148 The
media covered the hearings extensively. Wyden then held another hearing in December
of 1991, where leading European researchers, clinicians, and public policy experts testi-
fied about the European experience with RU 486. American scientists, pharmaceutical
industry representatives, and political activists testified about factors preventing RU 486
from coming to the United States. Eleanor Smeal testified that the import alert harmed
the reputation of the United States: “If we permit these forces to stop the pursuit of
knowledge, the United States will not be a first-​rate country in terms of health care, sci-
entific research, or human rights.”149 At the 1992 hearing, a brain tumor patient, actress
Cybill Shephard, and several pro-​choice groups testified. Wyden expressed frustration
that Roussel Uclaf had decided to go forward with breast cancer trials in Canada, but
refused to do so in the United States.150 The committee heard testimony from a man
with recurrent meningioma, who recounted his difficulties with obtaining RU 486 from
Roussel Uclaf to treat his condition. While Roussel Uclaf told him he could arrange a
compassionate use exemption from the import alert through the FDA, the FDA told
him he could not receive the exemption without a written guarantee of supply from the
company, which the company would not provide without FDA approval.151 The hear-
ings repeatedly exposed that the FDA had acted politically rather than based on scien-
tific evidence in imposing the import alert. In 1991, Wyden and Rep. Henry Waxman
(D-​CA) introduced the “RU 486 Regulatory Fairness Act” to reverse the import alert.
The bill had sixty-​eight other supporters in Congress, but never passed.152
To generate more publicity and awareness about abortion pills, Lader directly chal-
lenged the import ban in 1992 by arranging for a pregnant American woman named
Leona Benten to travel to London to obtain RU 486, then travel back to the United
States and carry the medication through customs. ARM had alerted customs officials
and the press in advance, so when customs officials confiscated the pills, ARM began
a press conference announcing their plan to file a lawsuit challenging the confiscation
and the import ban (see some of the press coverage in Figure 1.4). Lader, who had
written a biography of Margaret Sanger in 1955, was inspired by Sanger’s use of this
strategy in the 1936 case, United States v. One Package of Japanese Pessaries. Sanger
arranged to have a Japanese doctor mail contraceptives to her clinic in New York to
challenge the law. Customs seized the package and Sanger sued. She won the case.153
Lader explained his hope: “We were looking for a strategy that would challenge
President Bush and the Hoechst company directly, a way to dramatize the absurdity of
their positions and bring the importance of RU 486 to the country and the media in
vivid and simple terms.”154
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 35

Figure 1.4: A July 1, 1992 press conference held by Lenore Benten and Lawrence Lader at John
F. Kennedy airport was widely covered in the press (photo credit: Carrie N. Baker).

The Benten case generated extensive publicity and highlighted how the FDA’s
import ban was based on politics rather than science and harmed women. A federal
district court judge ruled in Benten’s favor, stating it was likely that “the decision to ban
the drug was not from any bona fide concern for the safety of users of the drug, but on
political considerations having no place in FDA decisions on health and safety.”155 The
case was eventually overturned on appeal,156 but achieved Lader’s goal of raising aware-
ness about RU 486, exposing the government’s biased actions and the harmful impact
they had on women. “The case had been a legal gamble from the start, of course, but
it had turned out far more successfully than anyone expected,” Lader said afterwards.
“Leona personally had lost, but the movement had made a striking advance in bringing
the issue of RU 486 to national attention and shaking up the government’s rigidity in
the process.”157
A second ARM strategy focused on developing an RU 486 clone to break Roussel
Uclaf ’s monopoly and put pressure on the company to either market RU 486 in the
United States or turn over its patent to a US-​based company. Lader hoped to test the
clone under New York’s “mini-​FDA” law allowing research on new medications. Lader
found a Chinese doctor to provide copies of their abortion pill as well as to share the
results of their clinical tests of the medication. ARM then raised money, found scien-
tists, and set up a lab in Westchester, New York, to produce their own abortion pill.
36 • Abortion Pills

On January 1, 1993, Lader held a press conference urging Health Secretary Donna
Shalala to “contract with a drug company in this country or elsewhere to manufac-
ture and distribute RU 486 to American women at cost.”158 Then on February 17, 1993,
Lader announced ARM would begin testing Chinese abortion pills in the United States.
In late March 1993, the ARM lab had produced 50 grams of RU 486—​enough to supply
abortions to about one hundred women. Lader explained, “testing this small a number
would essentially be symbolic, but it would prove to the country that RU 486 could be
made here, and a lot more of the drug would be available shortly thereafter.”159 ARM
then obtained FDA authorization to test their own pills under the Population Council’s
IND approval. At a press conference on April 1, 1993, Lader showed the pills ARM had
developed to reporters, stating, “Our purpose is to pressure Roussel Uclaf. We are try-
ing to get them into immediate and decisive action.”160
Both ARM and FMF worked to educate the public about possible other uses of the
medication, including treatment for Cushing syndrome, brain tumors (meningioma),
breast cancer, endometriosis, fibroids, and postpartum depression. Some hoped the
medication could reduce the need for Caesarean births by helping to dilate the cervix.
Baulieu even argued that RU 486 could be developed as a once-​a-​month contraceptive,
which would block implantation. “The whole concept of abortion must change,” said
Baulieu, noting that pregnancy does not commence until a fertilized egg is implanted
in the uterine wall. “If it works, it will be the end of contraceptives and the end of abor-
tion,” said gynecologist Raymond Faraggi. “No more daily pills, no more IUDs. You
take a pill on the twenty-​fifth to twenty-​eighth day of your menstrual cycle regularly,
every month. It means the end of abortion, anyway, and an end to all our problems.”161
Baulieu, who continued to promote RU 486 throughout the 1980s despite hate mail and
threats, published a book in 1990 in which he optimistically argued, “paradoxically, the
‘abortion pill’ might even help eliminate abortion as an issue.”162
Between the late 1980s and early 1990s, over three hundred newspapers across
the United States editorialized on RU 486, with 95 percent supporting research, even
including newspapers in conservative areas of the country. On December 11, 1990, the
Herald-​Press in Huntington, Indiana wrote in support of research on RU 486: “blocking
medical progress is where the sensible public should draw the line…the best solution is
to restore sanity to the abortion debate, and that can only mean respecting the honor-
able American institution of personal choice.” An editorial in the newspaper Mail in
Charleston, West Virginia, said, “The right-​to-​life movement is jeopardizing its claim
to compassion for all, born and unborn, in its unreasoning opposition to the so-​called
abortion pill, RU 486. By refusing to allow research on the drug for uses other than
abortion, the pro-​lifers risk looking like new-​Luddites who refuse to acknowledge the
benefits of technological progress.” The St. Petersburg Times editorialized on November
21, 1990, “Approval of RU 486 is not tantamount to endorsement of abortion. Indeed,
there are surely thousands of American who are opposed to abortion, but who would
use the drug for its other valuable functions.”163 Much coverage framed RU 486 as a
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 37

breakthrough that could completely change abortion. For example, Time magazine ran
a cover story on mifepristone in June 1993 with the headline, “The Pill That Changes
Everything”164 (see Figure 1.5). This Time cover indicated the high hopes that people
had for what mifepristone could do for women.

Figure 1.5: Time magazine cover in June 1993 (courtesy of Time).

38 • Abortion Pills

Abortion rights supporters in Congress tried to pressure the Bush administration

to lift the import ban and approve the medication. Rep. Pat Schroeder (D-​CO) and
Senator Paul Wellstone (D-​MN) introduced legislation to remove the Bush adminis-
tration’s import alert. In addition to holding hearings on the import alert, Rep. Wyden
sent a letter to Roussel Uclaf urging them to market RU 486 in the United States and
notifying them of three small pharmaceutical companies interested in marketing RU
486—​Gynex, Cabot Medical Corporation, and Adeza Biomedical Corporation.165 But
Roussel Uclaf said they would only license the drug to a major pharmaceutical com-
pany. The company’s reluctance led reproductive rights advocates to develop legal
strategies attempting to compel the company to make the drug available. University of
Southern California law professor Erwin Chemerinsky argued withholding the medi-
cation violated California’s constitutional right to privacy. ARM suggested the federal
government might have the right to seize patent rights and Rep. Jerry Nadler (D-​NY)
investigated the possibility of new legislation to remove the patent.166
The 1992 elections turned the political tides in favor of RU 486. In the fall of 1991,
President George Bush nominated Clarence Thomas to the Supreme Court. During
the confirmation process, law professor Anita Hill notified the FBI that Thomas had
sexually harassed her in the early 1980s, while she worked for the Office of Civil Rights
in the Department of Education, and then later at the Equal Employment Opportunity
Commission. Chair of the Senate Judiciary Committee Joseph Biden called a public
hearing on the matter, where the ten white members of the Committee questioned
Hill and Thomas, treating Hill terribly and then confirming Thomas’s nomination.
This spectacle led to tremendous anger among women and mobilized them to run for
office and vote in record numbers. In the 1992 elections, Americans elected pro-​choice
Democrat Bill Clinton as president of the United States and elected a record number
of women and pro-​choice members of Congress. The change created a more favorable
political climate for RU 486, but advocates still had a long road to travel before achiev-
ing FDA approval of mifepristone.

FDA Approval of Mifepristone

In the November 2022 Alliance for Hippocratic Medicine lawsuit challenging the FDA
approval of mifepristone, anti-​abortion doctors alleged that the Clinton administra-
tion’s FDA “fast tracked” the approval of mifepristone.167 Abortion opponents had
argued for years that the approval process had been “politicized science” and that the
Clinton administration had manipulated the approval of mifepristone and endan-
gered women’s health.168 In fact, it took the entire two terms of Clinton’s presidency
for the FDA to approve mifepristone.
During the 1992 campaign, Clinton pledged his support for bringing RU 486 to
the United States. After the election, FMF sent letters to Roussel Uclaf and Hoechst
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 39

AG informing them that the political climate was much more favorable for RU 486.
Feminist organizations, who had strongly supported Clinton’s campaign, raised the
issue of RU 486 in early meetings with the president and his advisors. Within days of
his inauguration and on the twentieth anniversary of Roe v. Wade on January 22, 1993,
President Clinton directed the Secretary of Health and Human Services Donna Shalala
to take steps to rescind the FDA import alert on RU 486 and to promote the “testing,
licensing, and manufacturing” of RU 486 in the United States.169 In response, Shalala
published a notice in the Federal Register directing the FDA “to initiate an immediate
and thorough review of the health and safety implications of the potential import of RU
486 for personal use.” Then Shalala urged on the negotiations between the FDA and
Roussel Uclaf. Eleanor Smeal declared that the Clinton administration actions were
“the end of an era of medical McCarthyism” in which Republican ideology “interfered
with the conduct of scientific research and medicine.”170 Despite Clinton’s actions, it
would take another eight years before the medication would receive FDA approval.
In December of 1992, after the election but before the inauguration of Clinton, FDA
Commissioner David Kessler wrote to Roussel Uclaf encouraging the company to sub-
mit an application to license RU 486 in the United States.171 On February 24, 1993,
Kessler met with Sakiz to discuss how to bring RU 486 to the United States by licensing
the medication to another entity, such as a US-​based pharmaceutical firm, a research
center, or a university. Under pressure from all sides, Roussel Uclaf decided they would
not market the medication themselves, but would negotiate giving the patent to market
RU 486 in the United States to the Population Council. Catherine Euvrard explained
why they chose the Population Council:

The idea was to give away the compound, but not to give to an organization which was not
reliable. We preferred not to give to somebody who was just interested in making money.
We knew the Population Council was not interested in making money, but was interested
in doing what was good for women. The Population Council had doctors and knowledge,
competence and experience to test new drugs, to do clinical trials, to register with the FDA.
The Population Council was a very reliable partner.172

The Population Council worked primarily in the global South, but reproductive health
advocate Francine Coeytaux and others convinced the organization to work on FDA
approval for RU 486. “We had to convince the board of directors of the Population
Council that it was okay for them to spend money and time on bringing [RU 486] to
the US because the mission of the Population Council was only to work for developing
countries,” said Coeytaux, who worked for the Population Council and was involved
with RHTP. According to Coeytaux, “The board of trustees said, ‘Our mission is to
work in developing countries. Why should we invest in the US?’ We were able to make
the case that if we are going to work in developing countries, we cannot go around
40 • Abortion Pills

advocating for a method that has not been approved by the US FDA. We have too
many historical examples of that not working out. So that’s how we convinced the
board of directors of the Population Council to do the work that allowed us to get to
the FDA.”173
The Population Council agreed to run clinical trials on RU 486, to apply for FDA
approval, and to find companies to manufacture and distribute the medication in the
United States. The Population Council’s director of reproductive health Dr. Beverly
Winikoff gave George Zeidenstein a lot of credit for this move: “The Population
Council put itself on the line. We had a very brave CEO, George Zeidenstein, who was
willing to bring this up to the board and advocate for being the agency that would take
it on for the US. He saw the importance of it and he was a person who stood up for
what he thought was right. He’s an unsung hero,” said Winikoff.174 Roussel Uclaf and
the Population Council began negotiations on the details to transfer the patent for the
US market.
On April 20, 1993, Dr. Kessler and Dr. Sakiz publicly announced that Roussel Uclaf
had made a verbal agreement with the Population Council of New York to supply two
thousand pills for testing and all of its research on the pill’s development.175 To put pres-
sure on Roussel Uclaf to move quickly with US clinical trials, Larry Lader and Eleanor
Smeal announced a strategy to remove Roussel Uclaf ’s patent on RU 486, using an exist-
ing law that allows Congress to remove patents on products not being marketed in the
United States. Lader also announced that the RU 486 compound had been replicated
by scientists in New York state. Then at a press conference sponsored by Physicians for
RU 486, Rep. Ron Wyden promised to hold a Congressional hearing on removing the
RU 486 patent from Roussel Uclaf if there was no agreement to commence US trials in
three months. In June 1993, when the anti-​abortion group Operation Rescue organized
a demonstration at the French embassy, FMF organized a counter-​protest that outnum-
bered RU 486 opponents by five to one. Meanwhile, the Institute of Medicine suggested
an expedited new drug application (NDA) be submitted to the FDA for the use of RU
486 as a method of early abortion and urged the FDA to consider the French research.
The FDA agreed to consider this research, but insisted on testing in the United States
as well.
In the meantime, FMF urged Hoechst AG and Roussel Uclaf to allow a US distribu-
tor to sell RU 486 until an American manufacturer was established and gained FDA
approval. Smeal sent a letter to Hoechst AG CEO Wolfgang Hilger urging the company
to permit the sale of RU 486 to the United States during the interim period. She also
sent another installment of 100,000 RU 486 petitions.176 When negotiations between
Roussel Uclaf and the Population Council stalled in October of 1993, FMF conducted
a “No More Delays” petition campaign to urge Hoechst AG to make RU 486 avail-
able for testing in the United States immediately. On the twentieth anniversary of Roe
v. Wade in January of 1994, FMF shipped another fifty thousand petitions to Hoechst
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 41

AG. Meanwhile, in February 1994, British doctors began offering abortion pills to US
women who could travel to Britain.177
When no agreement between Roussel Uclaf and the Population Council had been
reached for over a year, Shalala set a deadline of May 15, 1994. Rep. Wyden scheduled a
hearing on RU 486 for May 16. On that day, Roussel Uclaf announced they would trans-
fer the patent rights for medical uses of RU 486 in the Unites States to the nonprofit
Population Council, for free. The same day at congressional hearings on the transfer of
RU 486’s patent rights to the Population Council, a Roussel Uclaf representative testi-
fied about the importance of the Clinton administration’s efforts to their decision: “It
was only when President Clinton changed the government policy and specifically
asked Roussel to make the procedure available, here, that our client, out of respect
for the President of the United States, agreed to make every effort to comply with his
request.”178 In a private letter written to Eleanor Smeal two weeks later, Dr. Sakiz attrib-
uted this success to the persistence of the women’s movement. “It is mainly your own
determination and that of all the Feminist Majority Foundation’s members and other
pro-​choice supporters that largely contributed to this successful issue,” wrote Sakiz,
who by the time of the transfer had stepped down as CEO of Roussel Uclaf but still
served as chair of the Board of Supervisors.179 Smeal credited Sakiz: “He knew it would
save countless lives of women by reducing maternal mortality rates. If it was okayed
scientifically by the FDA, which has high standards, then people would realize it was
a safe medicine and it would be distributed around the world. He was trying to get an
important medical development to people in poverty who didn’t live in conditions that
a surgical abortion requires—​with sterilized equipment and clean water. A pill would
be safer and easier to administer.”180 After the transfer, since this drug would no longer
be licensed or developed in the United States by Roussel Uclaf, people no longer called
it RU 486, but instead referred to the medication by its scientific name, mifepristone.
Building on this progress, advocates kept up the pressure on Congress. In the
fall of 1995, RHTP conducted a briefing on medical abortion for legislative aides of
Congressmembers who supported abortion rights. Advocates also kept pressure up on
medical organizations to pass resolutions supporting the FDA approval of mifepris-
tone. In November of 1995, the family planning section of the American Public Health
Association passed a resolution supporting the expansion of options for early abortion.
In response to the announced transfer of patent rights, and after years of threatening
to boycott, abortion opponents launched a boycott against Roussel Uclaf and Hoechst.
Catherine Euvrard at Roussel Uclaf said she did not believe the boycott would work
because “American doctors prescribe drugs according to criteria which are rational,
and not emotional. I don’t believe for one minute that American doctors’ professional-
ism would allow them not to prescribe a drug that they know will help a sick patient.”181
A Hoechst Celanese spokesperson questioned the efficacy of a boycott strategy when
she said, “We’re an industrial company, so we do not sell consumer products. I don’t
42 • Abortion Pills

know how a consumer would tell.”182 Anti-​abortion groups nonetheless threatened to

pressure doctors not to prescribe Hoechst-​made medications.
Once they had the patent rights, the Population Council turned to conducting clini-
cal trials and finding a US manufacturer. Lawrence Lader of ARM offered to work with
the Population Council to produce and test abortion pills, but the Council declined the
offer. “Larry Lader was an impatient guy. He was like the schill in front of the carni-
val, getting people riled up,” said Beverly Winikoff. “The way he was managing was to
make it a public issue. The way the Pop Council was doing it was to make it quiet and
gentlemanly.”183 The Population Council’s clinical trials were funded by George Soros’s
Open Society Institute, the Kaiser Family Foundation, and the Buffett Foundation, as
well as the Council’s own resources. The Buffett Foundation made at least $2 million in
interest-​free loans to the Population Council used to conduct the clinical trials.184 The
Council immediately began trials of the drug with two thousand women at seventeen
sites in fifteen states, using the same protocol approved in France except that they tested
the medication through sixty-​three days rather than just forty-​nine days, which was
the timeframe used in France.185 One of the sites was the Brookline, Massachusetts,
Planned Parenthood clinic. In November, after the clinic made a public announcement
that it would be dispensing mifepristone, protesters began demonstrating outside the
clinic. The next month is when John Salvi shot and killed Shannon Lowney. After the
murder, the clinic stopped dispensing mifepristone.186
Meanwhile, advocates turned to another medication that could end a preg-
nancy: methotrexate. In July of 1995, RHTP convened a meeting in Washington, DC for
family planning and reproductive rights advocates to meet with scientists and doctors
working on methotrexate. The meeting included people from the National Institutes of
Health, FDA, Contraceptive Research and Development (CONRAD) Program, and pri-
vate industry.187 The following month, on August 31, 1995, Dr. Richard U. Hausknecht
published a study in The New England Journal of Medicine showing that the cancer
drug methotrexate combined with misoprostol was a highly effective and safe method
of abortion. Out of 178 women, 171 had a successful abortion after one dose of metho-
trexate and one dose of misoprostol—​a 96 percent success rate. There were no serious
side effects or complications for anyone.188 A wave of headlines and editorials expressed
hope that this combination of inexpensive medications would solve the abortion issue
and enable women to avoid anti-​abortion activists’ harassment outside of abortion clin-
ics, which had been virulent in the early 1990s. The Washington Post editorial board
argued, “intimidation loses its power when abortion drugs can be prescribed in any
doctor’s office and taken in the privacy of any home. These truly private actions afford
no opportunity for the kinds of pressure, harassment and in some cases violence now
used to deter women from entering abortion clinics and doctors from working in
them.”189 The New York Times editorial board announced, “in one swift technological
leap, women may be able to bypass the jeering pickets and potential violence that make
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 43

visits to abortion clinics such trying and dangerous experiences.”190 The Wall Street
Journal reported that Delta Science Research Foundation was trying to raise $6 million
to finance a large-​scale clinical trial.191 Another study in early September showed simi-
lar effective results.192 In March of 1996, researchers at the University of California, San
Francisco announced that they would be testing methotrexate as an abortifacient.193
Methotrexate eventually became a common treatment for ectopic pregnancies, but was
not used more widely for abortion. An early researcher on methotrexate and mifepris-
tone, Dr. Steve Eisinger at University of Rochester, later explained: “Methotrexate is a
cancer drug with some potential dangerous side effects and it doesn’t work as well as
mifepristone.”194 Nevertheless, in the mid-​1990s, the methotrexate studies put pressure
on the Population Council to move quickly with their mifepristone trials.
On March 18, 1996, the Population Council submitted an NDA to the FDA for
mifepristone combined with misoprostol as a method for early abortion based on
data from 2,500 French women and the promise they would submit data from 2,100
American women. By this time, there was research showing that a lower dose of
mifepristone was effective through sixty-​three days of pregnancy, but the Population
Council did not submit this research so as not to delay the approval process further.195
Advocates knew that clinical practice would follow the evidence so that physicians
could still prescribe the medication beyond forty-​nine days of pregnancy.196 On July
19, 1996, the FDA Advisory Committee on Reproductive Health Drugs held public
hearings on mifepristone safety and efficacy at which more than thirty people testified,
two-​thirds strongly in favor of making mifepristone available in the United States.197
The FDA took unusual security precautions for the all-​day meeting, stationing uni-
formed police officers at the entrances and requiring attendees to pass through metal
detectors. The FDA assembled people at a Washington, DC hotel and transported
them in vans to the hearing site.198 Cynthia Pearson at the National Women’s Health
Network remembered an anti-​abortion member of the committee who objected to
approving the medication. Referring to the committee’s task of weighing patient risks
and benefits, the anti-​abortion committee member said, “there is certainly no ben-
efit to her baby.” Pearson also remembered that one woman who supported abortion
rights was taken off the committee.199
Nevertheless, on July 19, 1996, the Committee recommended the FDA approve
mifepristone and misoprostol for abortions up to seven weeks gestation, but recom-
mended close medical supervision of mifepristone administration. Then on September
18, 1996, the FDA issued an “approvable letter” for mifepristone for early abortion, stat-
ing the combination of mifepristone and misoprostol was safe and effective when used
under close medical supervision, but noted that additional information was needed on
the manufacturing process and labeling before a final decision would be made.
Larry Lader became impatient to make mifepristone available to women right away,
so he devised a scheme: apply to conduct a clinical trial to test the mifepristone he had
44 • Abortion Pills

made inside the country. This plan got around the Bush administration’s import ban
still in place. Columbia University physician and researcher Carolyn Westhoff met with
Larry Lader and other researchers about his plan. “The studies were solely an excuse to be
able to distribute mife,” said Westhoff. “But there’s so much more we can learn. Let’s make
them real studies,” Westhoff told Lader, which they did. “We got an investigation new drug
approval from the FDA to do studies of this new molecule.” This research provided the first
evidence to support a lower dosage of mifepristone that became the modified treatment
protocol.200 Researchers also tested whether the medications were still effective if taken
closer together in time. Dr. Eric Schaff conducted research showing that the medications
were just as effective when taken twenty-​four hours apart as when taken forty-​eight hours
apart. Then Dr. Mitchell Creinin conducted research showing that an even shorter window
of time between taking mifepristone and misoprostol was effective in early pregnancy if
the misoprostol was taken vaginally. Dr. Creinin explained: “We did pilot studies looking
at a six to eight-​hour window. Can we do it in one day? It worked fine. Then I said, can
we go further? Let’s test the drugs at the same time and then allow people to make a free
choice of when they want to have their abortion. Do you want to have it two hours from the
time I see you in the office? Do you want to have it tomorrow? Do you want to have it in a
couple of days when the weekend comes?”201 As compared to oral or buccal administration
of mifepristone, vaginal use also had fewer side effects such as nausea and vomiting. Taken
buccally, the medications are most effective if taken twenty-​four hours apart.202
Meanwhile, with the support of ARM, researchers at the University of Rochester
obtained FDA approval in July 1996 to test mifepristone on two thousand women.
“It just kept dragging on the Pop Council side. So we felt that if we could test thou-
sands of women, that would show it was safe and effective. That would create a wave of
momentum that would be hard to stop at that point,” said Dr. David Horn of Columbia
University, who worked with Lader.203 Dr. Eric Schaff at the University of Rochester ran
the trials. Lader hoped to support the Population Council’s work, and speed it up.204 In
July 1997, ARM announced they had received funding from the John Merck Foundation
to expand the testing to ten thousand women. The research was conducted on women
in New York, Nebraska, Vermont, Montana, California, and Washington. Although the
Population Council held the US patent rights to RU 486, the FDA permitted others to
copy the patented drugs for research use so long as they were not sold commercially.205
ARM supplied researchers at the University of Rochester with mifepristone. “We got
from Larry all the mifepristone we could possibly use,” said Dr. Steven Eisinger, one of
the researchers leading the study along with Dr. Eric Schaff. “It came in bulk form—​
pounds and pounds of it. It was a powder. We had the Pharmacy Department at the
University of Rochester package it in capsules. They made sure the dosage was correct
and tested it for safety and purity.”206 The researchers tested a lower 200-​milligram dos-
age of mifepristone, which had fewer side effects, and allowed patients to take miso-
prostol vaginally at home, requiring only two doctor’s visits. The research, published
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 45

in 1999 and shared with the FDA, showed that mifepristone and misoprostol adminis-
tered in this fashion were safe and effective.207
In addition to obtaining FDA approval, the Population Council had to find a drug
company willing to manufacture and market the drug in the United States. Large drug
companies were wary of product liability lawsuits after the A.H. Robins Company had
to pay millions of dollars in compensation and punitive damages to women who were
harmed by the Dalkon Shield, an intrauterine contraceptive device (IUD) that caused
pelvic infection, infertility, unintended pregnancy, and death in the 1970s and early
1980s.208 US pharmaceutical drugs may have also been unable to obtain liability insur-
ance because of large damage awards to women claiming injury from contraceptive
drugs.209 The bottom line—​uncertainty about making a profit—​dissuaded many large,
for-​profit drug companies from taking on RU 486. Big drug companies were also the
target of threatened boycotts by anti-​abortion groups and pressure from conservative
investment funds. As a result, companies such as Teva, Merck, Abbott Laboratories,
Johnson & Johnson, and Upjohn declined to pursue the medication.210 “Pharmaceutical
companies abhor controversy unless they stand to make a great deal of money for their
trouble,” said Marie Bass of RHTP. “The profit potential for RU 486 was nowhere near
enough to make up for the headache a company would face. Major American compa-
nies wanted nothing to do with it.”211
In 1995, the Population Council entered into a contract with Gedeon Richter of
Hungary to manufacture mifepristone. They then sought another company to market
the medication in the United States. Of five companies submitting proposals to market
mifepristone, the Population Council selected a company named Advances in Health
Technology (AHT), headed by Joseph Pike, a lawyer with whom they had previously
worked on an IUD. On March 31, 1995, the Population Council transferred the exclu-
sive legal right to organize the manufacture and distribution of mifepristone in the
United States to AHT.212 Pike created Danco Laboratories to receive raw mifepristone
from the manufacturer and then package, market, and distribute the pills. AHT subli-
censed mifepristone to NeoGen Pharmaceuticals, also owned and controlled by Pike,
to test and market mifepristone for uses other than abortion. Danco received a $14 mil-
lion loan from the Packard Foundation in 1996 to bring mifepristone to market in
the United States.213 Pike also raised money from private investors, guaranteeing them
anonymity. He created a series of limited partnerships and companies in the Cayman
Islands, and raised $13 million from over four dozen investors, including from private
equity investors Greg Hawkins and Brad Daniel.214 But then one of his investors sued
him for breach of contract and fraud, alleging Pike had previously been disbarred in
North Carolina for falsely inflating the cost of a piece of property to two investors.
The Population Council then sued Pike for fraud.215 In a settlement, Pike sold all his
interests in Danco to Advances for Choice. Dutch attorney Jack Van Hulst became the
president and chief executive of Advances for Choice.216
46 • Abortion Pills

Meanwhile, Gedeon Richter backed out of its contract to manufacture mifepris-

tone in February 1997, further delaying the introduction of the drug. Finding a new
manufacturer was difficult because the anti-​abortion movement continued to threaten
boycotts. NRLC began a boycott of Hoechst’s antihistamine Allegra in April 1997,
after Roussel Uclaf and Hoechst agreed to grant the rights to mifepristone to Sakiz,
announcing the boycott in full-​page advertisements in USA Today and other publica-
tions.217 As a single-​product company, Danco was immune to anti-​abortion boycotts.
Anti-​abortion extremists also threatened to bomb manufacturers and distributors of
mifepristone.218 In June 1998, Danco announced they had found a manufacturer will-
ing to make the drug. Nevertheless, fearing anti-​abortion violence, the FDA and the
Population Council made the unprecedented decision to keep the manufacturer’s name
secret.219 The manufacturer was later revealed to be Shanghai Hua Lian Pharmaceutical
Co. Ltd., which was owned by the Chinese government. Despite the risks, researchers
continued to study mifepristone and published their results. In April 1998, The New
England Journal of Medicine publish a study showing that mifepristone in combination
with misoprostol terminated 92 percent of pregnancies when taken in the first forty-​
nine days of pregnancy.220
Opposition to FDA approval of mifepristone was strong. In 1998 and 1999, Rep.
Tom Coburn (R-​Okla.) led the charge to stop FDA approval of mifepristone, along
with two other Republicans, Reps. Chris Smith of New Jersey and Dave Weldon of
Florida. Conservative staffers formed the “Values Action Team” to coordinate efforts
to stop the approval.221 Coburn introduced an appropriations bill amendment to block
the approval of the drug by the FDA. FDA lawyers expressed concerns that the bill
would prevent the approval of medications such as methotrexate that could be used
to terminate pregnancy but also used to treat other conditions. After long debates, the
House voted to adopt the amendment in 1998 by a vote of 223 to 202, and again voted
for it in 1999 by a vote of 217 to 214, but the amendment died in a Senate committee.222
When Kessler left the FDA in 1998, conservative members of Congress grilled Clinton’s
nominee to head the FDA, Dr. Jane Henney, about mifepristone.
After research showed that mifepristone was effective in treating brain tumors
and providing palliative care for several forms of cancer, including breast and ovarian
cancer, the FDA agreed to allow use of the drug under a highly restrictive and hard-​
to-​access “compassionate use program,” where the FDA allowed patients to use medi-
cation for conditions for which it had not yet been approved. Roussel Uclaf and later
Sakiz’s company Exelgyn provided mifepristone to US patients under this program,
but in late 1998, Exelgyn decided they could no longer do this. After the Population
Council and Danco Group declined to take on the compassionate use program, the
FDA authorized FMF to assume sole responsibility for administering the mifepristone
compassionate use program for seriously ill patients in the United States in January
of 1999.223 Smeal explained how FMF ended up with that program: “They needed a
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 47

compassion use distributor, but nobody would do it. Catherine Euvrard and Jennifer
Jackman came up with the idea for the Feminist Majority to do it. They first came to me
and I said, ‘we’re not doctors!’ But before I knew it we were retaining a doctor.”224 FMF
hired Dr. Beth Jordan to administer the compassionate use program. But few doctors
and patients knew about this option and accessing the medication under this program
was very cumbersome. Physicians intending to administer mifepristone for any use
other than early abortion had to obtain an IND permit from the FDA, which they
granted only when patients had exhausted other treatment options and suffered from
serious diseases for which mifepristone showed some research promise as a treatment.
The physicians then had to apply to FMF for supplies of mifepristone for each patient.
FMF distributed mifepristone at cost to the patients’ physicians.
In the first two years, FMF provided mifepristone to seventy-​one patients—​fifty-​
three women and eighteen men—​for treatment of meningioma, leiomyosarcoma,
breast cancer, and Cushing syndrome.225 FMF president Eleanor Smeal explained why
the organization did this: “We thought that if people could see it was used for other ill-
nesses, they would start understanding that you can’t politicize the drug. Mifepristone
had more restrictions than some of the opioids that were really dangerous, which was
wrong. This pill can treat other diseases, most of which do not only affect women. We
need breakthroughs in the treatment of cancer. This is an antiprogestin. And some can-
cer cells are dependent on progesterone for growth. For us not to recognize that and not
to encourage research, that’s the politicization.”226 FMF later sponsored clinical trials on
use of mifepristone to treat ovarian cancer, with good results, but they couldn’t afford
to do the second round of trials and had to abandon the program.227
In February of 2000, the FDA issued a second “approvable” letter, but told the
Population Council that they would impose several extraordinary restrictions on mife-
pristone, including requiring physicians to be listed on a national registry, requiring the
use of ultrasounds to date pregnancies, and limiting prescription rights to licensed physi-
cians or doctors already performing aspiration abortion or those with hospital admitting
privileges.228 Many people believed that the FDA imposed these restrictions not because
of concerns about the safety of mifepristone, but because of the politically volatile context
and fear of violence. ACOG opposed these restrictions as unnecessarily burdensome on
patients and physicians.229 The Population Council also fought the restrictions.230 In June
of 2000, FMF launched an emergency campaign to urge the FDA to reject these unnec-
essary restrictions.231 Another obstacle to FDA approval was opposition by the manu-
facturer of misoprostol, Searle. Fearing controversy, the company lobbied hard to keep
misoprostol out of a medical abortion regimen at least until its patent ran out in July
2000.232 Then in August, as FDA approval was imminent, Searle issued a statement indi-
cating that its gastric ulcer treatment was contraindicated for use in pregnant women.233
After a long fight by anti-​abortion activists to block the drug from the US market, the
Clinton administration’s FDA finally approved mifepristone for use within the United
48 • Abortion Pills

States on September 28, 2000—​just before the 2000 presidential election. At the time, the
FDA refused to reveal the names of the manufacturer or the FDA employees involved in
approving the drug, citing fear of anti-​abortion violence. The threats were so serious the
agency had to increase security at its offices.234 Danco had an unlisted telephone number
and revealed only that their office was located in midtown Manhattan. At the time, The
Washington Post described the company as “one of the most enigmatic companies in the
pharmaceutical industry.”235 The company’s CEO was Roy Karnovsky, a former Merck
& Co marketing executive, and Dr. Richard Hausknecht was the part-​time medical
director. Hausknecht was an associate professor of obstetrics and gynecology at Mount
Sinai School of Medicine in New York, the medical director for Planned Parenthood of
New York City, and served on an advisory board for Planned Parenthood. Danco’s direc-
tor of public affairs was Heather M. O’Neill, who previously worked at the Population
Council. The Washington Post described the company as mission driven and dedicated
to making mifepristone available to American women.236
When the FDA approved mifepristone, they placed the medication under a regu-
latory restriction called subpart H. Under this restriction, the FDA prohibited retail
pharmacies from stocking and distributing mifepristone, instead requiring mifepris-
tone to be dispensed in an office, clinic, or hospital by a physician registered with the
drug manufacturer. The physician had to be capable of assessing the duration of preg-
nancy and to diagnose ectopic pregnancies. The FDA required patient access to a physi-
cian who was capable of administering a blood transfusion or doing a surgical abortion
due to the rare possibility of adverse reactions such as excessive bleeding or incomplete
abortion. Contrary to the scientific evidence demonstrating the safety of mifepristone,
the FDA required a black box warning on the package insert—​the strongest warning
that the FDA requires—​notifying consumers that medical studies indicated that the
drug carried a significant risk of serious or even life-​threatening adverse effects. The
FDA approved use of mifepristone for only the first seven weeks (or forty-​nine days)
after a patient’s last menstrual period, required patients to sign a patient agreement
form confirming that they had received counseling on the risks associated with the
medication, and required three office visits by the patient. The FDA required secure
manufacturing, receiving, and holding areas for the drug, and secure shipping proce-
dures, including tamper-​proof seals, controlled returns procedures, a tracking system
that could trace individual packages to a patient while maintaining patient confiden-
tiality, and the use of authorized distributors with the necessary expertise to handle
distribution requirements.237 The FDA’s medication abortion protocol required a 600-​
milligram dose of mifepristone dispensed to patients in clinic, then a 400-​microgram
oral dose of misoprostol administered in clinic forty-​eight hours later, and finally, a
follow-​up in-​clinic appointment to confirm the pregnancy had successfully ended.238
The FDA approved mifepristone under subpart two of subsection H so they could
place restrictions on the medication and require post-​ marketing surveillance to
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 49

establish that the safety results shown in clinical trials occurred in the much wider
population. Abortion rights supporters opposed these restrictions, and were frustrated
that the FDA insisted on them, but they were also eager to get the FDA to approve mife-
pristone before Republican George W. Bush became president in January of 2001.239
Ironically, abortion opponents would later claim the FDA used subpart H to speed up
approval of the drug and that therefore the approval was invalid. They also argued that
the Clinton administration fast-​tracked approval for mifepristone, causing the FDA
to ignore mifepristone’s risks to women—​arguments that would form the basis of the
legal case by the Alliance for Hippocratic Medicine, attempting to remove mifepristone
from the market after the Supreme Court overturned constitutional abortion rights in
2022.240 In fact, the process took many years, and the drug received considerably more
scrutiny than was typical.
The tense political climate at the time the drug was approved has led many to believe
that the FDA decision to place mifepristone under severe restrictions was the result of
political pressure and anti-​abortion threats of violence, rather than science.241 “It was
to pacify the right-​to-​life movement in our country,” said Eleanor Smeal.242 Beverly
Winikoff said FDA staff members were “frozen with fear.” She said the FDA typically
had detailed meeting minutes with participants’ names listed, but that they did not do
this for mifepristone for fear the names of staff members working on the application
would be revealed and they would be endangered.243 Winikoff described the precau-
tions taken by the FDA to protect people from anti-​abortion violence during an FDA
advisory board hearing on mifepristone in 1998: “We weren’t allowed to know where
it would be. We were assigned to go to a gathering place, and then we were loaded into
buses and then they took us there. It was all secret because they thought somebody
would throw a bomb in it. It was unbelievable how they were just so scared. Everyone
was scared.”244 Cynthia Pearson of the National Women’s Health Network agreed: “The
FDA’s visceral fear of violence on that day was emblematic of their fear of all kinds of
attacks. They had a specific fear around the day that they were going to be meeting
publicly to discuss it, but they also feared that they would be attacked by Congress and
take a lot of criticism for approving the abortion pill.” Asked whether she thought that
was why the FDA put mifepristone under so many restrictions, Pearson responded, “I
know it is,” citing conversations she later had with Dr. Philip Corfman, the Executive
Secretary of the Fertility and Internal Health Advisory Drugs Committee inside the
FDA.245 Pearson credited Corfman with guiding mifepristone “through a complex and
politically charged approval process.”246
But Kirsten Moore, who was at RHTP at the time and later worked to loosen FDA
restrictions, said the FDA restrictions on mifepristone had more to do with the con-
servative and bureaucratic nature of the FDA. “Everybody assumes there was political
pressure. I don’t think that’s the case here. They are bureaucrats. They get very conser-
vative and cautious. They aren’t regular abortion providers. This is an unknown world
50 • Abortion Pills

for them. They’re a little freaked out by it, and they’re like, ‘Oh, we have to put as many
belts and suspenders around this as we can because it’s abortion.’ It’s not a part of main-
stream health care. People don’t have experience doing it. They imagine the worst and
that’s what they then regulate against.”247 Amy Allina, who was at the National Women’s
Health Network at the time the FDA approved mifepristone, explained it this way: “The
entire process of bringing mifepristone to the United States was politically constrained.
There was no piece of it that happened without a high level of awareness that it was
politically fraught. It was the agency trying to stay out of the political line of fire.” Allina
said the FDA was as cautious as possible while “still getting to the outcome of approv-
ing a drug that clearly had a track record that merited approval.” She noted, however,
the outcome “reflects a failure on the part of our movement that we made them feel like
it was safer to go in that direction than to do what the data showed would have been
correct.”248 Allina also said that the restrictive design of the clinical trials gave the FDA
an excuse to approve the drug for use in the same way it had been provided in a clinical
trial, even though that’s not how drug approval normally works. “Normally they do a
clinical trial in very specific conditions, and then the drug is approved and it’s out there,
and it’s up to clinicians to provide it safely,” said Allina. “The FDA doesn’t regulate the
practice of medicine. But in this case, they put all of these belts and suspenders around
it to try to make sure that there was very little deviation.”249
In addition to the FDA restrictions, access was limited by the high price of mifepris-
tone. Roussel Uclaf gave the patent to the Population Council because they wanted a
nonprofit to distribute the medication at a cheap price so that it would be accessible to
poor women but Danco charged a high price for the medication—​initially over $100 a
pill. Smeal said she believed the Population Council gave the mifepristone patent to a
private company because they wanted a company with experience in making and dis-
tributing medications, but they couldn’t find a nonprofit that had this capacity. “They
felt that you needed somebody with experience of the private corporations and that’s
why I think they did it. But the price was kept high, and that was a very big disappoint-
ment to Sakiz,” said Smeal.250
In addition to approving mifepristone, the Clinton administration finally rescinded
the import alert on mifepristone in the fall of 2000. In November of that year, the first
shipments of mifepristone arrived in the United States from China and Danco began sell-
ing the medication. The Population Council subsequently transferred ownership of the
Mifeprex NDA to Danco. Led by FMF, ARM, and RHTP, women’s health advocates had
finally achieved their long-​fought-​for goal of FDA approval of mifepristone. Advocates
had worked hard to raise public awareness of abortion pills (see Figure 1.6), to mobilize
people to demand access to this important new medication, and to pressure drug manu-
facturers and the government to bring the medication to the American market.
Scholars have argued that the greater numbers of women in Congress and the exec-
utive branch after 1992 put mifepristone on the public agenda and drove approval of
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 51

Figure 1.6: Media references to RU 486 spiked in 2000. Based on Access World News database.

the drug. The 1991 Anita Hill and Clarence Thomas hearings mobilized women to
run for office and vote in higher numbers than ever, pushing women’s representation
in Congress to over 15 percent, a critical mass capable of rallying support from the
party’s leaders and moving issues onto the policy agenda. Female leaders in Congress,
such as Rep. Pat Schroeder, played an important role in advancing FDA approval of
mifepristone. By contrast, all of the leading opponents of FDA approval of mifepristone
in Congress were Republican men. Women’s groups also played a key role in the elec-
tion of Bill Clinton, which spurred him to appoint women to high-​level office, such as
Donna Shalala, who advanced the FDA’s approval of mifepristone.251
By the time the FDA approved mifepristone, many other countries in Europe had
already done so. In early 1997, Hoechst AG bought the remaining Roussel Uclaf stock,
then on April 8 announced the end of its manufacture and sale of Mifegyne, which
became its brand name for RU 486, and its transfer of worldwide patent rights for RU
486 to Dr. Sakiz, without remuneration. Sakiz, who had retired from Roussel Uclaf in
1993, formed a new company, Exelgyn, to develop and distribute RU 486 globally. By
1999, governments had approved mifepristone in Austria, Belgium, Denmark, Finland,
Germany, Greece, Luxembourg, the Netherlands, Spain, and Switzerland. Over the fol-
lowing decade, Exelgyn obtained approval for mifepristone in twenty-​eight other coun-
tries. In 2003, Dr. Beverly Winikoff formed an organization named Gynuity Health
Projects to work on increasing the availability of reproductive medications on the global
52 • Abortion Pills

market. In 2004, the World Health Organization approved mifepristone with misopros-
tol. By 2020, more than 90 countries had approved mifepristone. Many countries made
the medication much more accessible than the United States. For example, since 2017
Canada has permitted any physician or nurse practitioner to prescribe mifepristone
and any pharmacist to dispense it.252

Figure 1.7: In anticipation of FDA approval of mifepristone, The New York Times Magazine published a
cover story in July of 1999 with the headline, “This Pill Will Change Everything About Abortion.”
 Chapter 1: RU 486 Development and FDA Approval, 1980–2000 • 53

Back in the United States, the pro-​choice medical and political communities
hoped mifepristone would address the chronic shortage of abortion providers in many
places.253 Because medication abortion did not require surgical skills, they hoped that
primary care doctors would offer medication abortion integrated into their office
practices so access would increase and abortion opponents would not be able to target
and protest this service.254 In his 1991 book, Lader wrote: “The introduction of RU 486
into the United States could help solve this problem [of provider shortages]. If doctors
could give the pill in the privacy of their office, without the glare of publicity, abortion
would become as routine as the administration of an antibiotic.”255 In his 1995 book
he predicted, “If enough doctors administered the abortion pills from their offices, the
extremists would have trouble identifying them, invading the premises, or harassing
them with picket lines.”256
Advocates also pointed out how medication abortion had several advantages over
procedural abortion. No instruments enter the uterus, so there is no possibility of per-
foration of the uterus and little risk of infection. Also, there are no anesthesia-​related
complications because anesthesia is not used for medication abortion as it sometimes
is for suction abortion. Medication abortion was safer than procedural abortion, and
much safer than childbirth.257 Finally, mifepristone enabled women to obtain abortions
earlier in pregnancy. Physicians often waited until after eight weeks to perform proce-
dural abortions because before that time the embryo is so small that aspiration abor-
tion could fail or be incomplete.258 With FDA approval, advocates hoped abortion pills
would create greater access to early abortion in the United States.
In 1993, Time magazine had proclaimed on its cover that RU 486 was “The Pill That
Changes Everything.” Six years later, The New York Times Magazine cover still prom-
ised a revolution, declaring, “This Pill Will Change Everything About Abortion”259 (see
Figure 1.7). Hopes were high, but would the pill live up to these hopes? Reproductive
health advocates had their work cut out for them to make it happen.
 CHAPTER 2

“Thankful for Crumbs”:

The Fight to Expand Abortion
Pill Access, 2000–​2019

In the early days, we imagined that medication abortion was going to go into pri-
mary care. It was going to be family physicians and nurse practitioners who would
provide this care, not abortion clinics.
Tracy A. Weitz, Director for the Susan Thompson Buffett
Foundation and co-​founder and Director of the
Advancing New Standards in Reproductive Health

Abortion pill advocates had achieved a significant victory when the FDA approved
mifepristone for use in the United States in September 2000, but getting the pills
out to the women who needed them would prove to be an even more difficult task.
Not only did advocates for mifepristone have to deal with the onerous restrictions
placed on the medication by the FDA, but they had to negotiate with a conservative
and costly medical system. Despite mainstream medicine having largely abandoned
abortion care, which was offered mainly at specialized clinics, advocates hoped that a
wider range of clinicians would offer medication abortion to their patients. Advocates
organized efforts directed toward obstetrical and gynecological doctors, primary care
providers, and advanced practice clinicians, but multiple barriers—​including FDA
restrictions on the medication, abortion stigma, and fear of anti-​abortion harassment
and violence—​discouraged widespread availability of medication abortion for many
years. Most medication abortions came to be offered in the same places as procedural
abortions—​in dedicated abortion clinics from clinicians who were already provid-
ing procedural abortion. As a result, these medications did not in fact significantly
increase access to abortion, at least initially.1 A year after the FDA approved mifepris-
tone, the Kaiser Family Foundation reported that only 6 percent of gynecologists and
1 percent of general practice physicians reported that they had provided their patients
56 • Abortion Pills

with mifepristone.2 A decade later, only 1 percent of medication abortions were done
at private physicians’ offices; the rest were done at abortion clinics.3 Meanwhile,
Republican states passed an increasing number of abortion restrictions, making abor-
tion health care even more inaccessible and spurring activists to begin organizing to
support women who self-​induced their own abortions with medications. This chapter
traces how and why mifepristone access remained limited after the FDA approved the
drug, and how advocates fought to increase access, including persuading the FDA to
eventually lift some of its restrictions on mifepristone.
In the early 2000s, public health advocates worked hard to encourage a wide range of
clinicians to prescribe abortion pills, including not only doctors already offering proce-
dural abortion, but also gynecologists, family medicine doctors, and advanced practice
clinicians. The National Abortion Federation (NAF) and Planned Parenthood, funded
by private foundations, rolled out trainings for use of abortion pills and publicized
their availability.4 In 2001, the Center for Reproductive Health Research and Policy at
the University of California, San Francisco published a handbook with guidelines for
how to provide medical abortion.5 “We tried to push the least interventionist approach
to the provision of that care,” said Dr. Tracy Weitz, a co-​author of the handbook. For
example, the handbook said ultrasounds were not necessary. The handbook was dis-
tributed to all members of the American College of Obstetricians and Gynecologists.6
However by 2000, ultrasounds were commonly used for procedural abortions, so many
providers used them for medication abortion as well. Ultrasounds enabled providers to
date pregnancies to ensure patients were within the FDA-​approved gestational limit for
taking mifepristone, but they were used for bureaucratic reasons as well. “Ultrasound
had become standard practice in abortion clinics generally, not for safety reasons, but
for scheduling reasons—​to know exactly how far along somebody is so you can sched-
ule people much faster and easier,” said Weitz. “This is a way a clinic can manage its
patient population and not necessarily a clinically significant tool.”7 The perception that
ultrasounds were necessary for medication abortion contributed to some primary care
clinics declining to provide medication abortion because they did not have ultrasound
machines, which cost tens of thousands of dollars.
Abortion pill advocates also tried to encourage family care physicians to offer medi-
cation abortion. Even after the FDA approved medication abortion, very few fellowship
programs offered medication abortion training for family medicine doctors. Dr. Eric
Schaff had one at University of Rochester School of Medicine and so did Dr. Marji Gold
at Montefiore Medical Center of the University Hospital for Albert Einstein College
of Medicine in the Bronx. In 2004, Gold and others created RHEDI (Reproductive
Health Education in Family Medicine) to encourage the formation of programs to
train family medicine residents in reproductive health, with an emphasis on abortion.
“The theory of change was that institutionalized abortion training for family medicine
in residency programs would lead to advocacy inside institutions,” said Weitz. “Then
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 57

those professional advocates could change what is considered the standard of care or
the standard for the scope of practice. Then they will articulate abortion as part of
family practice and that will change malpractice carriers [to being willing to cover it].”8
Between 2006 and 2020, RHEDI faculty trained over two thousand residents in both
medication abortion and procedural abortion. Of those, 24 percent provided abortion
after residency, as compared to only 3 percent of comparable family physicians without
this training.9
But even if a family medicine doctor could get trained, they often faced barriers
to offering this care. Dr. Emily Godfrey, who trained with Dr. Schaff between 2000
and 2002, explained: “The FDA requirements made it so difficult for primary care to
offer medication abortion because you had to dispense it in your clinic. Your primary
care clinic had to be a pharmacy. There was no way around not telling your adminis-
tration that you’re going to be dispensing mifepristone from your clinic. That really
put the kibosh on it.” When Godfrey went to practice at the University of Illinois in
Chicago, she had to fight hard to be able to offer medication abortion. “It took meet-
ings with the pharmacy, and it took all sorts of time to make it happen. It was just so
hard. We’ve always been stretched. The fact that we can’t write a prescription for it the
way we do with every other medication is a huge impediment in primary care.”10 When
Godfrey tried to help others offer this care, she faced more barriers. “There were so
many bureaucratic barriers. I tried to help other family medicine clinics when I was in
Chicago between 2003 and 2010. Chicago is a progressive town. Family docs wanted to
offer this. I tried to help them, but sooner or later somebody up the line was somehow
a religiously affiliated hospital or program. You find out that there’s some agreement
that occurred in 1973 after Roe, and somebody signed something saying this hospital
will never do abortions.”11 Weitz explained, “there was never any real momentum to
change family medicine to incorporate abortion.”12 Columbia University physician and
researcher Carolyn Westhoff attributed these barriers to the corporatization of medical
practice: “When I started in medical practice 70 percent of doctors were self-​employed,
and 30 percent of doctors worked for some entity where they got a salary like me work-
ing for Columbia. But now those numbers have flipped and probably changes more
every day. In those larger entities, there’s going to be somebody who objects to abortion.
All kind of layers of administration have to agree with what I’m doing.”13
Another group, the Abortion Access Project (AAP) run by Susan Yanow, worked
in the early 2000s to recruit clinicians to offer medication abortion, particularly mid-​
level healthcare providers who were not physicians but who were qualified to perform
medical activities typically performed by a physician (later called advanced practice
providers). AAP identified states that allowed advanced practice clinicians to prescribe
medications, and then hired people to recruit providers to offer abortion pills. AAP
eventually had projects in seventeen states.14 AAP hired reproductive health advocate
Elisa Wells15 to do this work in Alaska, where she tried to recruit people to prescribe
58 • Abortion Pills

abortion pills. “It was so hard. I think I got one, or maybe two. Most of them were in
practice settings that wouldn’t allow them to do it,” said Wells. Some were at federally
qualified health centers restricted from offering abortion care by the Hyde Amendment.
Others were at religious organizations that blocked them from doing it. Even Planned
Parenthood wouldn’t do it initially, said Wells. “It was just really shocking how hard it
was to get people to see the potential of these pills.”16 Planned Parenthood eventually
added medication abortion when they opened a clinic in Fairbanks.
These efforts to expand access to medication abortion at a broad range of providers
were not successful. “By the time mifepristone got approved in the US, the complete
consolidation of abortion into clinics had happened, making it almost impossible for
it to be offered in any other place,” explained Weitz. “Planned Parenthood took advan-
tage of medication abortion and had a massive expansion of its abortion services into
their family planning clinics that had never done abortions. But that was the only place
where there was any diffusion of medication abortion into non-​abortion clinic set-
tings.”17 Even doctors working at abortion clinics were resistant to offering medication
abortion. Weitz explained: “Abortion providers didn’t like medication abortion. They
were like, ‘I can do an abortion procedure in a couple of minutes. Why in the world
would I do something that drags on for several days?’ ” Columbia University physician
Carolyn Westhoff, who described mifepristone as a “disruptive technology,” explained:

All the various abortion clinics and other abortion providers had a whole workflow set
up. Their business models were set up for doing procedural abortions. From the clinician
point of view, there’s really nothing to gain from doing medication abortion. You’ve got your
schedule. You see all your cases. You go home at the end of the day. Everybody’s taken care.
You know you’re gonna get paid. Mifepristone didn’t have a billing code for a long time.
I almost got in trouble for billing fraud because you couldn’t figure out how to bill mifepris-
tone because it didn’t have its own code.18

Westhoff also said that doctors didn’t want to stock an expensive medication in their
office without knowing when they would get paid back. Procedural abortion gave
physicians more control than medication abortion.
Research at the time showed that many clinicians had misconceptions about abor-
tion pills—​that they were complicated to prescribe, required extensive training and
sophisticated backup services, or that hemorrhage was a common risk, which it is
not. Others said there was no demand, although research showed that, given a choice,
more than half of women chose medication over procedural abortion.19 Clinicians
worried that medication was less reliable or acceptable to patients. Meanwhile, profes-
sional organizations in non-​reproductive health specialties did not provide guidance
about how to use this new technology.20 In 2003, Coeytaux, Moore, and Lillian Gelberg
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 59

published an article in Perspectives on Sexual and Reproductive Health explaining the

dilemma: “patients deserve to receive abortion care from their own provider, and medi-
cal abortion makes this feasible. However, neither US women nor their providers seem
to have grasped this possibility. Clients assume that their providers ‘do not do abor-
tions’ and therefore do not ask them for this method. As a result, providers are not
experiencing a demand for the service.”21 Coeytaux, Moore, and Gelberg made recom-
mendations for how to convince new medical providers to offer medication abortion,
including getting information to generalists, improving access to training for primary
care providers, and increasing demand. Otherwise, they warned, “we will have squan-
dered the opportunity this new technology offers us to increase access to safe abortion
for women everywhere.”22
Researchers and advocates later argued that FDA restrictions on mifepristone “set
the tone for widespread misperceptions about the complexity and safety of medica-
tion abortion.”23 The FDA imposed burdensome requirements to register with the drug
manufacturer and dispense the medications themselves, which many were not willing
to undertake. The FDA requirement that patients make multiple clinic visits increased
the cost and burdens of providing medication abortion as well. Some insurance com-
panies denied medical liability coverage to non-​specialists, or charged cost-​prohibitive
rates for this coverage.24 Many providers feared being labeled abortion providers and
becoming subject to protests and violence.25
Despite this situation, many reproductive health advocates did not object to the FDA’s
tight restrictions on the medication. Francine Coeytaux, who worked at the Population
Council at the time, explained: We said, “thank you very much FDA,” when they gave
us this horrible, horrible ruling. It’s partly because everybody had already been through
the wringer. We were thankful for crumbs. And then, over time, we forgot that we were
given crumbs. We forgot that it was politically motivated. We just all adapted to trying
to take advantage of what we were given.26 Winikoff, however, remembers it differ-
ently. She said they started immediately on research to support loosening restrictions
on mifepristone, acknowledging that the research often took years to complete so the
process was slow. “We were always working on peeling off the restrictions. Like peel-
ing a banana. One thing, then another thing.”27 Winikoff left the Population Council
in 2003 to form Gynuity Health Projects. “The person who assumed the presidency of
the Pop Council was scared of the work we were doing and didn’t want us to do it,” said
Winikoff.28
Opinion research from the early 2000s revealed strong public support for abortion
pills, bolstered by the fact that the medication was administered early in pregnancy.
But research also showed that opposition to the medication was related to fear that the
drug would “allow women to make hasty decisions about abortion without consult-
ing family and friends.” Researchers at the time suggested that “pro-​choice advocates
60 • Abortion Pills

should emphasize that RU 486 is prescribed after consultation with a doctor.”29 This
perspective, along with the election of anti-​abortion conservative George W. Bush, may
have fueled reproductive health advocates’ reluctance to challenge the in-​person dis-
tribution requirement for mifepristone in the 2000s. Bush appointed a strong abortion
opponent, former Wisconsin Governor Tommy G. Thomson, to replace Donna Shalala
as Secretary of Health and Human Services. Thomson promised to order a review of
the FDA’s approval of mifepristone.30 He also announced that the Hyde Amendment
restricting Medicaid funding for abortion applied to medication abortion and that state
abortion restrictions would apply to medication abortion, including waiting periods,
parental involvement laws, physician-​only laws, and targeted regulation of abortion
clinics, known as TRAP laws, which imposed expensive modifications to buildings and
the purchase of expensive and unnecessary medical equipment.31 These laws, combined
with burdensome FDA restrictions on mifepristone, meant that few doctors who were
not already offering abortion services could do so.
The application of the Hyde Amendment to medication abortion meant that
Indigenous women were not able to access abortion pills through the Indian Health
Service (IHS). The Hyde amendment did cover abortion for rape and incest, but the
medications were not made available at IHS. In a survey conducted by the Native
American Women’s Health Education Resource Center (NAWHERC) in 2002, only
5 percent of the IHS Service Units contacted performed abortion procedures at their
facilities and none of them had Mifeprex readily available for patient use.32 The Hyde
Amendment also blocked access to abortion pills for women serving in the US military
and those working for the federal government.
Some conservative states passed laws specifically restricting the use of medication
abortion. Michigan legislators, for example, passed a law prohibiting state-​mandated
abortion literature from including information about any procedure that uses a drug
not specifically approved for use in an abortion. The FDA had approved misoprostol,
the second drug used in medication abortions, as an ulcer drug and not as an aborti-
facient, so the law made medical abortion with misoprostol illegal.33 The Center for
Reproductive Rights (CRR) challenged the law and the state eventually settled the case,
allowing providers to create their own abortion literature if there was no state-​approved
literature.34 Abortion advocates focused most of their efforts on blocking or challenging
new laws restricting medication abortion access, but California passed a law to encour-
age further research into mifepristone as a treatment for purposes other than abortion.35
Meanwhile, activists pushed for increasing access on college campuses. FMF organized
a campaign called “Prescribe Choice” to increase abortion access on campus.36 In May
of 2001, the National Abortion Federation launched a $2 million public education cam-
paign on mifepristone, publishing ads in national magazines, including Self and People.
The ads offered information on mifepristone as well as directed readers to a toll-​free
hotline and website.37 Despite all of these efforts, the FDA restrictions on mifepristone
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 61

meant that few doctors provided medication abortion, which remained largely limited
to medical providers at abortion clinics, thereby not significantly increasing the num-
ber of places where women could access abortion.
Doctors’ resistance to offering medication abortion increased when, in the early
2000s, several cases of the extraordinarily rare but universally fatal clostridium sor-
dellii infection occurred in patients taking mifepristone and vaginal misoprostol.
In 2003, the FDA launched an inquiry into the possible role of mifepristone in the
death of a California woman, Holly Peterson. Concerned about how the FDA might
react, the National Women’s Health Network and the Public Citizen Health Research
Group wrote to the FDA in early 2004, reminding the agency of the strong safety
record of mifepristone.38 In 2005, the FDA issued a public health warning about
mifepristone/​misoprostol-​induced abortion and its association with C. sordellii-​
related deaths. In May of 2006, the CDC, FDA, and the National Institute of Allergy
and Infectious Diseases held a joint scientific gathering on the deaths of four women
after taking abortion medications. In response, Gynuity, Ipas, NAF, NWHN, and
RHTP pressed the agency to fully investigate the cases.39 Amy Allina, who was a
staff member at NWHN at the time, explained: “NWHN used its FDA policy and
public health expertise to hold agencies accountable for treating mifepristone fairly,
with rigorous regulation and without subjecting it to extra scrutiny or unneces-
sary restrictions driven by abortion politics.”40 Mifepristone likely did not cause the
clostridium sordellii infections, but these fatalities led to a shift away from vaginal
administration of misoprostol to oral administration, despite increased gastrointes-
tinal side effects.41
In the face of these headwinds, the use of medication for abortion as a percent-
age of all abortions increased slowly but steadily in the first seven years after the FDA
approved mifepristone, from 1 percent in 2000 to 13 percent in 2007, according to
the Centers for Disease Control data collection from thirty-​three states.42 Compared to
countries in Europe, however, the United States lagged significantly behind adoption
of medication abortion. In 2007, the percentage of all abortions done with medica-
tions was over 70 percent in Finland, 68 percent in Scotland, 58 percent in Switzerland,
50 percent in France, and 35 percent in England and Wales.43
Whereas in the early 2000s, few people knew about the abortion pills, by the 2010s,
many people knew about them and wanted to use them. Michelle Cohen, who worked
at abortion clinics in Mississippi and Texas between 2013 and 2018, spoke about what
she perceived to be the reasons people sought out abortion pills: “I think a lot of it was
their way of reconciling their guilt, their conscience, their fear, and the bullying from
the antis, that it wasn’t so much of an abortion if they took the pills versus getting a sur-
gical abortion. In conversations I had with patients, their whole thing was, ‘I just can’t
bring myself to have an abortion. It’s really not an abortion to me if I take this pill.’ ”44
Ironically, anti-​abortion propaganda conflating emergency contraception and abortion
62 • Abortion Pills

pills may have contributed to this attitude. “A lot of people were confused because to the
antis everything was abortion,” said Cohen.45
Medication abortion access, however, varied by state. Cohen said that it was easier
to get an appointment for medication abortion than surgical abortion in Mississippi,
but not in Texas, where the law required four appointments with the same doctor for
medication abortion, which was often difficult to schedule. “Where the pill was sup-
posed to be an easier, more convenient option, anti-​abortion policymakers in Texas
made getting abortion pills treacherous and so stressful,” said Cohen.46 Economics also
impacted decisions to use abortion pills, but in varying ways, according to Cohen:

Here in Mississippi, abortion pills were still more expensive than surgical, but it was more
convenient for providers. It was less time consuming to administer abortion pills than it
was to do the surgical procedure, so you could service more patients with the pill than you
can with surgical procedures. I love the reproductive rights movement, but we need to be
real. We need to be honest about what was going on in the world. Capitalism is its own little
monster, and so I think that may have been a force for some folks, the pressure to do the
pill rather than surgical. I heard that was what was going down in some places. There were
people who called me and told me that they were pressured, or they felt pressured, to take
the pill route versus the surgical. They wanted the surgical, but they felt like it was being
pushed on them to do the pills.47

Cohen’s comments demonstrate how abortion pill access varied by state and across
time, as did women’s motivations for using them, and how different factors—​including
state law, clinic conditions, and economics—​pressured women either to use abortion
pills or not use them.

FDA Risk Evaluation and Mitigation Strategy (REMS) and

Mifepristone Research
In September 2007, Congress passed the Food and Drug Administration Amendments
Act of 2007, expanding the authority of the FDA to review and regulate medica-
tions and medical devices. Among other things, the Act created a new drug safety
program called REMS, which allows the FDA to closely monitor medications con-
sidered to have serious safety concerns, in order to help ensure the benefits of the
medication outweigh its risks.48 A REMS requires four elements. First, a medication
guide or patient package insert to promote safe and effective use. Second, a com-
munication plan for healthcare providers, known as “Dear Healthcare Professional”
letters with additional information about the REMS, and other educational materi-
als directed toward the healthcare provider. Third, “elements to assure safe use” or
ETASU, which might include provider or pharmacy certifications requirements,
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 63

dispensing or administration information, patient monitoring, and/​or patient enroll-

ment into registries. Finally, the REMS requires an implementation system, which
includes how ETASU will be enacted, along with requirements for monitoring and
evaluating ETASU implementation by healthcare providers, pharmacists, and others.
In June 2011, the FDA established a REMS program for mifepristone, incorporating
the restrictions placed on the medication in 2000.49
Despite the REMS, medical research continued to show that mifepristone was safe
and effective. Many researchers focused on new approaches to increase access to mife-
pristone for abortion, hoping their results could improve treatment. At the time the
FDA approved mifepristone in 2000, research already showed that a lower dose of mife-
pristone was just as effective with fewer side effects, so many providers offered the
lower dosage off label,50 findings confirmed by later research.51 Danco charged $270
for the three-​tablet 600-​milligram mifepristone dose, so lowering the dose to a 200-​
milligram dose made the medication much more affordable. Research also showed
mifepristone was effective through sixty-​three days of pregnancy, so some clinicians
began offering medication abortion beyond the FDA’s recommended forty-​ nine-​
day limit. Subsequent research showed abortion pills were effective even later in
52

pregnancy—​through seventy days gestation53 and eventually seventy-​seven days.54 The

World Health Organization now says these medications can be used throughout preg-
nancy at different dosage levels.55
From the outset, most clinicians followed the science rather than the outdated FDA
label in treating their patients.56 By 2009, the off-​label use of a 200-​milligram dose of
mifepristone and an 800-​microgram dose of misoprostol through sixty-​three days was
routine in Great Britain, Sweden, and the United States, and endorsed in the guidelines
of ACOG and NAF, as well as the Royal College of Obstetricians and Gynecologists
and the World Health Organization.57 FDA labels often lag behind the science because
of the high cost of label changes for pharmaceutical companies. As a result, off-​label
use of medications—​allowing physicians to use their professional judgment in treating
patients—​is a common practice in the United States.58
Research showed that misoprostol taken one day after mifepristone was just as
effective as when the medications were taken two or three days apart.59 Clinicians ini-
tially administered both medications in person, so a shorter window between admin-
istration of mifepristone and misoprostol could expand the number of days of the
week clinicians could provide medication abortion to include Thursdays and Fridays.
Research also showed that women could safely self-​administer misoprostol at home,
which not only reduced the need for a second in-​clinic appointment but could reduce
the cost of medication abortion.60 This also gave women more flexibility for schedul-
ing an abortion and allowed them to take the medication in a location where they were
prepared for the cramping and bleeding, rather than experiencing these on their way
home from the doctor’s office.61 These findings were consistent with research from
64 • Abortion Pills

around the world showing women could successfully use abortion medications at
home on their own.62
Other research showed that misoprostol taken vaginally or buccally (absorbed in
the mouth between the cheek and gum) had fewer side effects, such as nausea and
vomiting, than if a patient swallowed the medication, because it allowed for a sustained
level of misoprostol in the blood rather than the quick peak that rapidly metabolized by
swallowing the medication.63 Research from abroad showed that doses of 50 milligrams
of mifepristone and 200 micrograms of misoprostol were effective in pregnancies of
less than thirty-​five days, with less vaginal bleeding and fewer side effects.64
Research on using telemedicine to prescribe abortion pills showed it could be done
in a manner that was highly acceptable to patients and providers.65 Other studies showed
that a wider range of medical providers than just doctors could safely offer medication
abortion66 and that pharmacies could safely dispense mifepristone.67 Advocates would
eventually use this research to ask the FDA to modify the REMS to increase access to
medication abortion.
Mifepristone became known as an abortion drug, but studies suggested other pos-
sible uses, including as a treatment for fibroid tumors—​non-​cancerous growths of the
uterus that often appear during childbearing years.68 This common condition, which
afflicts millions of women in the United States, causes heavy periods, severe pain, and
difficulty conceiving. In the early 2000s, researchers at the University of Rochester con-
ducted studies on the use of mifepristone to treat fibroids, using mifepristone they had
obtained from Larry Lader of ARM69 and later directly from Danco.70 Between 2003
and 2011, Dr. Eric Schaff, Dr. Steven Eisinger, Dr. Kevin Fiscella, and other researchers
at the University of Rochester published six peer-​reviewed articles showing mifepris-
tone was very effective for treating fibroids. The research was supported by grants from
the National Institutes of Health. Eisinger described what he observed when he first
gave mifepristone to women with fibroids: “Right away, it was obvious. It was a great
success. The fibroids shrunk. The bleeding stopped. Patients’ quality of life improved
dramatically. They felt better, had more energy, more color in their cheeks. They would
go about life with a lot more enthusiasm. The scores on quality of life were so dramati-
cally different that we actually considered the possibility that mifepristone was a mood
enhancer.” Before treatment, many of the patients were anemic due to heavy bleeding
from fibroids. “Their blood counts went up dramatically,” reported Dr. Eisinger, who
said as little as 2 milligrams of mifepristone daily was effective for reducing fibroids.71
According to Dr. Eisinger, fibroids have progesterone receptors that may contribute
to their growth. Mifepristone can block these receptors, which may be why the medi-
cation shrinks the fibroids. At the time, the only treatment for fibroids was surgery,
including hysterectomies.
Despite promising results, the researchers were not able to obtain funding to
continue the research. “Under normal circumstances, if you’ve got these kind of
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 65

results from a trial like this, you would do a phase three trial, and it would be funded
by a pharmaceutical company,” said Fiscella.72 Eisinger said Danco was interested and
supportive of the research: “Danco asked us what it would cost to do the ‘big’ study
that would allow FDA approval of mife for fibroids. After much number-​crunching we
told them $28 million. They offered us $300,000! It was all they had.”73 Fiscella said, “I
think it’s likely that they were not able to raise the capital.”74 Anti-​abortion politics as
well as violence and boycott threats may have discouraged any other pharmaceutical
company from co-​sponsoring the trials, said Fiscella. “I suspect the stigma of mife-
pristone probably made it a challenge to partner with other pharmaceuticals. Often
times you do that, co-​sponsor this. This wouldn’t have been a lot of money for some of
these giant pharmaceuticals. There was nothing else on the market. It was an impor-
tant niche. If it wasn’t mifepristone, I think it would have been a slam dunk.”75 Without
funding, they had to drop the research. “We wanted to sanitize the reputation of mife-
pristone,” Eisinger later said. “We wanted to make it harder for the anti-​abortionists
to demand banning the drug on the grounds that it was dangerous or something like
that. If we could find a useful non-​abortion application, that would be helpful.”76 No
one in the United States subsequently pursued research on mifepristone for the treat-
ment of fibroids, but researchers in other countries did, including India, China, Italy,
Japan, and Nigeria.77
The REMS meant that women could not access mifepristone for off-​label use to
treat fibroids either. Dr. Fiscella said women in the study begged him to continue the
treatment. “I had so many emails from the women in the study, who said, ‘How can
I get this medication after the trial?’ Over and over again, we had to say, ‘We’re sorry.
The drug is highly restricted to pregnancy termination. It’s not available in the United
States.’ That’s all we could say,” said Fiscella. “The women were very disappointed.”78
According to Dr. Fiscella, the research was strong enough to support prescribing the
medication off label to treat fibroids, but that was not possible because the FDA blocked
pharmacies from dispensing mifepristone—​including compounding pharmacies that
could make pills in the appropriate dosage to treat fibroids. The medication only came
in 200-​milligram capsules, but the fibroids dosage was 5 milligrams. “If mifepristone
were prescribed like any other medication, if it didn’t have all of these REMS restric-
tions, compounding pharmacies would have been happy to put it into powder and cre-
ate capsules for 5-​milligram doses and give them to patients under a doctor’s order.
That would have made a lot of women happy.”79
Some research has also suggested that mifepristone could be helpful for treating
endometriosis, where tissue that normally lines the inside of the uterus—​called the
endometrium—​grows outside the uterus.80 Endometriosis afflicts an estimated 10 per-
cent of reproductive-​age women. Common treatments include laparoscopic surgery—​
involving the cutting and removing of endometrial tissue or destroying it with a
laser beam or electric current—​and hysterectomies. Mifepristone could have been a
66 • Abortion Pills

non-​surgical alternative for treating endometriosis with the potential to reduce unnec-
essary hysterectomies. But the FDA REMS restrictions limited research and use of the
medication to treat endometriosis. Other research indicated that mifepristone could be
effective in treating depression, including postpartum depression, which affects one in
nine new mothers each year,81 and treating Gulf War illness,82 which increases risk of
heart disease, stroke, and type 2 diabetes.83 Some evidence also indicated mifepristone
could be an effective form of contraception and was an emergency contraceptive.84 Yet,
despite mifepristone’s promise to provide women with health-​enhancing treatments,
the FDA restrictions stymied the development of the medication for these uses. “Most
new applications of existing drugs are discovered and even developed by physicians
using drugs off-​label, but that path is not easily accessible because of the REMS,” said
Francine Coeytaux.85
Physicians at Stanford Medical School, however, were able to conduct research on
use of mifepristone to treat Cushing syndrome. Cushing syndrome is when a benign
tumor causes the pituitary gland to make too much of a hormone (called adrenocor-
ticotropic hormone or ACTH) that stimulates the production and release of cortisol
from the adrenal glands. The adrenal glands help control heart rate, blood pressure,
and other important body functions. Excess cortisol causes problems with the body’s
hormone balance and leads to high blood sugar in patients with Cushing syndrome. As
a hormone receptor blocker, mifepristone blocks the absorption of cortisol to restore
hormonal balance. In 2012, the FDA approved mifepristone for adult patients with
Cushing syndrome who have type 2 diabetes or glucose intolerance and have failed sur-
gery or are not candidates for surgery. The Silicon Valley-​based drug company Corcept
Therapeutics began marketing mifepristone as the medication Korlym to control high
blood sugar in patients with Cushing syndrome.86 In 2018, they were charging $550
for one 300-​milligram tablet of mifepristone.87 Korlym was not subject to a REMS or
in-​person distribution, despite the fact that it was taken daily in higher doses than the
single 200-​milligram dose of Mifeprex. As Policy Advocacy Director at the National
Women’s Health Network Sarah Christopherson later noted, “the risk to making mife-
pristone widely available for abortion has nothing to do with health and everything to
do with politics.”88

Self-​Induced Abortion?
The election of Barack Obama in 2008, and the surge of the rightwing Tea Party move-
ment, led to a wave of abortion restrictions in conservative states. In 2011, in the
run up to the 2012 presidential elections, conservative states passed a record num-
ber of abortion restrictions: ninety-​two new restrictions on access to abortion ser-
vices in twenty-​four states, shattering the previous record of thirty-​four restrictions
set in 2005.89 These restrictions included abortion bans, waiting periods, ultrasound
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 67

requirements, insurance coverage bans, targeted regulations of abortion providers,

and prohibitions on telemedicine abortion. Although early gestation bans were unen-
forceable under Roe v. Wade, high numbers of abortion restrictions continued to pass
in subsequent years (see Figure 2.1).
In light of these growing restrictions, reproductive health advocates began to
research and organize around “self-​induced abortion.”90 They initially focused on the
use of misoprostol alone for abortion. The use of prostaglandins for inducing abor-
tion was discovered in the 1960s by Dr. Marc Bydgeman at the Karolinska Institutet
in the Netherlands. Misoprostol for abortion was first widely used in the late 1980s
by women in Brazil, where abortion was severely restricted. In 1986, Brazil approved
Cytotec—​the brand name for misoprostol—​for treatment of ulcers. When women
discovered that misoprostol caused abortion, they requested it from pharmacies
for this purpose. Gynecologists and obstetricians supported this use because of the
reduction of morbidity and mortality due to illegal and unsafe abortion, often done
by the introduction of caustic substances into the uterus or use of knitting needles

Figure 2.1: US states passed an accelerating number of abortion restrictions after the election of
President Barack Obama in 2008 (courtesy of Guttmacher).230
68 • Abortion Pills

to dislodge a pregnancy. In response, and under pressure from the Catholic church,
the Brazilian government began to restrict Cytotec in the early 1990s.91 Nevertheless,
knowledge about misoprostol spread across Latin America and around the globe.92 In
November of 1990, women’s rights activists from across Latin America met in Argentina
to share the knowledge about misoprostol for medical abortions. Delegates from the
United States attended.93 Shortly after, reports circulated of self-​induced abortion with
misoprostol in immigrant communities in the United States, including a cross-​sectional
study published in 2000 of 610 women from the Dominican Republic in New York City
showing that 37 percent (225) admitted familiarity with the use of misoprostol as an
abortifacient and 5 percent (29) reported personal use of misoprostol.94 By 1999, miso-
prostol was available in over sixty countries worldwide for as little as thirty-​five cents
per 200-​microgram tablet.95
Reproductive health advocate Susan Yanow at the Abortion Access Project (later
named Provide) read this research and also heard about people using misoprostol to self-​
induce abortion in the United States. “I knew that people were getting pills in bodegas in
East Boston. I was curious about it. I wanted to learn more, so we had several meetings,”
said Yanow, who was also involved with the international organization Women on Waves.
Founded by a Dutch physician named Rebecca Gomperts, Women on Waves provided
abortion pills to women living in countries where abortion was illegal by sailing to the
international waters near these nations and transporting women out to the ships.96 The
Abortion Access Project convened a Misoprostol Alone Working Group between 2004
and 2010, which included Ibis Reproductive Health, Gynuity Health Projects, National
Latina Institute for Reproductive Health, and later, the Center for Reproductive Rights.
The Working Group sparked several research projects, developed talking points, and
began to raise awareness about self-​induced abortion in the United States. The Working
Group also discussed whether it was ethical to recommend self-​induced abortion with
misoprostol given it was not considered the “gold standard”—​that is, clinic-​based medi-
cal care with mifepristone and misoprostol.97 Ibis Reproductive Health and the Office of
Population Health at Princeton University developed a website, www.med​icat​iona​bort​
ion.com, in the early 2000s, providing information on three early abortion regimens,
including misoprostol alone, in multiple languages. People from 208 countries used the
website, but over one-​third of visitors to the website in 2009 were from the United States
and Mexico. Google search trends also revealed an increasing number of searches for
“Cytotec,” the brand name for misoprostol, from people in the United States over this
period.98 Meanwhile, research on misoprostol alone showed high levels of effectiveness.
In 2007, a systematic review of published research found that the efficacy of misoprostol
alone ranged from 84 to 96 percent.99
In several states, police and prosecutors charged women with crimes for using
medications to self-​induce abortions. In 2004, South Carolina authorities arrested a
twenty-​two-​year-​old undocumented migrant farmworker, Gabriella Flores, for taking
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 69

misoprostol sent to her by her sister in Mexico to end a sixteen-​week pregnancy. At

the time, misoprostol was widely available from pharmacies in Latin America.100
Prosecutors initially charged her with murder. Flores spent four months in jail before
the charges against her were reduced to violating a ban on “illegal abortions.”101 Then
in early 2007, authorities in Massachusetts arrested a teenaged immigrant woman,
Amber Abreu, for using misoprostol she had obtained from her sister in the Dominican
Republic. Abreu was indicted for procuring a miscarriage.102
In response to these cases, the organization Provide commissioned the CRR to con-
duct legal research on laws in Illinois, New York, South Carolina, and Texas that could
be used against people who self-​induce an abortion. CRR identified a wide range of state
and federal, civil and criminal laws that could be used to target women self-​inducing
abortion. In response, Gynuity and the RHTP co-​hosted a meeting in New York City in
August 2009 to examine the legal issues related to women’s use of misoprostol outside
of the formal medical system.103 The meeting convened twenty-​three medical provid-
ers, lawyers, women’s health advocates, researchers, and policymakers. The meeting
generated creative strategies to reduce the possibility of criminal prosecution of women
who self-​induce an abortion, including educating the legal and medical communities,
the media, and women themselves, as well as legislative and policy advocacy.104 In addi-
tion to educating people about the use of misoprostol, Winikoff said she hoped the dis-
cussion of using misoprostol alone for abortion would put pressure on Danco to reduce
the price of mifepristone: “if people know there’s a competing thing, even if it’s not
quite as good, at some price point, you begin to lose people.”105 A 2010 study revealed
that between 6 and 12 percent of pregnant women surveyed in clinic waiting rooms in
Boston, San Francisco, New York, and a city in Texas had tried to self-​induce abortion,
with higher rates in cities along the United States–​Mexico border.106
Between 2009 and 2011 with grant funding, Yanow conducted trainings on miso-
prostol in the Rio Grande Valley of Texas. She created a manual about how people were
safely using misoprostol for self-​induced abortion. She trained over seventy people,
from young clinic defense activists to people from abortion funds, and then she trained
another forty community health workers (promotoras). She also conducted research
on follow-​up care for people self-​inducing abortions.107 In the following years, Yanow
worked to educate the reproductive health and rights communities about self-​induced
abortion, presenting at professional conferences, such as the NAF annual meeting,
as well as training a wide range of groups about self-​induced abortion, including the
National Network of Abortion Funds. “My goal was to bring our movement to the rec-
ognition that what we then called self-​induced abortion was potentially a revolutionary
method of ensuring reproductive justice,” said Yanow.108 Research published in 2010
based on surveys of 9,493 patients at 95 facilities reported that 1.2 percent of women
obtaining abortion reported having ever used misoprostol on their own to “bring back”
their period or end a pregnancy and 1.4 percent reported using other substances, such
70 • Abortion Pills

as vitamin C or herbs.109 Reports of criminalization also indicated the growing preva-

lence of self-​induced abortion. In 2012, a Pennsylvania mother Jennifer Whalen was
criminally prosecuted for ordering abortion pills online for her 16-​year-​old daughter,
who used them in the early weeks of unplanned pregnancy. She could not afford to take
her daughter to the nearest clinic, seventy-​five miles away. Whalen was sentenced to
nine to eighteen months in jail.110
Despite the risk of criminalization, increasing abortion restrictions generated further
organizing on self-​induced abortion. In June of 2013, Texas Republicans introduced a bill
that would have shut down most of the abortion clinics in the state. Rep. Wendy Davis
staged a thirteen-​hour filibuster to block the bill from passage. During her filibuster,
President Barack Obama tweeted his support, intensifying interest and support. A live
stream of the filibuster on YouTube attracted more than 150,000 viewers.111 A similar bill
later passed, leading to the closure of more than half the clinics in the state.
At the time, immigrant women were obtaining misoprostol within their communi-
ties, said Diana Lugo-​Martinez, who was Senior Director of Community Engagement
Programs at the National Latina Institute for Reproductive Justice between 2013 and
2017. Undocumented women in the Rio Grande Valley who could not afford abortion
health care in the United States and could not travel across the border to obtain abor-
tion pills in Mexico because of their immigration status were able to buy misoprostol in
community flea markets. Lugo-​Martinez explained:

It was a matter of on some levels access and on some levels, community practice. We had a
tradition of community healing cultures. There might not necessarily be a culture of access-
ing care from doctors. For example, part of my family is from Puerto Rico and given the
devastating impact of sterilization and experimentation on our communities, folks did not
trust doctors. So you find other avenues of care. In the Dominican Republic, they had the
community health care worker model that comes from the developing world because folks
could not make it to the one town that has the hospital.112

In the news coverage about the Texas legislation, The New York Times quoted a com-
munity educator at the National Latina Institute for Reproductive Health saying, “The
only option left for many women will be to go get those pills at a flea market. Some of
them will end up in the E.R.”113 Diana Lugo-​Martinez, who was at the National Latina
Institute of Reproductive Health at the time, believed this led to Immigration and
Customs Enforcement (ICE) raids on the community. “When you shine a spotlight
on a particular community, a particular access point for that community, so that more
people are aware, there’s a detrimental impact on our most marginalized communi-
ties,” said Lugo-​Martinez.114
The new Texas law led Susan Yanow and Marlene Gerber Fried to convene a secretive
meeting in Texas in October 2013 to discuss the future of abortion access. Sponsored by
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 71

the Civil Liberties and Public Policy Program at Hampshire College, the meeting was
organized to offer support to people on the front lines in Texas. It included providers,
activists, and people from abortion funds from Texas and South Dakota, where advo-
cates were also facing draconian restrictions. “We felt like we needed to have a conver-
sation that was inside the family about what things people can do, what people need
support for, what people were prepared to do, and what were the limits of the law,” said
Fried. “It was a moment where medical abortion was not well accepted and certainly
not self-​managed medical abortion. I think it shifted people’s thinking about what was
possible. I feel like we were softening the ground within a movement where you would
have thought this ground would already be softened, but it wasn’t yet.”115
Two months later, on December 4, 2013, advocates with backgrounds in the global
women’s health movement organized a meeting in Washington, DC, to share what they
knew about the self-​use of pills to safely end an unwanted pregnancy. The organizers
of the meeting were Francine Coeytaux, who was at the Public Health Institute; Leila
Hessini of the global reproductive health organization Ipas; and Amy Allina and Kate
Ryan of NWHN. The meeting brought together twenty-​nine advocates, researchers,
and community-​based activists from ten US states and the Netherlands to the offices
of the Association of Reproductive Health Professionals for a “strategic conversation
about how to ensure that women in the US have the information, resources, and sup-
port they need to use abortion pills safely.”116
At the meeting, advocates discussed the history of self-​induced abortion, lessons
from other countries, and organizing around misoprostol in the United States. They
discussed the research on self-​induction in the United States,117 gaps in research, and
areas for future research. Participants brainstormed about what to call self-​induced
abortion so as to be informative but not stigmatizing, and debated whether miso-
prostol alone was substandard care compared to the mifepristone/​misoprostol regi-
men.118 They then discussed internet sources for misoprostol, including Women on
Web—​a website selling abortion pills to women in 102 countries where safe abor-
tion services were not available. Despite not serving the United States, the website
had recently experienced a dramatic increase in searches and questions from peo-
ple in the United States. Wells presented the findings from “Surfing for Abortion,”
a report on research about the availability of abortion pills on the internet. The
report recommended improving access to online information about misoprostol as
a harm reduction strategy. Harm reduction strategies work to lessen the negative
consequences associated with criminalized behaviors, such as needle and syringe
programs for drug users or condoms for sex workers. In the context of abortion,
this would include identifying reliable sources for misoprostol and informing peo-
ple about the legal implications of self-​inducing abortion in the United States.119
Lynn Paltrow of National Advocates for Pregnant Women presented information on
arrests of women self-​inducing abortions.
72 • Abortion Pills

Participants then shared ideas for future action. They discussed how to publicize
information on self-​induced abortion without causing a crackdown on availability
of medications or prosecution of women who use abortion pills. They brainstormed
about advance prescriptions for misoprostol and adding the medication to collabora-
tive practice agreements with pharmacies. They discussed using a train-​the-​trainer
model to educate people about self-​induced abortion and organizing a “red tent net-
work” for women to support each other through the process. On the legal front, they
proposed developing a network of attorneys to represent women arrested for self-​
inducing abortion and a legal defense fund to defend them. They also discussed the
need for educating healthcare providers on what self-​induction looks like and how
to provide follow-​up care.120 Many of these ideas would become a reality in subse-
quent years.
The next year, Coeytaux and Wells intensified their efforts to find ways to increase
access to abortion pills. Wells said she was inspired to do this work when she read
a study published by Coeytaux and others at the Public Health Institute and Ipas on
community-​based organizations sharing misoprostol information in two countries
with restrictive abortion laws, Kenya and Tanzania. Twenty-​eight community groups
were given small grants to disseminate information on the correct use of misoprostol
for both postpartum hemorrhaging and abortion, and they were connected to pharma-
cies selling misoprostol. The groups developed numerous creative strategies to reach
diverse audiences and ensure access to misoprostol pills. The groups attributed their
success to having addressed the use of misoprostol for both indications and to using
a harm reduction approach to frame their advocacy. The study concluded that “even
where abortion is legally restricted and socially stigmatized, community-​based orga-
nizations can publicly and openly share information about misoprostol and refer it to
women by using innovative and effective strategies, without political backlash,” and
that communities were eager for this information.121
After reading this study, Wells called up Coeytaux and said to her, “This is the most
exciting thing I’ve seen in years. Why can’t we do something like this in the US?!”122
That led to the formation of Plan C. A student working with them, Victoria Nichols,
came up with the name Plan C. Whereas Plan B prevented pregnancy, mifepristone
and misoprostol were something you could take when Plan B didn’t work. “We pur-
posely chose a name that didn’t automatically equate with abortion to leave open the
possibility of menstrual regulation and period pills,” said Wells.123 Plan C would work
to raise awareness about abortion pills, recruit more US providers to offer medication
abortion, and inform people about affordable access to abortion pills from abroad. The
organization would come to play an important role in increasing access to abortion pills
through telemedicine and online suppliers as states tightened restrictions on medical
providers in the United States, especially after the Supreme Court reversed constitu-
tional abortion rights in June of 2022.
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 73

In their work to increase access to abortion pills, Coeytaux and Wells drew upon
experience they shared in their years-​long campaign to increase awareness and accep-
tance of emergency contraception, create a dedicated emergency contraception prod-
uct (later called Plan B), and win FDA over-the-counter approval for it. In advocating
for abortion pills, they would draw on successful strategies they had used in the emer-
gency contraception campaign, including a major, ongoing media campaign to raise
public awareness, working directly with healthcare providers to educate and reassure
them, developing public-​and private-​sector collaborations, obtaining funding to
achieve their goals, conducting a large-​scale demonstration project, obtaining ACOG
support and FDA approval, and making access easier through advance prescription as
well as phone and pharmacy prescription. In these ways, advocates successfully moved
emergency contraception “from secret to shelf.”124 A report by Coeytaux and two other
advocates explained their strategy:

The overarching reason for the success to date is that activists began with what was intrin-
sically a very good idea and then were able to collaborate on multiple fronts to overcome
blockages and carry the idea to fruition. To bring the method to market required activists
to set the snowball rolling and keep it rolling forward. It took a combination of women’s
advocates, providers, entrepreneurs, legal and regulatory fighters and the foundation world,
working together from all different angles and willing to take risks.125

They highlighted an important lesson learned: “We learned that our fears—​fears of
opposition and backlash—​may have held back advances unnecessarily. Many of the
activists were nervous or afraid of what the anti-​choice movement would do and some
admit having let fear influence their willingness to move forward.” They summed it
up: “Be Bold. Give women the information and let them decide.”126 The FDA eventu-
ally moved emergency contraception over the counter. Coeytaux and Wells used this
extremely successful blueprint in their fight to increase abortion pill access.
Coeytaux and Wells were further inspired to work on increasing access to abortion
pills when they were in Ethiopia in 2014, conducting research on treating postnatal
hemorrhage with misoprostol. They knew that pharmacies sold abortion pills, so they
tried to buy some. Wells explained what happened next:

We sent our female colleague in and said, “See if you can get abortion pills.” She came out
five or ten minutes later and she had a pack. They cost six or seven dollars. Well, we were
standing there together just in awe. The pharmacists gave her a few instructions about how
to use it, which was good, and then we saw it was a DKT127 brand so we knew it was a good
product. We were standing there on the street of this little city, saying, “How is it that in this
resource-​poor country that is really stretched for health care and resources, that this product
could be available, whereas in our country it’s not available in this way?” It was basically over
74 • Abortion Pills

the counter, or a little bit behind the counter because they had to talk to the pharmacist to
get it. That was really the genesis of the idea to move forward and to do more.128

In the United States at the time, abortion pills were available only from certified doc-
tors, who usually charged between $500 and $700 for them and required multiple
in-​person appointments. “The discrepancy between what I knew was possible and
what was happening here in the US motivated me to found Plan C,” said Coeytaux.129
“Everywhere else you can get these mailed to you. Why can’t we?”130 The first dedi-
cated product containing both mifepristone and misoprostol pills called Medabon had
launched in Nepal in 2007 and was registered in forty countries by 2016, but a dedi-
cated product was not available in the United States.131
In 2015, Coeytaux, along with Leila Hessini of Ipas and Amy Allina of NWHN,
published a paper calling for “bold action to meet women’s needs: putting abortion
pills in U.S. women’s hands.”132 They made two proposals: first, eliminate the FDA’s
medically unsupported restrictions on access to mifepristone and, second, promote
the off-​label use of misoprostol alone. Coeytaux and her colleagues asked, “Why are
we not telling women about this safe and effective method?” They argued:

We realize just how audacious our proposal is. However, women are paying the price for
our current timidity. We believe it is time to use this potentially game-​changing technol-
ogy to facilitate women’s agency and autonomy, reduce barriers to care, and improve health
outcomes. And maybe, just maybe, by putting these pills in women’s hands, we can help to
reframe the way people think about abortion—​toward a process managed by and controlled
by women.133

But many women’s health advocates resisted these proposals. Some argued misoprostol
alone lowered the standard of care. Coeytaux, Hessini, and Alina countered by noting
the insurmountable barriers to accessing mifepristone experienced by many US women.
To those concerned about health risks of misoprostol alone, they noted the likelihood
of being harmed by misoprostol was very low and easily mitigated. They acknowledged
some legal risk, especially in restrictive states, but noted that off-​label use was both legal
and common in the United States, making a parallel to off-​label use of birth control
pills as emergency contraception before the FDA approved Plan B. Through Plan C,
Coeytaux hoped to help the United States catch up with the rest of the world:

Because of these REMS, we were left behind the rest of the world. We continued to think that
it was okay and we didn’t double check. That’s what the idea for Plan C was: to bring back the
evidence to the US and force all of us in the US to recognize that we had put our blinders on
and we moved forward. We did the best we could with the blinders that we had. Then it was
time to take off the blinders.134
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 75

But Coeytaux faced an uphill battle convincing people in the reproductive rights
movement to take these bold steps. When she met with a coalition of state-​based
law centers, the reactions were mixed. “Within our group of state-​based law centers,
there was a span of opinions, from really risk-​averse people, to the people who were
saying, ‘Great, let’s make this happen,’ ” said Jenifer McKenna, the executive direc-
tor of the Alliance: State Advocates for Women’s Rights & Gender Equality. “There
were people who were worried that Francine was putting too much information on
the website, that she was putting the people involved at risk. People who were more
attached to institutional and clinical expertise were concerned that the legal land-
scape was too uncertain.”135
In mid-​2015, the RHTP commissioned Coeytaux and Wells to write a research-​
based white paper on how to apply the lessons learned from emergency contraception
to “create new paths to abortion care.”136 Released in July 2016, the white paper focused
on “self-​induced abortion” using misoprostol alone, which they described as a “power-
ful tool for expanding access to abortion care options.” Drawing on harm-​reduction
models and self-​help frameworks, Coeytaux and Wells suggested misoprostol for early
abortion “may be the new ‘best kept secret’ ” and called this method a “potentially game-​
changing technology for women’s health.”137 The RHTP white paper, called “The Tale
of Two Methods,” compared emergency contraception to misoprostol, describing the
key similarities and differences. Coeytaux and Wells noted that the medications were
similar in that they were both easy to use, prescribed off label, and required medical
providers to “let go of control of the product.” Off-​label use, which posed liability con-
cerns, required educating clinicians about how to prescribe the medications off label.
They were both viewed as a second-​tier choice—​neither had pharmaceutical company
interest and both were seen as associated with sexual irresponsibility and stigma. The
white paper also explained the key differences between emergency contraception and
misoprostol for abortion. The different challenges were legal restrictions on abortion
and the complexity of the regimens and need for follow-​up care. Other differences pro-
vided new opportunities, including new communication platforms (e.g. the internet
and social media); new dispensing options, including online websites that sell pills and
telehealth services; women already leading the way on misoprostol use for abortion;
and new allies, including the robust reproductive justice movement.
In conclusion, Coeytaux and Wells made several recommendations. First, they rec-
ommended supporting women’s self-​care with misoprostol by raising awareness about
the option through public education campaigns, providing access to reliable and legiti­
mate medical and legal information about misoprostol, and facilitating self-​access to
the medication by sharing information about sources of supply, identifying and verify-
ing online services that ship misoprostol to the United States, and establishing alter-
native supply mechanisms such as pill banks. Their second recommendation was to
facilitate access to misoprostol through the medical community, including advance
76 • Abortion Pills

prescription, pharmacy access, and telemedicine. Finally, they recommended pursuing

the development of a dedicated product packaged for abortion use.138 In their conclu-
sion, Coeytaux and Wells summed up their approach:

We believe achieving meaningful access to medication abortion will necessitate a radically

different approach, one that acknowledges that given adequate information and access to
a product, women can use the method safely and effectively without intervention from a
healthcare provider. In this approach, providers and advocates must see themselves as sup-
porters of women rather than providers of services. Although this paradigm shift to give
women the means to care for their own reproductive health will likely unsettle some provid-
ers and regulators, it has already been proven feasible by women around the world.139

These recommendations went too far for many reproductive healthcare provid-
ers and advocates, but became the blueprint for Plan C’s approach to mifepristone
and misoprostol.
As the reality of self-​induced abortion became clearer, many advocates had increas-
ing concerns about the legal implications. In 2015, the Center on Reproductive Rights
and Justice at Berkeley Law School sponsored the formation of the Self-​Induced
Abortion (SIA) Legal Team, a consortium of organizations with the goal of “using law
and policy tools to ensure people throughout the U.S. can end their own pregnancies
outside of the formal healthcare system with dignity, safe from the threat of arrest for
themselves or anyone who assists them.”140 The SIA Legal Team advocated for expand-
ing access to reliable information about abortion medications, halting the criminaliza-
tion of people self-​inducing abortions, improving self-​help or community-​based access
to abortion medications, and building legal support for people self-​inducing abortions.
The same year, two reproductive justice activists, Pamela Merritt and Erin Matson,
formed Reproaction, a “left-​flank culture change organization” working to increase
access to abortion and advance reproductive justice through “strategic communica-
tions, opposition research and community organizing,” including non-​violent direct
action.141 “We knew then, in 2015, that medication abortion was going to be key,” said
Merritt, “that it was a liberating reality that Europe had been experiencing for many,
many years, and that Americans should have access to. The anti-​abortion movement
was terrified because you can’t stop medication abortion. The entire region of South
America and Central America proved that medication abortion is wonderful and as
liberating, in my view, as the vote. It takes the power away from the healthcare industry,
away from providers, and away from legislators, and puts it in the hands of the pregnant
person. It is a liberation tool.”142 Reproaction worked to educate the public as well as
legislators, policymakers, activists, and progressive people about self-​managed abor-
tion with pills and the World Health Organization protocol for abortion pills. Susan
Yanow trained Reproaction staff to share information about self-​induced abortion, and
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 77

the organization shared this information at community meetings and house parties in
Missouri, Illinois, Arkansas, and elsewhere. Merritt explained:

We had organizers on the ground who would contact an individual who had a network of
friends. They would organize the food and beverages and open up their home. I did one
training in a Union office. I did one in a sex-​positive coffee shop. The only thing we were
making sure was that the people who were coming to the house party were properly vetted
so that we could ensure safety. We were well trained in how to talk about self-​managed abor-
tion with pills as information sharing rather than advice.143

In this way, Reproaction prepared for the impending fall of Roe v. Wade. Merritt
later joined Medical Students for Reproductive Choice, which worked to train medi-
cal students in abortion in over thirty countries, including countries where abortion
was illegal.
In 2015, RHTP brought together several organizations to discuss self-​induced abor-
tion, including the SIA Legal Team, the National Institute for Reproductive Health,
Vision First, Reproaction, and Physicians for Reproductive Health. Coeytaux and Wells
presented a paper on strategies used to increase access to emergency contraceptive pills
and how these strategies could be used to expand access to misoprostol.144 At the meet-
ing, they decided to recruit a broader, more diverse range of organizations to partici-
pate in the conversations. Amy Allina, who coordinated the meetings, explained:

Our instinct, which has since been proven correct, was that people who face the greatest barriers
to care are going to be among the most likely to self-​manage. We know now that people self-​
manage both as a proactive choice, because it’s what they want, and because they face barriers
to care. But still those communities where the barriers are greatest have a higher prevalence of
self-​managing. But then the other reason was that we knew the big risk with self-​managed abor-
tion was criminalization and we knew who was most likely to be criminalized. One of the things
that made people hesitate to talk about self-​managed abortion—​to shine a light on it as a path to
ending pregnancy—​was a fear of increasing the risk of criminalization. None of those organiza-
tions wanted to be out there doing that without having visible vocal leadership from communi-
ties that are at greatest risk for criminalization across the board for any pregnancy outcome.145

Therefore, they reached out to organizations representing women of color, immigrant

women, and low-​income and poor women, and recruited several organizations to par-
ticipate, including the National Latina Institute for Reproductive Health, Advocates for
Youth, the National Network of Abortion Funds, the National Asian Pacific American
Women’s Forum, and the independent abortion provider Whole Woman’s Health. This
group later became the “Generative Learning Community” (GLC) for “self-​managed
abortion,” as they decided to call it. Many thought the label “self-​induced” was too
medical, while “self-​managed” had a sense of personal empowerment.146 This group
78 • Abortion Pills

focused on, as Allina described, “working to shift the public conversation and the
public narrative about self-​managed abortion, instead of talking about it as a danger-
ous way to end a pregnancy and as a negative outcome of restrictions on clinical care,
to having people understand it as an act of defiance and something that can be per-
fectly safe, effective, and supported as something that can be done in community.”147
The risk of criminalization, however, loomed. In May 2016, a 40-​year-​old web devel-
oper named Ursula Wing launched a website selling abortion pills. Years before, Wing
had purchased abortion pills online from abroad and used them herself. In 2012, after
she wrote about her experience on her blog, Macrobiotic Stoner, she received responses
from many women requesting information about how she did it, which inspired Wing
to start her business. She ordered the medications from India and created a web page
called “My Secret Bodega,” where she sold mifepristone and misoprostol for $85 with
expedited shipping, billing her customers for jewelry. She mailed inexpensive jewelry
in a shipping envelope with a packet of pills taped behind a hidden panel. The return
address read “Fatima’s Bead Basket.” In 2017, when Plan C evaluated eleven websites
selling abortion pills, Wing’s website performed the best. When Plan C published their
results, Wing’s weekly orders spiked from just a few to sixty a week. During two years
in business, Wing served thousands of customers across the country.148
But then in February 2018, a Wisconsin man named Jeffrey Smith was arrested for
allegedly giving his pregnant partner mifepristone he had purchased from Wing. The
FDA learned about Wing and began an investigation. In June 2018, the FBI showed
up with a search warrant at Wing’s apartment. She was accused of supplying abortion-​
inducing pills without a prescription to customers in the United States. Wing was
unrepentant: “I want some copycats,” said Wing in an April 2019 Mother Jones article.
“There’s not enough people doing this.”149 Wing eventually pled guilty to conspiracy to
defraud various US governmental agencies. In July 2020, a Wisconsin federal judge sen-
tenced her to a two-​year term of probation and a fine of $10,000. She also had to forfeit
$61,753, which was the cost of the pills she sold.150 Wing’s case, however, did not dis-
courage other people from establishing similar abortion pill businesses in subsequent
years as increasingly burdensome legal restrictions on abortion drove many people to
seek alternative avenues to obtain abortion pills outside of the formal medical system.

Campaign to Remove FDA Restrictions

While some advocates worked to develop support for self-​managed abortion, other
advocates worked to lift FDA restrictions on mifepristone in response to anti-​
abortion efforts to use the FDA restrictions to limit access to abortion pills. Research
had shown that a lower, 200-​milligram dosage of mifepristone was just as effective
as the higher 600-​milligram dose, and it had fewer side effects,151 so clinicians used
the lower dose off label. Updating FDA labels can take a long time and cost drug
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 79

makers many millions of dollars, so off-​label use of drugs is common and accepted.152
Abortion opponents, however, called for state laws prohibiting off-​label use of mife-
pristone by penalizing physicians who did not follow the FDA label, hoping to dis-
courage the use of medication abortion.153 Ohio, for example, passed a law in 2010
requiring abortion providers to use the FDA dosage level for medication abortion,
which resulted in the need for more medical interventions to complete abortions,
more side effects, higher costs for abortion, and an 80 percent decline in medication
abortion in Ohio between 2010 and 2014.154 Research revealed the Ohio law was
associated with reduced access among women who were younger, Black, less edu-
cated, and in lower socioeconomic groups.155 This situation led advocates to press for
revisions to the FDA label for mifepristone.
In 2015, Winikoff convened the Coalition to Improve Access to Mifepristone in the
United States, which held regular meetings of reproductive health researchers, pro-
viders, and advocates in New York City to discuss mifepristone access. This group
included Planned Parenthood, NAF, NARAL, and others. Concerned about conserva-
tive attacks on medical providers who offered 200-​milligram doses of mifepristone
off label, they urged the drug manufacturer Danco to petition the FDA to modify the
Mifeprex label. Danco said they didn’t have the funds to file a supplemental NDA to
make the change, which could cost millions. In response, reproductive health advo-
cates agreed to help Danco raise foundation money to support making the application.
At Coalition meetings, Coeytaux tried to persuade the Coalition to require Danco to
push for the full elimination of the REMS rather than just a modification of the label,
but the Coalition members supported Danco’s plan to request more limited changes.
Francine Coeytaux explained:

It suited everybody. The Coalition members didn’t have problems with the REMS. They
didn’t have a problem with the restrictions. They were the people who already had a great
agreement with Danco. They loved the special relationship they had with the FDA. The
need to change the REMS was not recognized. They were happy with leaving the REMS in
place and just asking for modifications. It was shocking, but not totally surprising. But it was
maddening and disappointing. I felt like when I looked around the room, everybody else
was very much defending the fact that we still needed the REMS, and feeling like we should
be thankful for what we had.156

Dr. Beverly Winikoff, on the other hand, defended an incremental approach:

We were always incremental in our approach because IRBs [Institutional Review Boards that
approve research projects] wouldn’t even touch it if you got too far out ahead of practice. You
have to do it incrementally for two reasons. One, it’s wise not to change a lot of things all at
the same time because if things go bad, then you don’t know which to attribute it to. But also,
80 • Abortion Pills

the more different things you do, the more somebody is gonna find something bad about it.
So one by one by one is a little bit easier, but it takes more time.157

Winikoff also said that Danco did not want to ask the FDA to remove the REMS. “I
think the REMS may have had some commercial advantage for Danco. And with-
out Danco being on board, we couldn’t do it,” said Winikoff.158 Kirsten Moore of the
EMAA (Expanding Medication Abortion Access) Project also believed Danco did not
want the REMS removed, which she attributed to concern about market competition.
She argued that the burdensome REMS restrictions discouraged other companies
from developing a generic medication that would compete with Danco’s brand name
medication.159 Not until 2019 did the FDA approve a generic mifepristone, marketed
by the company GenBioPro, founded by abortion pill advocates. Dr. Carolyn Westhoff
agreed: “Danco silently dragged their feet on the REMS issue because it would have
paved the way for GenBioPro to bring their generic to the market.”160 Cynthia Pearson
of NWHN suggested that the Obama administration’s refusal to make Plan B emer-
gency contraception fully over the counter may have made people believe the FDA
would be unlikely to remove the REMS on mifepristone. “There was some realism to
the desire to scale back our ask because we can’t win the whole thing,” said Pearson,
noting that Obama had bargained away abortion funding for Washington, DC, during
budget negotiations with Republican leader John Boehner.161 Dr. Carolyn Westhoff
agreed that the Obama administration was not hospitable to advances in reproductive
health: “Obama was not very good on reproductive health in general. He had some
deeply conservative views on reproductive issues. He wanted to see things restricted.
That’s how he came across, because at every single opportunity, he traded away repro-
ductive rights.”162
Contrary to the claims of many activists, however, a medical consultant with Danco,
Dr. Mitchell Creinin, argued that Danco did want to remove the REMS. “Danco fought
hard to remove the REMS multiple times, but the FDA made it really clear throughout
the whole process the REMS was not going away,” said Creinin.163 He attributed the
FDA’s refusal to remove the REMS to the political pressure they were under. Creinin
explained:

The FDA is a government agency and answers to Congress. As an agency, they have to say,
“What are we gonna do in a balance here to make ourselves functional?” Do they want to
create something where they are spending so much time and effort dealing with the reper-
cussions of a decision? Or do they want to have the time and effort to approve other drugs?
Taking away the REMS would mean constant inquiry from all the Republicans in Congress.
You know the amount of work and effort it’s going to take for them to constantly deal with
this battle? Danco is not a bad player. Danco fought tooth and nail to get rid of the REMS.
The FDA is not a bad player because the FDA is trying to say, “Look, we have all this business
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 81

to do.” If we’ve gotta deal with all of these Congressional inquiries and all these other prob-
lems that are gonna arise from this, what’s the best balance here? It doesn’t mean that they’re
doing wrong by people. They’re just trying to find a middle ground so that everything can
move forward.164

Creinin argued the FDA worked hard to increase access to mifepristone despite
extreme political constraints.
In May of 2015, Danco submitted a supplemental NDA to the FDA to obtain
approval to alter the Mifeprex indication, dosing regimen, and labeling to reflect an
updated, evidence-​based prescription regimen. Danco proposed decreasing the mife-
pristone dosage to 200 milligrams, increasing the gestational age limit up to which the
medication could be taken to sixty-​three days, eliminating the requirement that the
dose of misoprostol be administered in a medical facility, removing the requirement of
an in-​person follow-​up appointment, and expanding who could prescribe mifepristone
beyond physicians. But they did not challenge several restrictions that were part of the
REMS, including the provider certification requirement and the in-​person distribution
requirement for mifepristone.165
Nevertheless, individual members of the Coalition pushed for full removal of
the REMS. In November 2015, twelve leading researchers and four organizations—​
including the National Public Health Association, NAF, Ibis, and Gynuity—​submitted a
letter to the FDA asking the agency to change the label in three respects: 1) the location
where the patient should take mifepristone should not be restricted; 2) an in-​person
visit should not be mandated for follow-​up assessment; and 3) any licensed healthcare
provider—​not just physicians—​should be able to prescribe the drug. They also asked
for the elimination or substantial modification of the REMS, including the in-​person
distribution requirement, the provider certification requirement, and the patient agree-
ment form. Finally, they asked for an extension of the gestational age limit for medical
abortion to seventy days. ACOG submitted a separate letter making the same request.
Then in February 2015, thirty policy, advocacy, social science, research, and academic
organizations submitted a letter to the FDA asking them to lift the REMS.166 Winikoff,
Westhoff, and other researchers also decided to publish a special issue of the journal
Contraception with the latest research to support removal of the REMS, which they did
in the fall of 2015.167
In March 2016, during the last year of the Obama administration, the FDA issued a
new REMS for mifepristone and updated the mifepristone label, modifying the dosage
protocol to 200 milligrams of mifepristone followed twenty-​four to forty-​eight hours
later with an 800-​microgram dose of misoprostol taken buccally. The FDA extended
the recommended duration for use of the medications to ten weeks (seventy days after
the last menstrual period). The FDA also eliminated the requirement that the dose of
misoprostol be administered in a medical facility and allowed a remote follow-​up visit,
82 • Abortion Pills

reducing the required number of visits from three to one. The FDA replaced the term
“physician” with “healthcare provider,” opening the door for nurses, nurse midwives,
and physician’s assistants to dispense the medication. Finally, the FDA eliminated
the requirement that prescribers report all nonfatal serious adverse events.168 Kirsten
Moore gave the FDA credit for many of these changes: “Danco has said it fought the
REMS, but people from the FDA said Danco was dragging its feet in the whole process
and it was the FDA that took the initiative of changing the label. Danco sent in data to
go through nine weeks, and FDA said, actually, we’re going to go through ten weeks. It
was the FDA that said, we’re going to change ‘doctor’ to ‘licensed healthcare provider,’
and we’re going to remove from the label the requirement that patients take the drug
in clinic.”169 The FDA, however, refused to eliminate the patient agreement form that
FDA experts had determined was duplicative of standard informed consent practices
and recommended removing, but the FDA commissioner at the time, Robert Califf,
overruled the recommendation. “For the commissioner to be involved in the granular
details of a REMS, even down to the inclusion of an agreement form, and for the head
of CDER [Center for Drug Evaluation and Research—​the entity within FDA that tra-
ditionally has the final say] to openly acknowledge it, was a shocking break from the
norm—​and almost certainly represents the tip of the iceberg of political interference,”
said advocates at NWHN.170
Also in 2016, the FDA granted a research exception to the REMS for Gynuity Health
Projects to study telemedicine abortion. The study, called TelAbortion, began in four
states: New York, Hawaii, Oregon, and Maine. TelAbortion involved all the same steps
and procedures as an in-​person medical abortion, but the patient did not have to travel
to an abortion clinic. Under this study, the FDA allowed clinicians participating in the
study to provide medication abortion care by videoconference and mail without an in-​
person visit to the abortion provider. In order to receive care, the patient had to be in
one of the study states during the videoconference, and had to have a mailing address
in that state so the provider could mail the medications. The patient had screening tests
as needed with nearby healthcare providers, then a videoconference with the abortion
provider. If the patient was eligible for medication abortion, the provider then sent mife-
pristone and misoprostol with instructions by mail. Follow-​up was done remotely by
phone with local or home tests. Preliminary results of the study, published in September
of 2019, showed that the direct-​to-​patient telemedicine abortion service was safe, effec-
tive, efficient, and satisfactory.171 The TelAbortion study eventually expanded to nine
more states, including Washington, New Mexico, Colorado, Georgia, Iowa, Minnesota,
Illinois, Maryland, and Montana. Many physicians, however, were resistant to telemed-
icine abortion. “Such a big idea is so scary,” said Dr. Carolyn Westhoff. “I think it took
many of us a whole lot of experience to start feeling comfortable with telemedicine
abortion. This was something that was so new. So we were all too conservative in the
beginning. One of the first little steps was saying, ‘we can be flexible about when you
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 83

take the misoprostol. You can take the miso at home. You know you don’t need to come
for so many visits.’ Gradually, gradually we demedicalized it.”172
While the FDA changes in the mifepristone label opened the door to less burden-
some restrictions, the agency left the REMS in place, including the provider certifica-
tion and in-​person distribution requirements. Despite the ongoing FDA restrictions
on mifepristone, the use of medication abortion increased steadily over time. The
Guttmacher Institute reported that 17 percent of all recorded abortions in 2008 were
done with medications, 24 percent in 2011, 31 percent in 2014, and 39 percent in 2017
(60 percent of abortions performed within up to ten weeks gestation). By 2020, the
percentage of medication abortions overall had risen to 53 percent of all recorded abor-
tions (see Figure 2.2).173
In the summer of 2016, the Supreme Court released a five to three decision strength-
ening abortion rights. In Whole Woman’s Health v. Hellerstedt, the Court considered two
provisions of a Texas law, one requiring that physicians who performed abortions have
admitting privileges at a nearby hospital, and another requiring abortion clinics in the
state to have facilities comparable to an ambulatory surgical center. A majority of the
Court ruled that these requirements placed a substantial obstacle in the path of women

Figure 2.2: The percentage of medication abortions of all abortions in the United States between 2000
and 2020 (courtesy of Guttmacher).231
84 • Abortion Pills

seeking an abortion, constituting an undue burden on abortion access, and therefore

violated the Constitution. The majority ruled that courts must “consider the burdens a
law imposes on abortion access together with the benefits those laws confer,” and that
courts retained “an independent constitutional duty to review factual findings where
constitutional rights are at stake.” They ruled that an uncritical deference to legislative
factual findings was inappropriate. This decision created a strong new rule to challenge
state laws restricting abortion based on dubious claims that the restrictions protected
women’s health. Abortion rights supporters planned to use this decision to challenge
the increasing number of state restrictions on abortion, from mandatory waiting peri-
ods to ultrasound requirements and other measures that burdened abortion access with
no clear medical benefit and, in some cases, medical detriments.
Things were looking up for abortion rights advocates, but then a seismic political
shift changed their fortunes: the election of Donald Trump for president. During
his campaign, Trump had pledged to nominate anti-​abortion people to the Supreme
Court, and sure enough, over his four years in office, Trump appointed three people
who held strong anti-​abortion views—​Neil Gorsuch, Brett Kavanaugh, and Amy Coney
Barrett—​shifting the balance of power on the Court from a five to four pro-​choice
majority to a six to three anti-​abortion supermajority. The need for abortion pills
became more urgent than ever.

Political Shifts and Movement Mobilization

The same month the Hellerstedt decision came down, Plan C launched a new website
sharing information about self-​managed abortion, including how people were obtain-
ing abortion pills online. Researchers at Plan C began testing websites selling abortion
pills to evaluate the reliability of their services. They then teamed up with Gynuity
Health Projects to expand the research. They submitted the pills they purchased to
lab testing to measure the amount and quality of the medications. In 2017, Plan C and
Gynuity Health published a study of eighteen online abortion pill vendors. The study
concluded that ordering abortion pills online was simple, affordable, and safe. The
cost of the pills, including shipping, averaged about $235 for an “abortion kit” contain-
ing both mifepristone and misoprostol. Buying misoprostol (Cytotec) alone was less
expensive. The websites allowed standard mechanisms for payment, including credit
cards, money wires via Western Union, and bank transfers from platforms such as
Transferwise, Bitcoin, or PayPal. All of the mifepristone pills ordered contained the
expected amount of mifepristone and all of the misoprostol pills contained misopro-
stol.174 Plan C shared the results of this research as a “Report Card” on their website,
providing detailed information about product costs, ship times, and service reliabil-
ity. Plan C continued to test new online sellers of abortion pills and then update the
information on their website, helping people to find reliable sources for abortion pills.
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 85

As Plan C began receiving media attention, mainstream reproductive health orga-

nizations distanced themselves from the organization, believing what Plan C was doing
was illegal. Plan C’s fiscal sponsor, Oakland-​based Public Health Institute, dropped
them so they had to find a new fiscal sponsor, which became NWHN.175 Foundations,
too, refused to fund them and even the Generative Learning Community refused to
include them.176
Two days before the 2016 presidential election, Plan C co-​directors Elisa Wells
and Francine Coeytaux laid out their vision in an article, “Mail-​Order Abortion: The
Future is NOW,” published on the reproductive rights news website Rewire News. They
pointed out how women in dozens of countries around the world were using services
such as Women on Web, Women Help Women, and safe2choose for online consulta-
tions and express delivery of highly effective and safe early abortion pills directly to
their homes, all without a physical exam. But none of these organizations offered ser-
vices in the United States because they feared the virulent US anti-​abortion movement
might shut them down. “What is needed is for the medical field to fully relinquish
control of the method, thereby empowering women to manage their own care should
they choose to do so,” said Wells and Coeytaux. They explained how they were work-
ing to inform women about this option and identify individual providers who would
“champion women’s self-​use of abortion pills and be willing to pilot approaches that put
the pills more directly into women’s hands.”177
In addition to supporting self-​managed abortion, reproductive health advocates
continued to press the FDA to remove the REMS restrictions by challenging the FDA
restrictions in court, lobbying the FDA to remove the restrictions, and reinterpreting
the REMS restrictions to allow the mailing of abortion pills. In 2017, the Reproductive
Freedom Project of the American Civil Liberties Union (ACLU) sued the FDA in the
case of Chelius v. Azar, seeking the removal of the REMS restrictions on mifepristone.
In the complaint, brought on behalf of providers and patients in Hawaii, the ACLU
argued that the REMS violated women’s rights to liberty, privacy, and equal protection
as guaranteed by the Constitution by imposing significant burdens on abortion access
without proof of a valid medical justification.178
Reproductive rights advocates also pressured the FDA directly to release mifepris-
tone from the REMS classification, arguing that the restrictions were medically unnec-
essary.179 In January 2018, the American Medical Association—​on a motion from the
Medical Student Section—​passed a resolution urging the FDA to remove the mifepris-
tone REMS.180 Kirsten Moore founded the EMAA Project, which worked to inform
the FDA about the latest medical and scientific evidence relating to mifepristone and
the REMS.181 In March 2018 in response to a Congressional inquiry, the Government
Accountability Office (GAO) issued a report on the FDA’s Mifeprex labeling changes and
ongoing monitoring efforts. The GAO found that the FDA followed its standard review
process, based its approval on peer-​reviewed published research, and determined the
86 • Abortion Pills

rates of adverse events were acceptably low.182 In June of 2018, research showed mife-
pristone could effectively be used for miscarriage management.183 The same month,
the executive board of ACOG issued a position statement urging the FDA to remove
its restrictions on mifepristone.184 In August of 2018, the American Academy of Family
Physicians adopted a resolution stating that the REMS classification on mifepristone
was not based on scientific evidence, and limited access to abortion care and the best
evidence-​based medical management of miscarriage.185 Despite the onslaught of pres-
sure, the FDA did not lift the REMS or change the mifepristone label.
Meanwhile, Coeytaux and Wells moved ahead with actions to expand access to medica-
tion abortion through telemedicine. In early 2018, they published an article in the Stanford
Social Innovation Review with Dr. Sophia Yen titled “Reproductive Health Care by Mail.”
The article called for telemedicine abortion.186 “Web-​based, medically supported models
of medication distribution by mail are demonstrating a new means of service delivery for
reproductive health care that greatly increases access and puts convenience, confidentiality,
and control in users’ hands.”187 To realize their vision, Plan C had for several years been try-
ing to recruit an organization based outside of the country to offer telemedicine abortion
to people inside the United States. They spoke with several organizations without success.
“I had been begging every year. Please, please, please,” said Coeytaux. “Nobody wanted
to touch the US. They gave two reasons. One, they focused on countries where abortion
was illegal. And secondly, they said, ‘You take care of your own—​you’re the richest coun-
try in the world. And, well, we know how much money the antis have. We don’t want
them coming after us.’ ”188 After hearing about “The Tale of Two Methods” report, a man
at one of the organizations agreed to start serving the United States, said Coeytaux. Plan C
raised $50,000 to support the organization, but they later backed down and returned the
money. Eventually the Dutch physician and activist Rebecca Gomperts agreed to serve the
United States. Coeytaux explained, “She said, okay, this has gotten ridiculous. I can do it.
I’m not US-​based. I’m based in the Netherlands. I’m going to do it, and then she started
Aid Access.”
For decades, Gomperts had offered medication abortion services to women living
in countries where abortion was illegal or inaccessible. In 1999, she founded Women
on Waves then, in 2006, she founded Women on Web, offering medication abortion
services via the internet and shipping pills through the mail. Women on Web, how-
ever, did not serve people in the United States because abortion was a constitution-
ally protected right. But in 2018 when Women on Web began receiving a voluminous
number of inquiries from people in the United States who could not access abortion
because of legal restrictions and high costs, Gomperts considered serving the United
States. “Gomperts saw the real obstacle course that people in the United States were
having to go through to access abortion,” said Dr. Abigail R.A. Aiken, who conducted
research on Aid Access. “She could see it was legal in name, but it was not legal in
practice.”189 With Plan C’s support, Gomperts formed Aid Access to provide low-​cost
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 87

abortion pills to people in the United States. Aid Access required an online consultation
to determine eligibility for using abortion pills and provided information about how to
use them. Dr. Gomperts then sent prescriptions to a pharmacist in India, who shipped
the medications directly to US residents. Patients received the medications in two to three
weeks. Dr. Gomperts charged a sliding scale fee up to $105.190 Between 2018 and 2020, Aid
Access received 57,506 requests from people in the United States seeking abortion pills.191
Plan C supported Gomperts in several ways. Initially, they helped her find grants
and pro bono legal assistance. “We tested her service from a user perspective and pro-
vided feedback to make it more appropriate for a US audience,” said Wells.192 Plan C
shared information about Aid Access on their website and helped with their media vis-
ibility. In 2020, they found providers to take referrals from Aid Access in states where
telemedicine abortion was legal. They also strategized with Gomperts as new issues
arose, such as offering advance provision pills so people could have them on hand in
case they needed them. While Plan C supported Aid Access, they remained fiscally
independent from them. Coeytaux explained: “We were really careful from the get-​go
that she do it completely alone. We never gave her any funding, and in fact, whenever
I would go and meet her, I never even paid for lunch for her, or she never bought me
lunch. I mean we were so careful not to have any money exchange between us, so we
could say, and honestly mean, that we are totally separate entities. Yes, we partner. But
that’s it.”193
Research conducted with Aid Access patients revealed highly positive experiences
with the service and very low rates of complications. Between March 2018 and March
2019, Aid Access mailed abortion medications to 4,584 people. Of the 2,797 people
who used the medications and responded to a follow-​up survey, 96.4 percent reported
successfully ending their pregnancy without further intervention and only 1 percent
reported any treatment for a serious adverse event, a rate only slightly higher than in
clinical settings. No deaths were reported to the service by family, friends, the author-
ities, or the media. Respondents reported positively about their experiences of using
abortion medication through Aid Access: 98.4 percent were satisfied with their abor-
tion experience; 95.5 percent said using Aid Access was the right choice; 98.1 percent
felt they had enough information on how to use the medications; and 93.4 percent felt
they had enough information on what to expect from the process.194 “This study is the
first evidence from the US context that self-​managed medication abortion provided
using this online telemedicine model is safe, effective and acceptable to users,” said
the study’s lead author, Dr. Abigail R. A. Aiken, associate professor at the University of
Texas at Austin’s LBJ School of Public Affairs.195
One area of concern had been that medication abortion outside of the formal US
healthcare system might delay a diagnosis of an ectopic pregnancy—​a dangerous
condition where a fertilized egg implants and grows outside of the uterus. But Aiken
found the opposite: people were diagnosed with ectopic pregnancies right away during
88 • Abortion Pills

the initial screening of patients, which often happened more quickly than clinic-​based
care because patients could get telemedicine appointments right away rather than
having to wait for an in-​clinic appointment. The research also showed that patients’
self-​reporting of their last menstrual period was an accurate method for determin-
ing gestation duration in early pregnancy, meaning ultrasounds were not necessary.
Finally, the research provided evidence that medication abortion after ten weeks is
effective and safe, although slightly less so than before ten weeks. Of the patients tak-
ing abortion pills before ten weeks of pregnancy, 97 percent successfully ended their
pregnancies. The success rate for people taking the pills after ten weeks was 92 per-
cent. While only 0.08 percent of patients with pregnancies up to ten weeks had com-
plications, 2.3 percent after ten weeks did. “It’s of course higher, but it’s not alarmingly
high,” said Aiken, noting that the World Health Organization had approved the use of
abortion pills through twelve weeks of pregnancy. “I think self-​managed telemedicine
abortion will become seen as more legitimate and more of a real part of good quality,
safe, effective care as we see more of these results and see more about how it’s oper-
ating and working,” she said. “I think it’s a very legitimate option and so important
because of its affordability.”196
In February 2017, the international organization Women Help Women formed a
US project, “Self-​Managed Abortion. Safe and Supported” (SASS), to provide infor-
mation and support on using abortion pills to end an unwanted pregnancy without a
clinician. In January 2018, SASS launched a website located on servers overseas with
abortion information and an encrypted portal through which people could access
counselors based overseas. Through this secure portal, people could ask questions
about how to get and use abortion pills.197 Whereas Plan C took a very public approach
of creating a website where they shared information about how people were obtain-
ing and using mifepristone and misoprostol, SASS was more secretive and spread
information using a “train-​the-​trainer” model, where they would train others on how
people were using abortion pills, and then encourage the people they trained to train
others. They hoped that in this way, they could build community-​based networks of
people knowledgeable about abortion pills.198
Around this time, NWHN came out in support of self-​managed abortion. According
to Sarah Christopherson, NWHN went through a months-​long education and persua-
sion process with their board. In the spring of 2017, NWHN published an article in the
newsletter to their membership stating their support for self-​managed abortion: “We
believe that women and people who can become pregnant should have access to safe,
affordable abortion care with the assistance of a medical provider if and when they
so choose. Without exception. Women should not have to see a doctor or ‘get per-
mission’ from the medical community before ending their pregnancy with an FDA-​
approved medication.”199 In this article, they stressed that “medication abortion without
the involvement of a provider is not a failure of the system; rather, it is one option that
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 89

women ought to be able to choose.” They argued, “we must trust people to make the
decisions that are right for them.”200
Surveys of US women visiting abortion clinics in 2017 showed that 1.4 percent
reported ever having attempted to self-​manage an abortion. Based on this, researchers
estimated that 7 percent of women in the United States would attempt to self-​manage
an abortion at some point in their lives. They found that non-​Hispanic Black and
Hispanic women were more likely than non-​Hispanic White women to have attempted
self-​managed abortion, as were women living in poverty.201 Another study of people
searching for abortion care on Google in 2017–​2018 found that 28 percent reported
attempting self-​managed abortion, with 18 percent reporting use of mifepristone and/​
or misoprostol.202
As abortion access tightened, advocates at some abortion funds across the coun-
try began providing misoprostol to people who could not travel to obtain care. They
obtained the medication from abroad at a cost of $55 for a bottle of one hundred tablets,
and worked with local doulas to support people using misoprostol for abortion. “It was
very widespread, well before Roe fell,” said one advocate, who began mailing miso-
prostol pills to people in 2019. “In our little area, I knew of three different doulas who
were doing it. Then we started doing it. I figured if there were three in my little met-
ropolitan area that there must be several in every metropolitan area. I assumed there
were thousands of networks all around the country.”203 In 2019, researchers published a
systematic review of studies on misoprostol alone for first-​trimester medical abortion,
revealing high rates of efficacy.204
Some advocates, however, were concerned that if people obtained abortion medica-
tions outside of the formal medical system, they may be subject to investigations and
possibly criminal prosecution. While the FDA considered it “illegal” for overseas phar-
macies to ship medications into the United States, this practice was common and the
FDA had a policy of non-​enforcement about importation of up to a ninety-​day supply
of medicines for limited use.205 While only one state—Nevada—had an explicit crimi-
nal prohibition against individuals self-​managing abortion, thirty-​eight states had feti-
cide laws that equated causing the loss of a fetus with murder, although most explicitly
excluded pregnant people from criminal penalties.206 Nevertheless, some anti-​abortion
prosecutors across the country had investigated and criminally charged people for self-​
managing abortion.
Prosecutors used a range of laws against pregnant women, including laws against
feticide, child neglect, practicing medicine without a license, and possession of a dan-
gerous substance. As an increasing number of people began self-​managing their abor-
tions, advocates became concerned about the legal risks, particularly for women of
color and others living in communities subject to increased surveillance and criminal-
ization. In 2018, If/​When/​How created the Repro Legal Helpline—​a free, confidential
helpline for callers to get legal information or advice about self-​managed abortion. The
90 • Abortion Pills

helpline assisted people concerned about being criminalized for ending, or attempting
to end, a pregnancy to learn more about their rights, submit questions by phone or
through encrypted communication, and get connected with an attorney in their state if
needed. In March of 2019, the SIA Legal Team at Berkeley merged with If/​When/​How
to become If/​When/​How: Lawyering for Reproductive Justice, which ran the Repro
Legal Helpline. “With added legal and policy expertise, we’ll draw on our roots in the
movement and connections across communities to educate, train, organize, and mobi­
lize a network of legal professionals who can bring their skills and privilege to bear on
reproductive oppression in myriad ways,” said Mariko Miki, the organization’s deputy
director.207 In 2019, If/​When/​How published a study reporting twenty-​one adults were
criminalized for self-managed abortion with medications since 2000.208
Advocates also created medical support services for people self-​managing abor-
tion. Two primary care physicians in New York, including Dr. Linda Prine, formed the
Miscarriage and Abortion Hotline in 2019. The M+​A Hotline, as it was called, started
with eleven volunteer clinicians, who answered texts and calls from people with ques-
tions about abortion pills and miscarriage. To ensure confidentiality, the M+​A Hotline
used an encrypted platform and did not ask people for any identifying information.
Callers asked questions about how to take the pills, their symptoms, whether the pro-
cess worked, and contraception options going forward.209
Meanwhile, Plan C focused on developing telemedicine abortion by promoting
research on the “test-​free” telemedicine model of providing abortion pills to patients.
They first approached researchers at Advancing New Strategies in Reproductive Health
(ANSIRH) at the University of California, San Francisco to do a study in California, but
the FDA refused to approve their study. So Plan C took the idea to Washington state. They
approached Dr. Deborah Oyer at Cedar River Clinics in the Seattle area with the idea of
offering an asynchronous telehealth abortion service based on data showing that blood
testing and ultrasound tests were not needed to safely offer medication abortion. Oyer
ended up providing telemedicine consultations by videoconference, not asynchronously,
and giving patients the option of receiving the medications by mail or by picking them up
from the clinic, including at a remote site in Yakima. Lawyers at NAF discouraged Oyer
from mailing the medications. They wanted everyone to stay within the strictest defini-
tion of the REMS—​interpreting the word “dispensing” in the REMS to mean in-​person
dispensing—​because lawyers had filed a lawsuit in Maryland asking a federal court to
order the FDA to allow mailing abortion pills during the pandemic and they didn’t want
to put that case in jeopardy. “I knew I was pushing the bounds by mailing the meds, but
one could argue that if the meds were sent by and from the clinic that they were ‘dis-
pensed’ by the clinic,” said Oyer.210 Plan C supported this interpretation of the REMS.
Plan C raised money to hire Dr. Emily Godfrey at University of Washington to con-
duct research on the new telemedicine delivery approach. Dr. Godfrey found that tele-
health abortion improved access to reproductive health services, especially for people
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 91

living long distances from specialized family planning clinics.211 Dr. Godfrey and col-
leagues also conducted research on family physicians providing telemedicine abortion
in New York, New Jersey, and Washington state, who used asynchronous online consul-
tations and medications mailed directly to patients. The research found that this model
was successful.212 Meanwhile, people flocked to the Plan C website, which received
around fifty thousand hits per month in 2019 from all over the United States, with over
half of those visitors seeking out the Report Card.213
Plan C was further inspired by new research demonstrating the safety and effi-
cacy of self-​managed abortion in India. In late 2017, researchers at the International
Institute for Population Sciences in Mumbai, the Population Council in New Delhi, and
the New York-​based Guttmacher Institute published the first national study of the inci-
dence of abortion and unintended pregnancy in India.214 They estimated 15.6 million
abortions were performed in the country in 2015 and concluded that “close to three in
four abortions are achieved using MMA [medical methods of abortion] drugs from
chemists and informal vendors, rather than from health facilities. MMA is safe and
effective when used in accordance with World Health Organization guidelines.”215 This
research demonstrated the widespread and safe use of abortion medications outside of
the formal medical system.
In August of 2019, more studies confirmed the safety of using telehealth for medica-
tion abortion. Based on data from five states where participants had a videoconference
with a clinician and pre-​treatment laboratory tests and ultrasound, the TelAbortion
study found that direct-​to-​patient telemedicine abortion service was safe, effective,
efficient, and satisfactory, with 93 percent of patients having complete abortions with-
out a procedure, and only two hospitalizations out of 248 patients. All patients who
completed questionnaires were satisfied with the service. Researchers concluded, “the
model has the potential to increase abortion access by enhancing the reach of providers
and by offering people a new option for obtaining care conveniently and privately.”216
Meanwhile, ANSIRH at University of California, San Francisco advanced an aggressive
research agenda to support increasing access to medication abortion and eventually
removing all FDA restrictions on mifepristone. For example, one ANSIRH researcher
completed a study about the barriers to medication abortion experienced by public
university students in California, which supported the passage of a law in 2019 requir-
ing public universities to offer abortion pills.217
Advocates also pushed for a generic mifepristone to help lower prices and
increase access. Danco’s patent expired in 2004, but no one stepped forward to cre-
ate a generic until years later. Around 2012, several mission-​driven pharmaceutical
professionals formed the company GenBioPro with the goal of bringing a generic
mifepristone to the market. Before coming to market, GenBioPro advocated for
reduced dosage requirements, fewer required patient visits, and other improvements
to access.218 With the support of the Packard Foundation, GenBioPro pursued the
92 • Abortion Pills

approval of a generic with the FDA. The head of the FDA at the time, Dr. Scott
Gottlieb, was focused on increasing the number of generic medications on the mar-
ket in order to encourage competition, especially for drugs in the REMS program.219
On April 11, 2019, the FDA approved GenBioPro’s generic mifepristone.220 Coeytaux
said the generic made a huge difference:

The minute GenBioPro was in the act, all sorts of things started happening. Danco reduced
its price because there was competition. All the stuff that we did with the providers during
COVID—​we couldn’t have done it with Danco. Danco wasn’t interested at all in anything
innovative because they were happily doing their thing and already had their people on
board. So having competition in the market was critical.221

FDA approval of the generic set price competition in motion: GenBioPro set their price
lower than Danco, which then dropped their price. Lower prices and more options
increased access to mifepristone for clinicians and patients across the country. The
generic also established competition for new services from the drug sponsors, such
as mail order at scale, but it also extinguished the rationale for Danco to pursue the
miscarriage indication since most pharmacies could swap out brand-​named mifepris-
tone for the generic, regardless of what the prescription was written for.222 Dr. Mitchell
Creinin, however, believed that the drop in price had only a “marginal benefit” for
patients because clinics did not drop their prices for medication abortion.223
But anti-​abortion advocates pushed back against increasing access. In March of 2019,
the Trump administration’s FDA issued a warning letter to Dr. Gomperts, demanding
that she stop “causing the introduction of a misbranded and unapproved new drug into
interstate commerce.”224 The FDA threatened to seize the drugs. Gomperts explained
what she did next: “I stayed in my bed for three days, researching and reading every-
thing that existed on the FDA regulations, calling all the people I could call in the
US. I came to the conclusion that it’s okay, I can do this.”225 Then she fought back.
In September 2019, Gomperts sued the FDA, alleging they had seized between three
and ten doses of abortion drugs she had prescribed through Aid Access since March
and that the government had blocked Aid Access from receiving payments from some
patients.226 The lawsuit was eventually dismissed, but Gomperts continued to mail the
medication and did not experience any more interference.
Anti-​abortion states also tried to block the increasing access by fighting for restric-
tions at the state level, including passing laws banning mailing of abortion pills, requir-
ing ultrasounds which limited telemedicine access, and requiring that physicians alone
may prescribe mifepristone. For three weeks in June of 2019, the Missouri health
department required doctors prescribing abortion pills to conduct an extra medically
unnecessary pelvic exam on their patients before the state-​mandated waiting period so
that patients had to have two pelvic exams to receive the pills—​one when they initially
 Chapter 2: Fight to Expand Abortion Pill Access, 2000–2019 • 93

saw the doctor and a second when patients came back for the pills. In other words, doc-
tors were forced by the state to insert their fingers into patients’ vaginas while pressing
their abdomens to feel their reproductive organs, for no medical reason. One doctor
described the requirement as “state sanctioned, essentially, sexual assault.”227 After three
weeks, doctors at the one remaining abortion clinic in Missouri, a Planned Parenthood
clinic in Kansas City, refused to comply with the order, and the state health department
backed down, rescinding the requirement.228 During that time period, over one hundred
women experienced invasive, medically unnecessary, and unwanted vaginal probes, by
order of the state. In response, Planned Parenthood created a new clinic across the river
in Illinois so as not to be subject to the Missouri Department of Health.229 Meanwhile,
states increasingly passed abortion bans, hoping to tee up a case for the Supreme Court
to finally overturn Roe v. Wade. These developments spurred Plan C to push harder to
make abortion pills available by telemedicine and mail. The declaration of a pandemic
in March 2020 created new opportunities to make this vision a reality.
 CHAPTER 3

“Greased the Wheels”: COVID-​19

Pandemic and the Rise of
Telemedicine Abortion

The COVID-​19 pandemic led to a fundamental shift that eventually would greatly
increase access to abortion pills: the advent of telemedicine abortion, where doctors
consult remotely with patients and mail abortion pills to them. This shift was particu-
larly significant because it undermined a central strategy of the anti-​abortion move-
ment: to limit abortion to a dwindling number of brick-​and-​mortar clinics and then
target patients and healthcare providers entering these clinics with harassment and
violence. As Republican lawmakers passed increasingly burdensome laws and drove
clinics out of business, this strategy made abortion increasingly inaccessible, espe-
cially for people living far from cities where abortion clinics were generally located.
Telemedicine abortion offered a convenient, private, and more affordable way to
access abortion care, no matter where people lived, for the first time in American
history. Through litigation and grassroots advocacy, reproductive health advocates
demanded that the FDA remove its burdensome and medically unnecessary in-​person
distribution requirement for mifepristone. Their success led to the creation of many
virtual abortion clinics. While some mainstream abortion clinics resisted the rise of
telemedicine abortion, fearing it might undermine their business model, many abor-
tion doctors and other clinicians welcomed the increased convenience for patients.
But advocates saw the writing on the wall: Roe’s days were numbered. Alternative sup-
ply systems would be necessary to ensure ongoing access to abortion pills post Roe. So
activists organized for that looming reality by setting up a web of organizations to sup-
port people self-​managing abortion. These efforts experienced some resistance from
within the abortion rights movement, from some clinic-​based abortion providers who
did not believe women were capable of using abortion pills on their own, but also from
some reproductive justice activists fearful of the legal risks for people self-​managing
96 • Abortion Pills

abortions. This chapter traces these important developments and divisions during the
first year of the pandemic.
Shortly after the World Health Organization declared COVID-​19 a pandemic in
early March 2020, several states such as Texas declared that abortion was not essential
health care and therefore had to be delayed in order to conserve personal protective
equipment (PPE), such as masks and gloves. Reproductive health advocates responded
by asserting that abortion was time-​sensitive, necessary medical care. But they also
used the pandemic as an opportunity to promote telemedicine abortion. They argued
that telemedicine abortion could minimize exposure to COVID-​19 without using PPE.
Medical researcher and doctor Daniel Grossman of ANSIRH at University of California,
San Francisco said at the time, “During the pandemic, it would be possible to provide
medication abortion through eleven weeks of pregnancy without an in-​person visit and
by mailing pills to a patient. This would reduce the patient and clinician’s risk of acquir-
ing the virus and not a single piece of PPE would be used.”1
In 2020, demand for telemedicine services in the United States soared. Abortion
health care was no exception. But the FDA restrictions under REMS for mifepristone
were widely interpreted to block telemedicine abortion. The Trump administration
suspended in-​person dispensing requirements for all medications under REMS
except for one—​mifepristone—​disallowing telemedicine abortion while allowing
telemedicine access to medications far less safe than mifepristone, including for
opioid drugs like fentanyl and OxyContin.2 Building on evidence of telemedicine
abortion’s safety, researchers and clinicians published a new protocol for medica-
tion abortion that did not require an in-​person meeting between patients and clini-
cians. In early 2020, Elizabeth Raymond from Gynuity and nine doctors and public
health experts published a “no-​test” medication abortion protocol.3 This protocol
challenged the standard medical protocol requiring two tests to determine eligibility
for a medication abortion. The first test was an ultrasound, to ensure the pregnancy
was within the FDA’s gestational limit of seventy days and was not ectopic. The
second was a blood test to determine whether the patient had a Rh-​negative blood
type—​in which case they may receive counseling and/​or anti-​D immunoglobulin
treatment. These tests, which were not required in other countries, had to be done
in person, thereby precluding fully remote telemedicine abortion. Research in the
early 2000s indicated that these tests were medically unnecessary, but they became
the standard of care. Dr. Emily Godfrey believed this was done at least in part to
prevent family care physicians from offering medication abortion and thereby tak-
ing business away from obstetricians, gynecologists, and abortion clinics. “OB/​
GYNs [obstetricians and gynecologists] can be very unfriendly to family physicians
and very territorial. They’re not always welcoming of the family docs. But it’s very
regional,” said Godfrey. For the same reason, family care providers sometimes had
a hard time finding an obstetrician or gynecologist to agree to provide back-​up care
 Chapter 3: COVID-19 Pandemic and Telemedicine Abortion • 97

in case their patients needed a procedural abortion, which discouraged them from
offering medication abortion.4
Based on extensive medical research, Raymond and her colleagues concluded that
ultrasound and blood tests were usually unnecessary for safe and effective abortion
because women could reliably report their last periods for dating pregnancy, and abor-
tion in early pregnancy does not create an immune response. The study cited research
conducted in the United States, Mexico, and Moldova where medical professionals pro-
vided medication abortion to 406 patients without a screening ultrasound or pelvic
examination.5 No serious adverse events resulted from the omission of these tests, and
participants were highly satisfied. They noted that international organizations for the
past fifteen years had safely provided abortion pills by mail to tens of thousands of
patients screened only by a brief medical review and that in many European countries
medical standards do not recommend Rh testing for abortion or miscarriage in early
pregnancy. In addition to the preliminary tests, standard medical protocol required
a follow-​up appointment to confirm the absence of a continuing pregnancy. The no-​
test protocol recommended a planned follow-​up contact conducted by videoconfer-
ence, telephone, patient portal, email, or text, along with urine pregnancy tests that
the patient purchased online or from a local pharmacy and performed at home. The
new protocol allowed for clinicians to safely administer medication abortion to their
patients without any preliminary tests or in-​person encounters.
One of the study’s co-​authors, Dr. Jamila Perritt, reported that her patients had
responded very positively to the new protocol. “Folks love it. They opt for it. Especially
[women] who are confident about when their periods are,” said Dr. Perritt. “Sixty-​two
percent of folks who have abortions already have children. Many already know their
blood type. They can tell you. People are really good at self-​screening. If we actually
trust people, as providers we can stand with them in partnership. This is a really good
way to take care of our community.”6 Dr. Perritt was hopeful the no-​test protocol would
increase access. “This is a move toward a broader goal,” Dr. Perritt said. “This medica-
tion is safe. People know how to take it on their own. We should trust people to care for
themselves in the way that they see best. And the evidence supports it. My hope is that
this no-​test protocol is an early step to broadening access.”7
Dr. Perritt predicted that the elimination of unnecessary medical tests would
likely decrease the cost of abortion health care and increase access because ultrasound
machines can cost providers $30,000—​at the low end. If states mandated ultrasounds
or standard medical protocols recommended them, doctors could not provide abor-
tion care without making this sizable investment, said Dr. Perritt. Similarly, standard
Rh testing increases the cost of abortion—​since, in order to be able to perform the
testing, providers have to be part of a system of regulation and inspection by health
departments, which could be burdensome for a private practice. “Because of the way
that medication abortion is restricted, part of the cost of medication abortion includes
98 • Abortion Pills

mandated ultrasounds, blood work, and follow-​up appointments,” said Dr. Perritt.
“If based on [the no-​test] protocol, we are able to show that this medication is safe
and effective and works really well, then the hope will be that the cost will go down.”8
The publication of the no-​test medication abortion protocol by Raymond and her co-​
authors in April of 2020 was “hugely important” in getting people to accept the no-​test
model, said Wells.9
Around this time, several organizations made statements affirming a no-​test pro-
tocol. On March 30, 2020, the American College of Obstetricians and Gynecologists
issued guidance stating that clinicians could perform an assessment, counseling, and
consent for medication abortion by video or telephone and that an ultrasound and Rh
testing were not necessary in most cases.10 Similarly, the Reproductive Health Access
Project, which trains and supports clinicians to make abortion, contraception, and mis-
carriage care more widely accessible, issued a “no-​touch” medication abortion protocol
that did not require in-​person visits and tests. Cynthia Pearson, executive director of the
National Women’s Health Network, publicly noted that the FDA REMS restriction on
mifepristone did not explicitly require providers to perform ultrasounds. “I believe that
the assumption that an ultrasound was required was a result of community standards,
under which most clinicians used ultrasound to date pregnancies,” said Pearson.11
Advocates argued the REMS restriction especially harmed marginalized women.
“Policies need to work for all women, including women who have trouble getting time
off work, who have trouble traveling, who have limits on their financial situations,” said
Cynthia Pearson. “To help those that need it most, the REMS restriction needs to be
gone.”12 Pearson also expressed concern that the REMS restriction might discourage
some doctors from providing medication abortion because they don’t want to be on a
registry that could be made public, making them and their families the target of anti-​
abortion harassment and violence at clinics and even at their homes. “Abortion provid-
ers are singled out for public attacks, including violent attacks. It’s common sense that
that would stand in the way of at least some providers who might otherwise be willing
to write prescriptions for mifepristone.”13 While the list of mifepristone providers was
supposed to be confidential, some providers feared that anti-​abortion politicians would
try to obtain the lists of providers from drug manufacturers and make their names pub-
lic. Finally, Pearson said that the REMS stigmatized medication abortion, and contrib-
uted to the misperception that medication abortion was dangerous. “The fact that the
FDA has kept medication abortion in a restricted access program for twenty years con-
tributes to that false sense of abortion as being dangerous,” said Pearson.14 “The REMS
restriction has been wrong for twenty years,” said Pearson. “It is extra wrong now.”
On March 30, 2020, a coalition of twenty-​one state attorneys general led by
California Attorney General Xavier Becerra sent an forceful letter to the US
Department of Health and Human Services and the FDA, urging the Trump admin-
istration to waive or utilize its discretion on enforcement of its REMS designation.15
 Chapter 3: COVID-19 Pandemic and Telemedicine Abortion • 99

“As communities across the nation shelter in place to help prevent the spread of
COVID-​19, we must ensure that women can continue to safely access essential health
services including safe and legal abortion,” said Attorney General Becerra. Another
signatory of the letter, New York Attorney General Leticia James, spoke up, calling on
the FDA to lift the REMS restrictions on mifepristone. “As the coronavirus spreads
across the country and residents are asked to stay at home, the federal government
should be doing everything in its power to ensure women can maintain control of
their reproductive choices,” James said in a press release. “Control over one’s repro-
ductive freedom should not be limited to those able to leave their homes as we battle
the coronavirus. Our coalition [of attorneys general] is calling on the federal govern-
ment to make mifepristone more easily accessible so that no woman is forced to risk
her health while exercising her constitutional right to an abortion.”16 The American
College of Obstetricians and Gynecologists, the American Medical Association, and
the American Association of Family Physicians all supported removal of the REMS
on medication abortion for the duration of the pandemic.
Reproductive health advocates also pressed the Trump administration to lift the FDA’s
in-​person distribution requirement for mifepristone. On April 6, 2020, NWHN sent a let-
ter on behalf of eighty women’s health organizations to FDA Commissioner Stephen Hahn
demanding that the FDA remove the REMS restriction on mifepristone.17 Then on April
27, Cynthia Pearson of NWHN teamed up with former FDA Assistant Commissioner for
Women’s Health Susan Wood in an opinion piece published in The Hill entitled “The U.K
Allows Home Use of the Abortion Pill—​the U.S. Should Do the Same.” Noting that at the
end of March, the United Kingdom authorized physicians to provide medication abor-
tion through telemedicine for the duration of the coronavirus crisis, they argued that in
light of the pandemic, the FDA “should allow pregnant people to get the pill where they
take the pill—​at home—​and not require them to make an unnecessary and risky visit to
a clinic.”18 NWHN created a social media campaign called “Get the Pill Where You Take
It—​At Home!” with the hashtag #FreeTheAbortionPill, a video, a petition, and digital bill-
boards in New York state. On their website, NWHN shared data on the safety of abortion
pills, noting they were six times safer than Viagra—​yet the FDA allowed men to receive
this medication by mail. Dr. Jamila Perritt of Physicians for Reproductive Health spoke
out about the safety of abortion pills. “There are more complications and deaths associ-
ated with Tylenol than mifepristone,” said Dr. Perritt. “If we are looking at it truly based on
safety, then the argument doesn’t hold water.”19 Cynthia Pearson said that the moment was
right for the campaign. “We might not have even tried without the pandemic. But it was
just the moment. Things were really different. We realized, we could do things now that we
couldn’t have done two or four months ago.”20
Members of Congress put pressure on the FDA as well. On April 14, 2020, Senators
Patty Murray (D-​Wash.), Elizabeth Warren (D-​Mass.), and Tammy Baldwin (D-​Wisc.)
sent a letter asking the FDA to lift the restriction during the pandemic.21 In June, a
100 • Abortion Pills

group of 109 lawmakers, led by Reps. Diana DeGette (D-​Colo.), Barbara Lee (D-​Calif.),
Ayanna Pressley (D-​Mass.), and Jan Schakowsky (D-​Ill.) sent a letter urging the FDA
to permanently ease the dispensing restrictions on mifepristone. “The REMS in its cur-
rent form creates an illogical situation in which a patient can meet with her doctor by
telehealth from the safety of her home, take the pills at home, safely have her abortion
at home, and follow up with her doctor after the abortion by telehealth again, but must
first travel in the midst of a global pandemic just to pick up the pills from a regis-
tered facility or provider,” the lawmakers wrote to FDA Commissioner Stephen Hahn.
“For many patients, this requirement can mean taking public transportation, riding in
someone else’s car, or traveling hundreds of miles away from home to another county
or state—​significantly increasing their risk of exposure to the virus. It also means that
some providers and clinic staff are forced to have unnecessary in-​person interactions
that increase their own exposure risks.”22 NWHN’s Sarah Christopherson drafted the
letter and lobbied members of Congress to sign it. NWHN also collected over twelve
thousand signatures on a petition demanding that the FDA allow people to receive
abortion pills through the mail. In September, NWHN staff delivered the petition sig-
natures via a twenty-​foot banner that they held up in front of the FDA headquarters
(see Figure 3.1). The FDA did not respond.23

Figure 3.1: Sarah Christopherson, NWHN Policy Advocacy Director; Gabriela Salas, Policy Fellow; and
Julia Kagan, Interim Communications Associate, holding a banner with the names of people signing the
petition, in front of the FDA offices in Washington DC (courtesy of NWHN).
 Chapter 3: COVID-19 Pandemic and Telemedicine Abortion • 101

Meanwhile, Plan C began recruiting medical providers across the nation, beginning
in March of 2020, asking them to step up and consider providing telemedicine abortion
to patients during the pandemic. Hundreds responded to the call. Plan C talked to 120
people to get the first nine providers who offered telemedicine abortion.24 Plan C then
worked with researchers at the University of Washington School of Medicine to exam-
ine these remote abortion service operations in four settings: family planning clinics,
online medical services, independent primary care practices, and multispecialty health
systems. Clinicians used both synchronous methods, taking 10–​30 minutes of clinician
time, and asynchronous methods, taking 2–​5 minutes of clinician time.25 Based on this
research, Plan C and University of Washington created the Access Delivered Provider
Toolkit with step-​by-​step instructions on how to set up telehealth services for medica-
tion abortion.26 Primary care providers, however, sometimes faced barriers to obtaining
insurance. Some insurance companies would only cover obstetricians or gynecologists
providing this care, or they required a special policy for covering abortion care, which
could be expensive, despite the fact that medication abortion was so safe.27
In May 2020, ACOG filed a lawsuit challenging the FDA restriction. Represented
by the ACLU’s Reproductive Freedom Project and joined by the Council of University
Chairs of Obstetrics and Gynecology, the New York Academy of Family Physicians, and
SisterSong Women of Color Reproductive Justice Collective, ACOG asked a federal
district court in Maryland to order the FDA to lift the REMS restriction on mifepris-
tone during the COVID-​19 epidemic. The plaintiffs argued that the in-​person distribu-
tion requirement subjected patients to unnecessary risks of contracting COVID-​19 as
a condition of receiving the medication. “Our request in this case is simple: the federal
government should permit patients seeking safe and effective reproductive health care,
which includes care for miscarriage and termination of pregnancy, the same ability
to access care and protect themselves from exposure as patients in other contexts are
afforded,” said ACOG president Dr. Eva Chalas. “Lifting the barriers to mifepristone
will allow women, including those from underserved communities that are dispro-
portionately affected by both COVID-​19 and the ongoing maternal health crisis, the
ability to obtain necessary and essential evidence-​based care without having to risk
potential life-​threatening exposure.”28 SisterSong’s executive director, Monica Simpson,
said, “It is unconscionable that the FDA is subjecting women of color, who are dis-
proportionately represented among patients seeking abortion and miscarriage care, to
life-​threatening viral risks as a condition of obtaining these urgent reproductive health
services. Because of longstanding disparities in access to and quality of health care and
other manifestations of structural racism, Black and Brown people are more likely to
have preexisting health conditions that increase the likelihood of severe illness and
death from COVID-​19.”29
Rather than trying to change the FDA REMS, some advocates used an alternative
approach: reinterpret the REMS as not requiring in-​person distribution of mifepristone.
102 • Abortion Pills

The general consensus was that the REMS required medical providers to meet with
their patients twice, once to dispense the abortion pills to them in person, and a second
follow-​up appointment to confirm the successful termination of the pregnancy. But
some medical providers and advocates began challenging this interpretation. Plan C
argued that the REMS did not require clinicians to hand the mifepristone to patients in
person. The language of the FDA REMS said that pills must be “dispensed in a clinic”
but did not explicitly say that the medication must be handed to the patient in person.
Elisa Wells told The New York Times, “Most U.S. providers have taken the REMS to
mean that mifepristone cannot be mailed. We disagree. We think providers have clear
latitude to ‘dispense’ the drug from their offices and then ship it to patients, and we’re
hearing from more and more of our colleagues who see it the same way.”30 By early
2020, Plan C was working with clinicians across the country to help them register with
the manufacturers of mifepristone so they could provide telemedicine abortion and
mail pills to patients. Dozens of doctors signed up and some started mailing abortion
pills to their patients, despite the REMS.31
But the REMS wasn’t the only barrier to medication abortion. Nineteen states
required the prescribing clinician to be physically present when prescribing the abor-
tion pill, fifteen states required ultrasounds, and thirty-​two states only allowed physi-
cians to prescribe mifepristone. These requirements were not medically warranted but
served as a mechanism to decrease access to abortion by limiting the number of clini-
cians able to offer the service and driving up the cost of abortion.32
At the time, advocates were very concerned about a Supreme Court case challeng-
ing Roe v. Wade. The case, June Medical Services v. Russo, involved a fifteen-​week abor-
tion ban in Louisiana, which was identical to a Texas law the Court had struck down in
the 2016 case of Whole Woman’s Health v. Hellerstedt. With Brett Kavanaugh now on the
Court, advocates worried that the Court would overturn constitutional abortion rights
and uphold the abortion ban. But on June 29, 2020, Chief Justice Roberts joined Justices
Breyer, Ginsburg, Sotomayor, and Kagan in striking down the Louisiana law, although
Roberts wrote a concurring opinion inviting another challenge to Roe. Thomas, Alito,
Kavanaugh, and Gorsuch dissented.
Just weeks later, on July 13, 2020, a Maryland federal court issued an eighty-​page
decision temporarily suspending enforcement of the FDA requirement that patients
make in-​person visits to medical providers to get abortion pills. In ACOG et al. v. FDA,
US District Court Judge Theodore Chuang ruled the FDA requirement of in-​person
visits during the pandemic imposed a “substantial obstacle” to abortion health care
that was likely to be unconstitutional. Judge Chuang’s order, which he declared would
remain in place until at least thirty days after the end of the federal government’s
declared public health emergency, allowed patients to receive mifepristone from their
doctors through the mail.33 “Today’s decision means that the Trump administration can
no longer force patients to incur unnecessary COVID-​19 risks as the price of getting
 Chapter 3: COVID-19 Pandemic and Telemedicine Abortion • 103

abortion care,” said ACLU Reproductive Freedom Project staff attorney Julia Kaye, who
represented the plaintiffs in the case. “We look forward to a day when federal reproduc-
tive healthcare policy is grounded in science, not animus, and this medically baseless
requirement is lifted once and for all.”34
The Trump administration immediately appealed Judge Chuang’s ruling to the
Supreme Court, attempting to obtain a stay of the lower court’s injunction. The Supreme
Court denied the request in October 2020, but after the Fourth Circuit upheld Judge
Chuang’s ruling in November, the Trump administration appealed that ruling to the
Supreme Court again.35 In the meantime, healthcare providers began mailing abortion
pills to their patients.

Virtual Abortion Clinics

In the months following Judge Chuang’s ruling, telemedicine abortion startups opened
up across the country, including Just the Pill in Minnesota (Figure 3.2) and Choix in
California. New online abortion clinics offered medication abortion for significantly
less money than brick-​and-​mortar clinics, making abortion more affordable, which
was especially important for young and low-​income women without health insurance.
These virtual clinics screened patients remotely using the no-​test, no-​touch medi-
cal protocol, then mailed abortion pills to eligible patients at home. The nonprofit Just
the Pill opened for business on October 12, 2020, offering telemedicine abortion care

Figure 3.2: The website of telemedicine abortion provider Just the Pill opened in Minnesota in October
2020, after Judge Chuang’s ruling allowing mailing of abortion pills (courtesy of Just the Pill).
104 • Abortion Pills

to people in Minnesota.36 Choix opened on October 28, 2020, offering abortion care to
people in California.37
At Just the Pill, patients filled out an online form and then had a follow-​up phone
call with a patient educator and a doctor, who then mailed the pills to eligible patients.
There were follow-​up phone calls at seven days and four weeks. Just the Pill did not take
insurance, but had a sliding scale fee structure up to $350. A Minnesota abortion fund,
Our Justice, supported patients who couldn’t pay the full fee. According to Medical
Director Dr. Julie Amaon, Just the Pill formed to serve people in rural Minnesota who
lived far from the state’s five abortion clinics, which were concentrated in urban areas.
After seeing her first thirty patients, Dr. Amaon reported that most of her patients lived
more than one hundred miles from the nearest clinic. Dr. Amaon explained:

Ninety-​seven percent of counties in Minnesota do not have an abortion provider. In our

research, people are having to sometimes drive three or four hours for services. That’s tough
when you have kids at home and you’re trying to look for childcare. This is a very safe
early option—​that you can have a telemedicine appointment with a doctor in the comfort of
your home and you get something mailed to your home. You don’t have to leave the house.
Women know how to take care of their bodies. This is just inducing a miscarriage. This is
very safe. People have been doing this for centuries on their own. To have that ability to be
able to take care of yourself at home, I think that’s just an amazing service. And it should
continue to be an option for women.38

Just the Pill offered translation services and soon expanded their services into Montana,
where they were also licensed to practice and allowed telemedicine abortion.
At Choix, patient care was conducted asynchronously through encrypted texting
that was fully compliant with federal privacy standards established by the Health
Insurance Portability and Accountability Act (HIPAA) (see Figure 3.3). Patients filled
out an online form and medical professionals consulted with them by text or telephone,
then mailed the abortion pills. There were follow-​up check-​ins seventy-​two hours and
one month after the abortion. Choix charged $199 (compared to $500 for in-​clinic
medication abortion in California at the time). They did not take insurance, but they
worked with the digital mutual-​aid abortion fund Reprocare, which supported a sliding
scale payment mechanism right on the Choix website. The co-​founders of Choix, Cindy
Adam and Lauren Dubey, had both worked as clinicians in a primary care practice,
but they wanted to be able to provide a different type of care. “We wanted to expand
access to folks who have limited access,” said Adam, who was CEO at Choix. “We really
wanted to help revolutionize abortion care. We are both really passionate about sexual
reproductive health care.”
Dubey, who was the chief nursing officer at Choix, hoped that services like Choix
and Just the Pill would normalize abortion care. “Abortion is a totally normal part of
 Chapter 3: COVID-19 Pandemic and Telemedicine Abortion • 105

Figure 3.3: An image from the Choix website. The copy reads, “Online access to safe & affordable sexual
& reproductive healthcare, including abortion care. Your body. Your health. Your time” (courtesy
of Choix).

your reproductive health care. Having a pregnancy that you no longer want to continue
is for some people a very huge grave decision and for other people it’s not a big deal.
People coming to our platform can come with pride or with shame—​whatever their
own feelings are, we will treat everybody with dignity and respect. We want people
to feel like we’re their partners in their reproductive future. We’re not here to judge
them.”39 Telemedicine made abortion accessible for people in rural areas, but it also
made abortion access faster and more convenient for people living in urban areas. “In
rural parts of California and urban parts of California, the desire is there,” said Dubey,
“whether it’s an access issue or whether it’s because the appointments are all booked up
in urban areas.”40
Clinic-​based medication abortion care was often time-​consuming and costly, said
the medical director at Choix, Dr. Aisha Wagner, who noted that clinics were crowded,
appointments could take several hours, providers often insisted on an in-​person follow-​
up appointment, and many clinics required ultrasounds and blood tests, which were no
longer the standard of care and made abortion care more expensive. “Some people may
not have the time and money to go to a clinic and pay the higher cost associated with
106 • Abortion Pills

a medicalized abortion and take the hours of time,” said Dr. Wagner. “You need to find
childcare, you need to take time off of work.”41 Telemedicine care, on the other hand,
could be scheduled quickly and happen wherever patients are, on their phone or com-
puter. And virtual abortion clinics could provide eligible patients care right away, even
in early pregnancy, unlike traditional abortion clinics, noted Dr. Wagner. “You usually
can’t proceed until there’s a pregnancy seen on ultrasound. If you’re only four weeks
pregnant, you’re not going to see anything on the ultrasound and therefore you’re going
to be turned away. For our platform, if you realize your period is two days late, you take
a pregnancy test, and your pregnancy test is positive, you can zoom online right away
and we can get this taken care of,” said Dr. Wagner.42 Online abortion care also allowed
people seeking abortion care to avoid protesters at clinics and maintain more privacy
than in-​clinic care at traditional abortion clinics. “Even though you know you’re going
somewhere that’s supportive, you’re still meeting a lot of people, you’re telling your
story to a lot of people,” said Dr. Wagner. “Even if you’re not required to, I think people
feel obligated to explain why they’re there. It’s just emotionally easier to do this at home
on your own time.”43
Reprocare worked with Choix to support their sliding scale fee structure and
also offered peer-​based support for people during a medication abortion.44 “The
potential for democratizing abortion access through these platforms is promising,”
said Morgan Love, a Reprocare co-​founder and software engineer. “But it is impera-
tive that this not become an ‘elite’ option, available only for those who can afford to
pay out of pocket or have a strong personal network of support from which to draw.
Reprocare offers a robust financial support platform designed to shift how abortion
funding is achieved and perceived.”45 Reprocare co-​founder Phoebe Abramowitz
explained: “We were really excited to learn about the prospect of having medica-
tion abortion be accessible via the telehealth platforms. But we knew that for it
to be truly accessible, it would need to be financially accessible.”46 Reprocare also
offered peer-​based support for people during a medication abortion through a con-
fidential “healthline.” “We provide emotional support and medical information for
people planning abortion with pills at home,” said Love. “We support the abortion-​
at-​home model and make sure that folks who are having an abortion have peer-​
based support. We offer culturally congruent care because folks have the right to be
supported by people who have a lived experience that resembles theirs,” said Love.47
Reprocare supported all callers, without asking for personally identifiable health
information.
After Judge Chuang’s ruling, several TelAbortion sites, including carafem and Maine
Family Planning, began offering telemedicine abortion care without requiring ultra-
sounds. The FDA’s COVID-​19 guidance for testing relating to REMS drugs provided
some flexibility in whether clinicians had to do ultrasounds for medication abortion.
The guidance stated that healthcare providers should “use their best medical judgment
 Chapter 3: COVID-19 Pandemic and Telemedicine Abortion • 107

in weighing the benefits and risks of continuing treatment in the absence of laboratory
testing and imaging studies.”48
Carafem, a nonprofit that offered in-​person abortion care in several states since
2015, participated in the TelAbortion study from the outset, but expanded tele-
medicine care significantly during the pandemic after Judge Chuang’s ruling. By
November of 2020, they were offering telemedicine abortion care to approximately
fifty clients a week in Georgia, Illinois, Maryland, Washington, DC, and Virginia
combined. Melissa Grant, chief operating officer of FemHealth USA, which owned
carafem, said that carafem “seeks to normalize, ‘de-​medicalize,’ and remove the social
stigma from the provision of birth control and early abortion care.”49 Carafem offered
video visits for medication abortion, which lasted about thirty minutes. Then they
provided a secure text messaging platform with a virtual assistant, named Cara, who
connected patients with staff if needed twenty-​four hours a day, seven days a week.
Carafem charged between $325 and $375, depending on the medication selected,
and included a follow-​up check-​in within forty-​eight hours and confirmation of a
negative pregnancy test at thirty days. Unlike many other telemedicine abortion pro-
viders, carafem took insurance, including Medicaid in Illinois and Maryland. Some
brick-​and-​mortar clinics also began offering curbside pick-​up of abortion medica-
tions after a telehealth consultation.50
A key development facilitating access to telemedicine abortion was the decision in
the fall of 2020 by the online pharmacy Honeybee Health to dispense abortion pills.
Coeytaux and Wells had been working to find a pharmacy to mail abortion pills. “We
approached reproductive health delivery services early on and asked them to add abor-
tion pills, but they couldn’t get their boards to do it,” said Wells. “They thought it was too
big a risk and that they would lose business, which I think was totally wrong. Fear and
the stigma influenced their decision.” Then Judge Chuang ruled that providers could
contract with mail order pharmacies to dispense mifepristone.51 “I heard it on a briefing
call by the ACLU and immediately followed up with them to hear more of the details,
letting them know that we were already in touch with a pharmacy that wanted to do
this—​Honeybee,” said Wells. “They got it set up about three weeks later!”52 Honeybee
Health, which Jessica Nouhavandi and Peter Wang had launched in California in 2018,
sold generic abortion pills at steep discounts without billing insurance.53 In fall of 2020,
they began filling abortion pill prescriptions from certified clinicians in Washington,
New York, and New Jersey, and quickly expanded to other states. Honeybee was able to
offer low prices because they bought medications directly from FDA-​approved, whole-
sale distributors and cut out intermediaries, such as insurance companies and pharmacy
benefit managers. As a result, they could sell generic medications for up to 80 percent
less than what traditional pharmacies charged—​often less than copays or coinsurance.
The option to use Honeybee Health to dispense mifepristone and misoprostol made
it easier for healthcare providers to offer medication abortion services because they
108 • Abortion Pills

did not have to stock and dispense the drugs themselves. After screening patients for
eligibility, clinicians could just send prescriptions directly to Honeybee, where trained
pharmacists would process and ship the medication to the patients directly.
Advocates hoped mail order pharmacies paired with the no-​test protocol would
increase the likelihood that more family medicine providers who did not own expen-
sive ultrasound machines and did not want to stock and dispense mifepristone them-
selves would now provide medication abortion services. “The exciting thing is that
we’re moving towards this twenty-​first century model of abortion care where abor-
tion pills can be obtained through a pharmacy like almost every other medication that
people get from a doctor, and it can be done without an in-​person visit,” said Plan C
co-​CEO Elisa Wells. “This type of access is inevitable. It is the future of abortion here
in the United States,” she added optimistically.54 However, while the Honeybee Health
board and current investors were very supportive, Nouhavandi said that many people,
including those who say they support women’s health, were “skittish” about helping
startups that work on abortion.55 Dr. Nouhavandi also spoke out about the importance
of increasing access to abortion pills:

This is a momentous achievement for Americans, particularly for women of color and
others who historically faced barriers to reproductive health care that are made even
worse by COVID-​19. As a pharmacy, we believe everyone has the right to choose whether
or not an abortion is right for them. We’re deeply honored to be part of the pioneering
group of medical professionals who are bringing increased access to safe abortion pills
across the country.

Dr. Nouhavandi saw Judge Chuang’s ruling as a window of opportunity to prove the
viability of a new model of abortion health care: “Abortion pills are extremely safe,
effective, and widely used in other countries without the kind of political scrutiny we
see in America. We hope that by shipping abortion pills now during COVID-​19, we
increase access for the years to come.”56 Shortly after, American Mail Order Pharmacy,
based in Michigan, began mailing abortion pills to patients who obtained prescrip-
tions via telehealth or in clinic.57

Organizing to Support Increased Access to Abortion Pills

Outside of the Medical System
The future of Roe v. Wade became increasingly precarious when Supreme Court
Justice Ruth Bader Ginsburg died on September 18, 2020, just forty-​six days before
the 2020 presidential election. Donald Trump nominated Amy Coney Barrett nine
days later. Despite having refused to hold hearings on President Barack Obama’s nom-
ination of Merrick Garland ten months before the election because it was “too close to
 Chapter 3: COVID-19 Pandemic and Telemedicine Abortion • 109

the election,” the Republican-​led Senate quickly confirmed Coney Barrett on October
26, 2020, just eight days before the presidential election. She was sworn in on the same
day. Conservatives now had a 6–​3 supermajority on the Supreme Court, setting the
stage for the overturn of Roe v. Wade.
Anticipating this development, Plan C rolled out a new website at plancpills.org in
November of 2020. The website had comprehensive information about how people in
the United States were obtaining abortion pills by mail. The website included a Plan C
Guide to Pills, searchable by state, with information about telemedicine services avail-
able in each state. They listed Aid Access, Just the Pill, and Choix, and added new
services as they started up. Aid Access served people in all fifty states, offering online
consultations and shipping of abortion pills for a sliding scale fee up to $95. In some
states, including New York, New Jersey, Washington, Nevada, Idaho, and Alaska, Aid
Access had contracted with US-​based clinicians so patients could receive their medica-
tions directly from clinicians or from Honeybee Health in just a few days. For people
living in other states, Aid Access sent their prescriptions to a pharmacist in India, who
shipped the pills to them within two to three weeks.
Plan C also listed websites selling abortion pills, which did not require a prescrip-
tion or any screening process. Researchers at Plan C ordered pills from these web-
sites, documenting the process, and then tested the medications in a lab to determine
whether they were the correct medication and dosage. They never found any fake
abortion pills. On their website, they listed the best companies and shared informa-
tion about cost, payment options, and shipping time. A third option described on the
Plan C website was to use mail forwarding to obtain abortion pills from a US-​based
telemedicine provider, which for people in states without telemedicine providers was
quicker than using Aid Access. Plan C described how people were renting an address
through mail forwarding services such as iPostal1.com or Anytime Mailbox in a state
allowing telemedicine abortion, then doing an online consultation with a telemedicine
provider in that state and listing the mail forwarding service address as the shipping
address. On the website they explained, “If asked, they confirm they are in that state
at the time of the consultation (since the providers are only allowed to serve people in
those states)…When the mail forwarding service tells them that a package has arrived
at their ‘address,’ they ask for it to be forwarded to them at their home address.”58 Others
used “general delivery” at a US Post Office on the state border to reduce the distance
they had to travel. “General delivery” meant that mail was sent to a person at a specific
US post office and the person receiving the mail would go there in person to pick it
up with an ID that matched the name on the package. There was no need to set up
a post office box and no charge for this service.59 In addition to information about
how people were obtaining abortion pills, the Plan C website shared information about
medical, emotional, financial, and legal support services, including the M+​A Hotline,
Reprocare’s Healthline, abortion fund information, and If/​When/​How’s Repro Legal
110 • Abortion Pills

Helpline. The Plan C website also had information for medical professionals about how
to become medication abortion providers.60
Advocates were optimistic that telemedicine abortion could revolutionize abortion
health care by significantly expanding abortion access in the United States. “We’ve been
fighting for a long time to say abortion should remain legal,” said Grant of carafem in
November of 2020. “But it’s equally important in the places where it’s legal to make sure
it’s accessible. Because if you can’t get to the care, whether it’s legal or not doesn’t really
matter. So if you’re in a small town, and don’t have a car, and don’t have a job, and are
stuck without anyone that’s going to be supportive of your decision, then you effectively
still have no choice even though it is legal in your state.”61 Advocates hoped the pan-
demic had opened a door that would be hard to close back up. Once people realized
how safe, easy, and accessible medication abortion could be, they were unlikely to go
quietly back to the old days of cumbersome, over-​medicalized, time-​consuming, and
expensive abortion health care.

Supreme Court Stops Telemedicine Abortion

But the counterforces were powerful. In September 2020, nearly a hundred
Republicans from both chambers of Congress urged the FDA to take the drug off the
market entirely.62 Despite losing the 2020 election, Donald Trump’s administration
persisted in a second Supreme Court appeal of the Maryland court ruling allowing
telemedicine abortion. On January 12, 2021, just days before the inauguration of
Joseph Biden, the six conservative members of the Supreme Court—​three of whom
were appointed by Trump—​granted the Trump administration request to reinstate
the FDA rule requiring patients seeking medication abortion to make an in-​person
visit to their healthcare provider, despite research showing this served no medical
purpose.63
Justices Sotomayor, Kagan, and Breyer dissented from the Court’s majority.
Sotomayor joined Justice Kagan in a scathing dissent, castigating the majority for cal-
lously forcing patients to expose themselves and others to the deadly COVID-​19 virus
for no medical benefit. Citing Justice Ruth Bader Ginsburg, Justice Sotomayor wrote:

Maintaining the FDA’s in-​person requirements for mifepristone during the pandemic not
only treats abortion exceptionally, it imposes an unnecessary, irrational, and unjustifiable
undue burden on women seeking to exercise their right to choose. One can only hope that
the Government will reconsider and exhibit greater care and empathy for women seeking
some measure of control over their health and reproductive lives in these unsettling times…
“[Women’s] ability to realize their full potential…is intimately connected to their ability to
control their reproductive lives.”64
 Chapter 3: COVID-19 Pandemic and Telemedicine Abortion • 111

Sotomayor and Kagan argued that requiring in-​person visits to doctors placed an
undue burden on abortion access: “Due to particularly severe health risks, vastly limited
clinic options, and the 10-​week window for obtaining a medication abortion, the FDA’s
requirement that women obtain mifepristone in person during the COVID-​19 pandemic
places an unnecessary and undue burden on their right to abortion.” They emphasized
that many medical offices had closed or dramatically reduced their open hours dur-
ing the pandemic. They argued that this policy particularly endangered minority and
low-​income populations, who are “more likely to live in intergenerational housing, so
patients risk infecting not just themselves, but also elderly parents and grandparents,”
making the in-​person medical visit a significant deterrent for women seeking medica-
tion abortion. Sotomayor also noted the district court’s finding that the in-​person visit
requirement could cause women to miss the ten-​week window for a medication abor-
tion. Sotomayor condemned the majority’s response that women can just get a surgical
abortion as “callous,” describing in detail this “far more invasive” procedure:

Medication abortion involves taking two pills and is the equivalent of an early miscarriage.
When a woman undergoes surgical abortion, she requires local anesthesia and sometimes
sedation, her cervix is stretched with dilating rods, a tube is inserted through her cervix
into her uterus, and, depending on the particular procedure, various medical tools are used
to remove fetal tissue from her uterus. On top of this, surgical abortions carry all the same
(and likely greater) risks of exposure to COVID–​19 as do medication abortion’s in-​person
requirements.65

Sotomayor concluded, “Together, patients’ health vulnerabilities, public transporta-

tion risks, susceptible older family members at home, and clinic closures and reduced
services pose substantial, sometimes insurmountable, obstacles for women seeking
medication abortions during the COVID–​19 pandemic.”
After the decision was released, medical providers and advocates expressed outrage.
“It is disgraceful and frankly frightening that instead of listening to expert medical and
scientific consensus about the safety of medication abortion and the risks imposed by
these unwarranted restrictions, the Supreme Court chose to listen to politicians with
an anti-​science, anti-​abortion agenda,” said Dr. Jason Matuszak, president of New York
State Academy of Family Physicians. “It’s past time for the FDA to eliminate these base-
less restrictions—​not only during the pandemic, but for good.”66 The ACOG president
Dr. Eva Chalas agreed: “Despite the administration’s claims, the facts in this case remain
clear: Mifepristone is a safe, effective medication for termination of pregnancy, and its
use should not expose patients or clinicians to added risk of COVID-​19 infection.”67
ACLU Reproductive Freedom Project staff attorney Julia Kaye, who represented the
plaintiffs, also condemned the decision:
112 • Abortion Pills

The Court’s ruling rejects science, compassion, and decades of legal precedent in ser-
vice of the Trump administration’s anti-​abortion agenda. It is mind-​boggling that the
Trump administration’s top priority on its way out the door is to needlessly endanger
even more people during this dark pandemic winter—​and chilling that the Supreme Court
allowed it. The Biden–​Harris administration must right this wrong on day one and hold
firm to its commitment to support both evidence-​based regulations and reproductive
freedom.68

Advocates emphasized the particularly negative impacts on low-​income women and

women of color, who were more vulnerable to COVID-​19. Monica Simpson, execu-
tive director of SisterSong Women of Color Reproductive Justice Collective, noted,
“With today’s ruling, the Supreme Court told people of color that unnecessary risk of
exposure to a virus that is disproportionately killing our communities is a fair price
to pay for access to abortion. Black, Brown, and Indigenous folks should not have
to endure yet another form of state violence while we are fighting for our lives in
this pandemic.”69 Sung Yeon Choimorrow, executive director of National Asian Pacific
Women’s Forum, agreed: “Asian American and Pacific Islander women and other
women of color are disproportionately harmed by restrictions on abortion, just as
we have disproportionately suffered the health and economic effects of COVID-​19.”70
Advocates called on the Biden administration to act immediately to lift the in-​person
distribution requirement for mifepristone.
As a result of the Supreme Court’s January 12 decision, many virtual clinics stopped
mailing abortion pills, while others, such as Abortion on Demand, delayed launch-
ing. Some found other ways to get abortion pills to their patients like Just the Pill,
which started using a Class B RV as a mobile clinic to deliver pills to their patients.71
Others, however, insisted the REMS did not disallow mailing of abortion pills. In fact,
two new virtual abortion clinics launched in early 2021. Hey Jane, which raised more
than $3 million in venture capital funding,72 launched in Washington and New York
in January of 2021. Forward Midwifery launched in California in February of 2021.73
These providers offered services asynchronously by online form, increasing conve-
nience and access to more people.
The Gynuity Health Project’s TelAbortion study, which provided medication abor-
tion via the mail as part of a research exception to the FDA restriction, was able to
continue, but patients were again subject to the FDA requirement that they obtain
ultrasounds beforehand, which meant they had to make an in-​person visit to a medical
clinic. “The ruling means additional hurdles and barriers to accessing medical abor-
tion and it means putting people’s health in jeopardy during a pandemic,” said Tara
Shochet, co-​director of the TelAbortion Project.74 Advocates at Plan C, however, per-
sisted in their belief that the REMS did not require clinicians to hand the abortion pill
to patients in person but required only that the clinician “distribute” the medication to
 Chapter 3: COVID-19 Pandemic and Telemedicine Abortion • 113

their patients, which Plan C said they could do by mail. Most advocates and doctors,
however, believed that an in-​person visit was required.
Despite the Trump administration’s opposition to abortion and the erection of
heightened barriers to reproductive health care and abortion at the state and fed-
eral levels, the number of abortions in the United States increased by 8 percent dur-
ing Trump’s presidency—​from 862,320 in 2017 to 930,160 in 2020, according to a
Guttmacher report. Overall, fewer people became pregnant, but among those who did,
a larger proportion chose to have an abortion. About one in five pregnancies in 2020
ended in abortion.75 Guttmacher suggested several factors may have contributed to this
increase, including more unintended pregnancies due to the Trump administration’s
policy of dramatically slashing Title X family planning services and access to contra-
ception. Other possible factors included expanded access to Medicaid coverage of abor-
tion health care in blue states and impacts of the COVID-​19 pandemic. This research
revealed a dramatic reversal of a thirty-​year trend of declining numbers of abortion,
“underscoring that the need for abortion care in the United States is growing just as the
U.S. Supreme Court appears likely to overturn or gut Roe v. Wade,” said the Guttmacher
report. “Rather than focusing on reducing abortion, policies should instead center the
needs of people and protect their right to bodily autonomy.”76
According to the Guttmacher report, the number of abortions increased in all
four regions of the country between 2017 and 2020. The rise was largest in the West
(12 percent increase) and Midwest (10 percent increase); abortions increased 8 per-
cent in the South and 2 percent in the Northeast. But there was significant varia-
tion across and within states. In some states—​including Illinois, Mississippi, and
Oklahoma—​there were substantial increases in the number of abortions. In others—​
such as Missouri, Oregon, and South Dakota—​there were substantially fewer abor-
tions in 2020 compared with 2017. Expanded Medicaid coverage of abortion health
care likely contributed to more abortions in some states, including a 25 percent
increase in Illinois and a 16 percent increase in Maine, which also required private
health insurance plans to cover abortion health care for the first time. The increased
number of abortions in Illinois was also due to people coming from nearby states that
imposed new restrictions, such as Missouri, where the number of abortions decreased
from 4,710 in 2017 to 170 in 2020. Illinois actually increased the number of clinics
from twenty-​five in 2017 to thirty in 2020. Overall, the number of abortion facilities
in the United States increased from 774 in 2017 to 790 in 2021, but with significant
geographic variation.77
COVID-​19 had varying impacts on abortion numbers across states. In hard-​hit
New York, where at least 10 percent of clinics paused or stopped providing abortion
care early in the pandemic, the number of abortions dropped 6 percent between
2019 and 2020. Meanwhile, the number of abortions dropped in states like Texas
and Alabama, which imposed COVID-​19 restrictions on abortion health care,
114 • Abortion Pills

falsely deemed “nonessential,” but the number of abortions in surrounding states

increased, likely due to women traveling from restrictive states to find abortion
health care. The Guttmacher report noted other factors that likely contributed to
state variation and overall increase in the number of abortions, including increased
fundraising by local and national abortion funds so they could help more people
pay for their abortions, increased abortion restrictions and bans (twenty-​five states
enacted 168 laws between 2017 and 2020, some of which were blocked by courts),
and seventy-​five new provisions to protect abortion rights (repealing restrictions,
expanding insurance coverage, and allowing more qualified clinicians such as nurse
practitioners, physician assistants, or certified nurse midwives to provide at least
some abortion care). “The Supreme Court is poised to overturn Roe v. Wade at a
time when need for abortion care has been increasing,” concluded the report. “This
means the impact of the ruling could be even more devastating than predicted by
prior analyses, particularly for people across the country who already struggle to
access abortion care.”78
In December of 2020, the Generative Learning Community (GLC) for self-​managed
abortion expanded, opening membership to more organizations. GLC grew to over
seventy organizations and held meetings every other month as a “gathering space” for
“shared learning and problem solving” on self-​managed abortion. GLC also engaged in
“culture change work” to normalize self-​managed abortion.79 GLC had two goals: “to
give every person the option to end a pregnancy safely and with support, within the for-
mal healthcare system, or outside it” and to “ensure no one risks punishment or impris-
onment for their reproductive choices or for supporting a person who is self-​managing
the end of a pregnancy.”80 Their purpose was to normalize self-​managed abortion by
promoting a “positive narrative, and avoiding harmful messages, about self-​managed
abortion.”81 They focused on “developing tools and actions for use in communications”
and committed to “do nothing that puts pregnant people, or those who support them,
at increased risk of investigation, prosecution, and punishment for their reproductive
choices.” This limited approach later led to a break with Plan C because of their work
to make pills available to people in states with abortion bans, which inevitably created
some legal risks.82
The GLC focused primarily on normalizing abortion pills inside the reproduc-
tive health movement. “The medical community could get overly controlling about
mifepristone,” explained Kirsten Moore. “What the GLC did was hold a mirror up to
the medical professionals and say, ‘you know you’re overthinking this, you’re over-​
traumatizing this.’ They consistently normalized the idea that patients can manage their
abortions on their own,” said Moore, noting that GLC held a full-​day workshop on self-​
managed abortion at a NAF meeting in early 2022. “It’s about getting the movement
itself to move into the twenty-​first century.”83
 Chapter 3: COVID-19 Pandemic and Telemedicine Abortion • 115

The Pendulum Swings: Biden Administration Expands Abortion

Pill Access
Immediately after the 2020 election of Joseph Biden, reproductive rights advocates
asked the new administration to review the FDA’s abortion pill restrictions. “These
restrictions place more of a burden than a benefit on providers and their patients,”
said Kirsten Moore, referring to the FDA standard for imposing the REMS restriction.
“Based on opinion research we conducted last year, people like the idea that women
have access to an option for ending an early pregnancy,” said Moore. “And they like the
idea that it’s an FDA-​approved drug that’s been around for twenty years. We think it’s
time to revisit these restrictions and move forward.”84
Even before the election, medical professionals and activists were calling on Biden
to reverse the Trump policy and end the FDA restriction on the abortion pill altogether.
A coalition of more than ninety women’s rights organizations released a “Blueprint for
Sexual and Reproductive Health, Rights and Justice” that made two demands with
regard to mifepristone. The first was that President Biden issue an executive order on
his first day in office directing the Secretary of Health and Human Services to lift the
in-​person distribution requirement for mifepristone during the pandemic. The sec-
ond demand was that within ninety days of assuming office, the president direct the
FDA to review the mifepristone REMS to determine whether it should be modified or
removed to “best reflect scientific evidence and real-​world use.”85 On January 27, 2021,
Guttmacher Institute’s president and CEO Herminia Palacio and Dr. Daniel Grossman
of ANSIRH wrote an op-​ed in The Washington Post urging Biden to remove the in-​
person distribution requirement. “Facts matter, and the facts couldn’t be clearer,” they
wrote. “In this moment, when the country is looking to the administration to heed
public health experts, it must suspend this requirement for the duration of the public
health emergency and direct the FDA to ensure its medication abortion policies are
aligned with the scientific evidence.”86 At a more personal level, Sarah Christopherson
of NWHN found people to speak directly with President Biden about mifepristone. “I
spent some time organizing high-​net-​worth major donors. I had some leftover contacts
and some leftover favors to call in from people I knew would be receptive and get it, and
be good spokeswomen for it,” said Christopherson.87
On February 9, 2021, eleven female Democratic members of the House Committee
on Oversight and Reform wrote a letter to the Acting Commissioner of the FDA Janet
Woodcock88 urging her to lift the in-​person abortion pill distribution requirement. In
the letter, they emphasized the FDA’s illogical policy on mifepristone: “Of the more
than 20,000 drugs regulated by FDA, mifepristone is the only drug that FDA requires
patients to obtain in person at a hospital, clinic, or medical office, but it does not restrict
the ability of patients to self-​administer—​unsupervised—​at home or at a location of
116 • Abortion Pills

their choosing.” They described a strong safety record of mifepristone, and the risks
imposed on patients by the in-​person distribution requirement. They concluded, “In
light of the clear danger that the reinstated requirement poses to people seeking com-
prehensive reproductive health care at the height of the coronavirus pandemic, we urge
you to immediately eliminate the medically unnecessary in-​person dispensing require-
ment for mifepristone.”89
On March 18, fifty-​five reproductive health, rights, and justice groups sent a letter to
President Biden urging his administration to lift FDA restrictions on mifepristone. The
letter emphasized the burden of the FDA restrictions on marginalized communities:

Consistent with your important commitment to follow the science in responding to COVID-​
19, as well as your critical promise to tackle issues of systemic equity across the govern-
ment, it is imperative that your administration prioritize safe access to medication abortion.
Burdensome restrictions on medication abortion, which are not based in medical evidence,
deepen the health inequities already experienced by those who are struggling to make ends
meet, particularly people of color, who comprise a majority of medication abortion patients
and are now being hit hardest by the COVID-​19 pandemic.90

Along with the letter, they delivered a petition with over 200,000 signatures of
supporters.
On April 12, 2021, under the leadership of Dr. Janet Woodcock, the FDA finally
lifted the in-​person distribution requirement for the duration of the COVID-​19 public
health emergency, allowing clinicians to resume telemedicine abortion services.91 In a
letter to ACOG and the Society for Maternal-​Fetal Medicine, Dr. Woodcock wrote that
the FDA would waive the requirement that clinicians dispense mifepristone to their
patients in a clinic or hospital setting. The letter said research studies on telemedicine
abortion “do not appear to show increases in serious safety concerns occurring with
medical abortion as a result of modifying the in-​person dispensing requirement during
the COVID-​19 pandemic.”92 ACOG issued a statement praising the new guidelines: “We
are pleased to see mifepristone regulated on the basis of the scientific evidence dur-
ing the pandemic, rather than political bias against comprehensive reproductive health
care, and we look forward to working with policy makers to ensure this principle gov-
erns post-​pandemic care.”93 Advocates celebrated the decision for following the sci-
ence. “We know from twenty years of research that medication abortion is extremely
safe—​even safer than some over-​the-​counter medications. It’s past time to permanently
lift the restrictions and make medication abortion more accessible for those who need
it,” said Dr. Grossman of ANSIRH. Online pharmacies resumed distribution of mife-
pristone by mail. Sarah Christopherson said all the strategies contributed toward their
success: “I don’t think any one strategy would have been sufficient on its own. I think
it took all of them. It took the medical studies, proving how safe it was. It took EMAA
 Chapter 3: COVID-19 Pandemic and Telemedicine Abortion • 117

working the inside angle with the FDA staff. It took us and others working the political
angle with the incoming Biden administration. It took public outrage. It took all of it.”94
After their success with lifting the in-​person distribution requirement for mife-
pristone for the duration of the pandemic, reproductive health advocates immediately
pressed the FDA to permanently drop the restriction. “We must now fight to make
this change permanent, and to lift all medically unnecessary restrictions on medication
abortion during the pandemic and beyond,” said Cynthia A. Pearson, NWHN execu-
tive director.95 Advocates emphasized that the FDA action was not enough because
many states still had laws prohibiting telemedicine abortion or requiring ultrasounds
that had the same effect. “This is great that the FDA used science to reduce this barrier,
but it’s clearly not enough,” said Plan C’s Elisa Wells. ”We have a huge equity issue in our
country for access to abortion because of the state-​based laws. We know that the people
who are the hardest hit by abortion restrictions are people who are already marginal-
ized either by their skin color or their socio-​economic status or, in some cases, their
gender identity.”96 At the time, a new ban on telemedicine abortions in Ohio had just
been blocked by a state court, but other states were considering similar bans, including
Indiana, Arkansas, Iowa, Alabama, Texas, Oklahoma, Wyoming, and West Virginia.
Wells predicted that increasing access would create change across the country.
“With the FDA ruling and with the types of services that are going to pop up, it’s really
going to raise awareness in this country that we have this option of abortion pills, which
a lot of people don’t even know about, and of the fact that you can get them in this very
simple, very private, and very safe and effective way,” said Wells. “Once that genie is out
of the bottle, it’s not going back in. It’s going to be available in more liberal states. As
it becomes more normalized and more mainstream, then people who live in the more
restrictive states will have more ammunition to demand access to it in their states as
well. That’s always been our strategy to start with the low-​hanging fruit—​the liberal
states—​demonstrate the model, and then generate demand for it in the states that are
more restrictive.”97
On May 7, the Biden administration announced that the FDA would undertake a
full review of the in-​person distribution requirement for mifepristone and consider
permanently removing it. The announcement came as part of a joint legal filing in
the ACLU lawsuit Chelius v. Becerra, challenging the REMS restrictions.98 As a result
of FDA actions, more virtual telemedicine abortion clinics opened (see Figure 3.4).
Abortion on Demand launched in twenty states and Washington, DC, in April of 2021,
conducting appointments by videoconference, using express shipping for next-​day
arrival, and charging $239. They checked in by text after the patient had taken the
pills and offered support from a doctor twenty-​four hours a day, seven days a week.99
Pills by Post, launched in Colorado, Illinois, and Minnesota in the fall of 2021, offered
telemedicine abortion by phone consultation for a sliding scale fee of $150.100 Hey Jane
offered telemedicine abortion in Washington and New York for $249 using the Spruce
118 • Abortion Pills

Figure 3.4: Logos from some of the telemedicine abortion providers in 2020 and 2021 (design by
Roxy Szal).

app, a HIPAA-​compliant texting app, but allowed patients to request a videoconfer-

ence or telephone call any time.101 Forward Midwifery offered telemedicine abortion in
California by telephone for a sliding scale $150 fee.102
More brick-​and-​mortar reproductive health clinics began offering telemedicine
abortion as well, often charging more than virtual clinics but sometimes less than in-​
clinic medication abortion. Unlike many virtual clinics, brick-​and-​mortar practices
usually accepted insurance. A nurse practitioner, Robin Tucker, at the Bethesda-​based
Metro Area Advanced Practice Healthcare began offering telemedicine abortion in the
fall of 2021, serving people in Virginia, Maryland, and Maine for a sliding scale fee
of $150.103 A reproductive healthcare provider in Seattle, Dr. Deb Oyer, was an early
adopter of this approach when she began offering telemedicine abortion via videocon-
ferencing in April of 2020 as part of her reproductive healthcare practice. She accepted
health insurance and charged $600 for cash pay patients, which included a follow-​up if
they needed a procedural completion.104
Family medicine doctors also began offering telemedicine abortion as part of their
general practice or on the side. Dr. Michele Gomez, a family medicine doctor work-
ing for Family Care Associates in Burlingame, California, began offering telemedicine
abortion by videoconference to her patients shortly after the pandemic started. She
charged a self-​pay price of $280 but also accepted insurance.105 Dr. Alison Case based in
Indiana and working at a federally qualified health center began offering telemedicine
abortion part time in the fall of 2021 through Whole Woman’s Health to people in New
Mexico for $400. Half of her patients came from Texas.106
Research on telemedicine abortion during the pandemic confirmed that many
patients preferred telemedicine to in-​clinic abortions. Telemedicine patients reported
 Chapter 3: COVID-19 Pandemic and Telemedicine Abortion • 119

that they liked to choose their consultation location and reported feeling more relaxed
during the consultation, whereas women with in-​clinic appointments reported their
consultations as “lengthy, chaotic and lacking comfort.”107 One telemedicine patient
explained, “I like the flexibility of doing things virtually, so I was able to just do it while
I was at work. I didn’t have to take time off because I [have to be at work during] the time
that clinics are open.” Telemedicine patients reported that they appreciated that there
was no one else around or that their friends could be with them. On the other hand, an
in-​clinic patient reported, “While at the clinic, it felt like cattle herding, go in, get it done,
go out, and go to the next room.” In-​clinic patients also reported discomfort having
to pass protesters at the clinic. Researchers concluded that telemedicine consultations
allowed patients to “feel like their encounter was more controlled and relaxed.”108
To help medical providers wanting to offer telemedicine abortion, Plan C worked
closely with them through the process of registering with the drug manufacturers
Danco or GenBioPro, developing their telemedicine platforms, and signing up with
Honeybee Health, American Mail Order Service, and later a third dispensary, Manifest
Pharmacy. These new telehealth abortion providers made medication abortion more
convenient, affordable, and accessible for many people, especially low-​income people
and those living in rural areas. Some traditional abortion providers, however, did not
welcome telemedicine abortion. “Clinics that have been providing in-​clinic care all
these years are feeling threatened by alternative modes of care,” said Emily Godfrey, a
primary care provider who conducted research on telemedicine abortion.109
To encourage broader access to medication abortion, the New York City-​based fam-
ily medicine doctor Joan Fleischman issued a call to action to primary care providers to
integrate early abortion services into their practices. Around sixty clinicians expressed
their support. Dr. Michele Gomez and Dr. Erica Bliss from Seattle, Washington, joined
Dr. Fleischman to form an organization called the MYA Network to train and sup-
port primary care physicians and other medical providers to offer medication abortion.
“Early abortion can be part of a regular primary care practice, so the patient doesn’t
have to be referred anywhere else,” explained Gomez. “Because it’s medically simple,
you don’t need to have a high volume to be good at it. Early abortion is not medically
complicated and can be safely provided by any primary care clinician with the right
training. Telemedicine abortion is particularly easy. Family medicine doctors, primary
care internal medicine doctors, and advanced practice clinicians like nurse practitioners
and physician assistants are perfectly capable of providing early abortions.”110 The MYA
Network created a website listing primary care providers offering medication abortion
by state so patients could find them. By early 2022, they listed clinicians in seven states.
According to ANSIRH, the number of providers of medication abortion and tele-
health abortion increased significantly between 2020 and 2022. The number of facili-
ties offering medication abortion increased from 733 in 2020 to 773 in 2021 to 789 in
2022. The proportion of those facilities that provided telehealth with the option to have
abortion pills mailed to pregnant people increased from 52 (7 percent) facilities in 11
120 • Abortion Pills

states in 2020 to 91 (12 percent) facilities in 25 states in 2021 to 243 (31 percent) facili-
ties in 27 states in 2022. The number of virtual clinics increased as well. In 2021, 32
virtual clinics were providing care via telehealth in 22 states and DC (4 percent of 773
facilities offering medication abortion). By 2022, 69 virtual clinics provided this care in
23 states and DC (9 percent of 789 facilities offering medication abortion).111
As legislators and courts erected higher and more daunting barriers to delay and
obstruct access to abortion health care, public health experts began arguing for creative
new ways to ensure that people who want or need to end unwanted pregnancies could
get abortion pills quickly and use them safely. One strategy was advance provision of
abortion pills—​to have them on hand prophylactically. In December of 2021, Katherine
Ehrenreich, Antonia Biggs, and Daniel Grossman at ANSIRH published an editorial in
a leading public health journal, arguing for advance provision of abortion pills as an
option and explaining how it could work in practice. They recommended that clini-
cians who prescribed abortion pills in advance should provide patients with informa-
tion about how to take the pills and offer support and follow-​up care if patients later
chose to use them.
Ehrenreich, Biggs, and Grossman argued that this model could significantly shorten
the time between the decision to end a pregnancy and having an abortion, and short cir-
cuit the medically unnecessary obstacle course that existed in many states for people try-
ing to access medication abortion.112 “Patients often face unnecessary delays in accessing
abortion care—​from state-​mandated waiting periods to delays due to overcrowded clin-
ics. If patients have pills on hand in advance, those delays are eliminated,” said Grossman.
“Before emergency contraception (aka the morning-​after pill) became available over the
counter, clinicians often gave it to patients in advance to have on hand when they needed
it. Given the restrictions on abortion, we should think about this strategy for abortion
pills.”113 They noted that mifepristone had a shelf life of about five years, and misoprostol
had a shelf life of about two years when stored in a dry, dark place. “There are some chal-
lenges with advance provision, including the cost of the pills and state legislation that may
limit this model,” said Grossman. “But I hope clinicians will consider this option given the
crisis in abortion access we are currently facing.”114
Research showed many women wanted to have abortion pills on hand in case they
had an unintentional pregnancy. In one national survey, 44 percent of respondents said
they would be interested in advance provision of abortion pills. Those who faced bar-
riers to reproductive health care were more likely to want pills in advance.115 “While
a future landscape of medication abortion may include telemedicine and mail-​order
pharmacy dispensing, advance provision may be a preferable option for those who
would continue to face barriers to care,” wrote Ehrenreich, Biggs, and Grossman.116
As the FDA considered whether to permanently remove the in-​person distribution
requirement, Plan C and telehealth providers made significant progress in developing sys-
tems to get pills in people’s hands as easily as possible, preparing the way for what would
come as the Supreme Court readied itself to overturn constitutional abortion rights.
 CHAPTER 4

“Trying to Shake Abortion

Pills Free from the Gatekeepers”:
Eroding Abortion Rights and
Expanding Self-​Managed Abortion

FDA restrictions on mifepristone and the medical profession’s tight control of abor-
tion pills combined with the anti-​abortion movement’s success in closing down clinics
to leave many women without access to medication abortion. An increasing num-
ber turned to self-​managed abortion. With a supermajority of anti-​abortion judges
on the Supreme Court and the overturn of Roe v. Wade looming, activists worked
to increase access to telemedicine, but they also doubled down on finding creative
ways to help people access abortion pills outside of the medical system. Despite the
legal risks, US advocates worked with women in other countries to develop alterna-
tive supply networks for abortion pills that would play a critical role post-​Roe. But
not everyone agreed with this approach, leading to divisions in the movement. This
chapter describes the growing legal restrictions on abortion in 2021, advocates’ work
to increase access to abortion pills both inside and outside of the medical system,
conflicts among abortion advocates about self-​managed abortion, and concerns about
legal risks.

Texas Bans Abortion: S.B. 8 Spurs Self-​Managed Abortion

In the first four months of 2021, anti-​abortion lawmakers introduced 536 abortion
restrictions in forty-​six states, including 146 abortion bans, according to a report
released by the Guttmacher Institute. They enacted sixty-​one restrictions in thirteen
states, including eight “trigger” bans that would go into effect when the Supreme
Court overturned Roe v. Wade.1 As abortion in the formal medical system became less
accessible and more expensive, people increasingly turned to alternative sources such
as Aid Access to obtain abortion pills.
122 • Abortion Pills

Online demand for abortion pills had surged when the pandemic hit in early 2020,
especially in states that closed abortion clinics such as Texas, where requests for abor-
tion pills made to Aid Access increased by 94 percent.2 Another surge began on May
17, 2021, when the US Supreme Court announced they would hear a case involving
a Mississippi abortion ban. Online searches for terms related to abortion pills such
as “misoprostol” and “medical abortion” exploded by more than 5,000 percent in the
twenty-​four hours after the Court’s announcement. “We see a definite spike in visi-
tors to our website when there is news about abortion bans,” said Elisa Wells after the
announcement. “People are looking for ways to access abortion pills. The need for
abortion is never going to go away. When you cut off mainstream supply of it through
clinical means, people will look for other ways to access the service.”3
A similar surge happened on May 19 when the Texas governor signed legislation,
called Senate Bill 8 or S.B. 8, banning abortion at six weeks, enforceable by private
civil suits.4 Six weeks is only a week or two after most women first miss a period after
becoming pregnant. S.B. 8 allowed anyone to sue another person for assisting someone
to have an abortion after six weeks of pregnancy and rewards them with $10,000 and
attorney fees if they succeed—​creating a bounty-​hunting scheme that encouraged the
general public to bring costly and harassing lawsuits against anyone who they believed
had violated the ban. The law authorized lawsuits against health center staff, abortion
funds providing financial assistance, anyone who drives a friend to obtain an abor-
tion or otherwise provides help, and even a member of the clergy who counsels an
abortion patient. The law also allowed anyone to file a lawsuit, including a parent, an
abusive partner, or even a stranger. By delegating authority to enforce the law to private
individuals, Texas hoped to evade judicial review because abortion rights were pro-
tected by the 14th Amendment, which applied to state action but not private action.
The Guttmacher Institute estimated that the law would increase the average distance
traveled one way to obtain abortion care twenty times, from twelve miles to 248 miles.
They predicted the law would be particularly harmful to women of color in Texas,
where 19 percent of Black women and 20 percent of Latinx women lived in poverty.5
Reproductive rights advocates challenged the constitutionality of S.B. 8 in federal court,
but lower courts ruled against the challengers, who appealed to the US Supreme Court.
These developments spurred Plan C activists into high gear (see Figure 4.1).
In the days leading up to the ban’s effective date on September 1st, Plan C joined up
with Progress Texas to drive a mobile billboard truck around West Texas for three days
to educate people about how they could access abortion pills online (see Figure 4.2). “As
Texas increases restrictions on abortion care, we’re here to let folks know that abortion
pills by mail are a safe and effective alternative,” said Francine Coeytaux, co-​director of
Plan C. Advocates drove a truck with illuminated billboards around the Texas towns of
Lubbock, Amarillo, Midland, and Odessa. The billboards read, “Missed period? There’s
a pill for that. PlanCPills.org. #TXDeservesBetter.” The back of the truck read “Plan
Figure 4.1: Plan C strategy meeting in 2021 (photo credit: Tracy Droz Tragos).

Figure 4.2: Plan C’s illuminated mobile billboard truck driving a Texas highway to inform the public
about how to get abortion pills (photo credit: Plan C).
124 • Abortion Pills

C. Convenience. Confidentiality. Control. PlanCPills.org.” They drove to universities,

past City Hall, around the medical district, and in the evenings by bars and restau-
rants.6 “We went on an abortion road trip to let people know that you don’t need to go
on a road trip anymore to get an abortion. You can get an abortion by mail basically
anywhere in the United States, including in Texas,” said Elisa Wells. “The reception was
fantastic.”7 Plan C advocates posted stickers in bathrooms saying, “Want to be unpreg-
nant?” with a QR code for their website (see Figure 4.3).
Throughout the campaign, Plan C shared activist art on Instagram and hosted a
lively dialogue in the comments (see Figures 4.4 and 4.5). At one point, Instagram sus-
pended Plan C’s account for violating community guidelines by sharing information
about abortion. Undaunted, supporters flocked to other platforms like TikTok and
Twitter to raise their voices and amplify Plan C information and art. Instagram later
reinstated Plan C’s account after Jezebel published an article condemning the suspen-
sion. The campaign sought to reach students in particular. The truck visited Texas Tech
University in Lubbock and West Texas A&M near Amarillo, talking to students and
handing out flyers. Many students had never heard of online access to abortion pills
and expressed interest and gratitude to Plan C advocates for the information. “We want
to make sure that people know that you don’t have to drive twelve hours for an abor-
tion,” said Wells. “You don’t have to take time off from work and get childcare and pay
hundreds or thousands of dollars in order to get an abortion. You can get an abortion by
mail. It’s the twenty-​first century. Between safe and effective pills by which people can

Figure 4.3: Francine Coeytaux placing a Plan C sticker on a bathroom mirror in Texas in 2021. The
sticker reads, “Want to be unpregnant?” with a QR code to the Plan C website (photo credit: Tracy Droz
Tragos).
 Chapter 4: Eroding Abortion Rights and Self-Managed Abortion • 125

Figure 4.4: Plan C shared this image as part of a social media campaign to inform Texans about how to
obtain abortion pills after S.B. 8 went into effect in September 2021 (designed by @yessiichula).

easily self-​manage an abortion and the modern miracle of the internet and the global
economy, we have access.”8
The United States Supreme Court allowed S.B. 8 to go into effect on September 1,
2021,9 leading to the shut-​down of abortion services after six weeks across Texas. Anti-​
abortion groups set up online forms enlisting people to sue and encouraging anyone to
submit “anonymous tips” on doctors, clinics, and others who violated the law. The anti-​
abortion group Texas Right to Life created a website, ProLifeWhistleblower.com, which
was quickly flooded with fake reports from abortion rights supporters. In the first week
after S.B. 8 went into effect, Plan C saw traffic on its website spike 2,357 percent—​with
30 percent of those new visits coming from Texas.10 While 2,220 Texans had visited the
Plan C website in April 2021, 34,996 Texans visited the website in September.11
126 • Abortion Pills

Figure 4.5: Plan C shared this image as part of a social media campaign to inform Texans about how to
obtain abortion pills after S.B. 8 went into effect in September 2021 (designed by @rhiannamariechan).

The enactment of S.B. 8 drove people to Aid Access. The average daily requests for
abortion pills from Texas to Aid Access increased almost twelve-​fold—​from 10.8 to
137.7 per day. In the following three months, requests remained higher than before,
at 29.5 per month or 174 percent higher than before S.B. 8 went into effect.12 In a
study of the Aid Access website traffic, Abigail Aiken of University of Texas at Austin
explained: “The bottom line here is that this study provides us with pretty strong evi-
dence that Senate Bill 8 was directly related to an increase in the need for self-​managed
abortion in Texas. Senate Bill 8 remains the strictest gestational limit on abortion any-
where in the United States. We know that there has been a decrease in the number of
abortions within Texas clinics. A direct result of that has been that more people have
been looking into the option of an abortion outside of the formal healthcare setting.”13
 Chapter 4: Eroding Abortion Rights and Self-Managed Abortion • 127

The number of abortions in Texas clinics dropped by over half between September of
2020 and 2021—​from 4,511 to 2,164, but Aid Access received 1,831 requests for abortion
pills from Texas in September 2021 alone. Aid Access requests in September equaled
78 percent of that month’s drop in the number of abortions due to S.B. 8. “We can see
here that self-​managed abortion is filling a gap that has been left by the impacts of Senate
Bill 8 on access to in-​clinic care,” said Aiken.14 Even before the law went into effect, pro-
viders saw an uptick in abortion pill orders when in late March 2021 the Texas House
passed S.B. 8. Requests made to Aid Access increased not only in Texas but in other
states as well.15 “It’s a smaller uptick than in Texas but follows a pretty similar pattern,”
said Aiken. “We wondered if all this attention on S.B. 8 may have drawn the attention of
people in other states to self-​managed abortion and Aid Access. Even without a law as
extreme as S.B. 8, abortion is extremely hard to access in many other U.S. states.”16
In Mississippi, where there was only one abortion clinic left, many women were
already obtaining abortion pills outside of the formal medical system by 2021, accord-
ing to Michelle Cohen, executive director of Sisters Helping Every Woman Rise and
Organize (SHERo) in Mississippi. “People were probably using Aid Access because it
was everywhere. But there were other ways that they were getting the pills as well, such
as going to Mexico and getting the pills themselves. A lot of activists were preparing
for this.”17 Mississippi, like Texas, was one of the states where abortion became largely
unavailable even before the Supreme Court overturned Roe v. Wade, so people there
were early adopters of strategies that later became widespread.
Aiken said increased awareness of abortion pills may have led to more people
choosing to self-​manage their abortions even when they had access to clinic-​based care
for reasons of affordability, privacy, and convenience. “Self-​managed abortion is the
backup, second-​string option for many, but for some people, it may be a preference. We
know that from prior research,” said Aiken. “It may be something they’ve been unaware
of previously, so knowing about it might mean that more people for whom it is a prefer-
ence might choose it.”18
Texas’s newly enacted abortion ban was blocked by a federal court on October 6, then
reinstated on October 8 by the Fifth Circuit Court of Appeals. Meanwhile, the Texas
Governor Greg Abbott signed a new law, Senate Bill 4 or S.B. 4, making it a felony for
doctors to mail abortion pills to patients. Violating the law was punishable by up to two
years in jail and a fine of $10,000. The law applied only to doctors and explicitly exempted
pregnant people from criminal penalties for ordering pills online. In addition to banning
doctors from mailing abortion pills, S.B. 4 also prohibited doctors from prescribing abor-
tion pills after seven weeks of pregnancy—​three weeks before the FDA limit of ten weeks.19
At the time, Wells said the laws would not affect the flow of abortions pills into the state:

The antis are trying anything and everything they can to stop access to the medications.
The good news for our model is that it’s not really going to have any effect on the supply
128 • Abortion Pills

sources that we point people to, like Aid Access and online pharmacies mailing pills to
people in Texas because those are all operating outside of these regulated structures. They
probably don’t have people sitting in Texas who are doing the mailing, but they are prob-
ably mailing from other states or mailing from post office boxes or fake return addresses or
hidden return addresses.20

Anticipating the overturning of Roe v. Wade, Texas politicians in June adopted a “trig-
ger ban” that would immediately outlaw abortion in Texas if the Supreme Court over-
turned Roe v. Wade.
The increase in telemedicine and self-​managed abortion in 2021 provided new
opportunities for researchers to study abortion pills—​research that would play an
important role in determining the future of abortion pills in a post-​Roe America.

New Research Supports the Safety of Telemedicine and

Self-​Managed Abortion
As the Supreme Court appeared poised to overturn Roe v. Wade and states passed
abortion restrictions in unprecedented numbers, many people feared a return to the
pre-​Roe nightmare, when women suffered severe health consequences and even death
from illegal abortions. Aiken said her research gave her hope that this would not hap-
pen. “I think we’re talking about a very different overall picture because of the acces-
sibility of abortion pills and because of the model of care that Aid Access provides,”
said Aiken. “In the pre-​Roe period, hospital wards were full of people suffering ter-
rible infections because of the effects of unsafe abortion. Self-​managed medication
abortion is a lot safer. And, thankfully, people are reporting it as something that is
acceptable to them as an experience, which is also very important.” Aiken said what
happened in Texas showed what could happen in other states in the future. “We defi-
nitely have a window on what the rest of the country may look like, especially in
states where there are already trigger laws in place where abortion will be banned
immediately or severely restricted if Roe is overturned. People still need to find ways
of accessing the care they need. It’s reassuring to think that we have a safe, effective,
and acceptable way for people to go ahead and access that care and preserve their
reproductive autonomy.”21
A study released in May 2021 explained why people turned to Aid Access. “Even
though we still have the right to abortion in this country, so many people struggle to
actually exercise that right and access abortion,” said the study’s lead author, Dr. Aiken.22
The study revealed that the rate of requests increased steadily between 2018 and 2020.
“As more people are finding out about it, we are seeing the rate of requests going up. As
legislators make in-​clinic abortion harder and harder to get, people are having to look
for viable alternatives,” said Aiken.23 The research found that states with the most policy
 Chapter 4: Eroding Abortion Rights and Self-Managed Abortion • 129

restrictions on in-​clinic abortion had the highest rates of requests to Aid Access, such as
Louisiana, Mississippi, Wyoming, and Alabama. The lowest rates of self-​managed abor-
tions were in Vermont, Connecticut, Oregon, and California, but requests to Aid Access
came from all fifty states. Dr. Aiken attributed this to the burdens inherent in medical-
ized abortion care: “Even if you live in a state where you don’t have to jump through a
lot of state-​mandated hoops to get an abortion, you still have to take time away from
your job, or away from your family, or away from your other responsibilities.”24
The most common reasons people used the Aid Access services were the inability
to afford in-​clinic care (73.5 percent), a desire for privacy (49.3 percent), and clinic
distance (40.4 percent). Other reasons given were the inability to take time away from
work or school to go to a clinic (37.6 percent), greater comfort self-​managing their
abortion at home (28.2 percent), and greater convenience of self-​managed abortion
(27 percent). About a quarter of respondents said they were self-​managing their abor-
tion because they didn’t want to deal with protesters outside of clinics.25 “Cost and pov-
erty are motivators when it comes to self-​managed abortion,” said Aiken. “The more
people who live in poverty in an area, the higher the rate of requests.” A 10 percent
increase in the population living below the federal poverty level was significantly asso-
ciated with a 20 percent increase in requests. States with restrictions on insurance and
Medicaid abortion coverage tended to have higher baseline request rates. Traveling
long distances to clinics was particularly hard on those in poverty. Counties with high
levels of poverty located far from abortion clinics had the highest rates of Aid Access
requests. An increase of forty-​seven miles in distance to the nearest clinic was associ-
ated with a 41 percent increase in requests. However, in places where individuals could
not afford the cost of an in-​clinic abortion, a shorter distance to a clinic was not associ-
ated with improved access.
Dr. Aiken’s research highlighted the inequities people experienced. “We already
know that access to reproductive health care, including abortion, depends on where
you live and how much money you make,” said Aiken, “but with our recent evidence
showing strong associations between the distance to the nearest abortion clinic or living
below the federal poverty level with higher rates of requests for abortion pills online,
we can see that state bans are being layered upon structural inequities to restrict abor-
tion access in our communities.”26 Aiken summed up her research: “people are resilient
and resourceful. They are going to find other ways. People have always found ways to
get the abortion care they need.”27 She also concluded that Aid Access provided quality
services. Based on interviews with over eighty people who had used Aid Access ser-
vices, Aiken concluded, “it’s a well-​run service. It’s trustworthy. It’s run by people who
actually care about the folks that they are trying to serve. It’s also affordable—​entirely
non-​profit.”28
Research on telemedicine abortion within the formal medical system also showed
patients were having positive experiences. Expanding telemedicine abortion services
130 • Abortion Pills

due to COVID-​19 not only increased access to abortion health care for people living
in states allowing the service, but also created new opportunities for research on the
practice both in the United States and abroad, which provided scientific evidence later
relied on by the FDA in its consideration of whether to lift the in-​person dispensing
requirement.
Unlike the piecemeal implementation of telemedicine abortion during COVID in the
United States, the United Kingdom implemented a nationwide telemedicine abortion
policy early in the pandemic. The Royal College of Obstetricians and Gynaecologists
published new guidelines for medication abortion: consultations were encouraged to
take place by telephone or video call, and an in-​person visit and ultrasound scans were
required only if indicated. By the end of March 2020, the British government had issued
emergency legal orders allowing no-​test medication abortion where abortion providers
could treat their patients via telemedicine and mail abortion pills to their patients to
take at home.
This shift in policy allowed researchers for the first time to assess a real-​world no-​
test telemedicine abortion care model in a national population. Researchers compared
patients receiving the traditional in-​patient model of care, with in-​clinic ultrasounds, to
a telemedicine-​hybrid model where patients are screened for eligibility for telemedicine
abortion care without an ultrasound but by patients reporting their symptoms. Based
on a sample size of 52,142 people, researchers found that the no-​test telemedicine abor-
tion model was just as safe and effective as the traditional in-​person medication abor-
tion model. Patients actually preferred this option to the in-​person model. The study
found that patients reliably reported their last menstrual period, with only 0.04 percent
estimated to be over ten weeks gestation at the time of the abortion. Overall effective-
ness was higher with telemedicine than in-​person care (99.2 percent vs. 98.1 percent)
and in-​clinic and telemedicine abortion were equally safe, with very low rates of serious
adverse events (0.02 percent vs. 0.04 percent). There were no cases of significant infec-
tion requiring hospital admission, major surgery, or death.29
“We have now robust evidence that providing early medication abortion using a
model that has no clinical tests and is done by telemedicine is just as safe and effective
as a fully in-​person model,” said Dr. Aiken. “That is particularly significant because we
have so many state laws here in the US that are set up to prevent exactly that type of a
model from being put into place. This study is showing us that there is really no reason
in terms of safety, or effectiveness, or indeed patient acceptability not to go ahead with
that kind of model.”30
In the UK study, telemedicine abortion was in fact superior to in-​clinic care in sev-
eral respects. For example, patients received treatment more quickly. Whereas the wait
time for in-​clinic medication abortion was 10.7 days, the wait time for patients using
the new no-​test telemedicine model was only 6.5 days, 4.2 days shorter.31 “When some-
one is experiencing a pregnancy that they don’t want, the longer they are kept waiting
 Chapter 4: Eroding Abortion Rights and Self-Managed Abortion • 131

to end that pregnancy, the more likely they are to experience anxiety, stress, and nega-
tive emotions,” said Aiken. “In terms of good patient care, allowing people to access
services when they want to access them is a patient-​centered thing to do.”32 As a result,
patients are able to receive care earlier in their pregnancy—​with duration of the preg-
nancy at the time of the abortion significantly reduced with the telemedicine model of
care. Only 25 percent of in-​clinic medication abortion occurred at or before six weeks,
whereas 40 percent of telemedicine abortions did. Earlier treatment decreased patients’
experiences of nausea or other negative symptoms of early pregnancy.33
Telemedicine abortion was also less expensive, said Aiken. “If we require patients
to come to a clinic, maybe on more than one occasion, if we are asking them for a
waiting period or to come for an ultrasound and then come back for a clinical test and
come back for the abortion pills—​that adds up. The more you can establish the medica-
tion abortion procedure through telemedicine and in somebody’s home, the more costs
you can avoid to both the patient and the healthcare system.”34 She noted affordability
was particularly important in the United States because, unlike the UK, the United
States does not have universal health care and many patients pay for abortion out of
pocket. Furthermore, Medicaid does not cover abortion, and many states block private
insurance plans from covering it. Finally, anti-​abortion laws were leading to the closure
of many clinics so patients often had to travel long distances to reach in-​person care,
which increased not only the cost but also the likelihood of exposure to COVID-​19.
Aiken conducted additional research on whether the telemedicine-​hybrid model of
care decreased the number of patients seeking medication abortion outside the formal
healthcare setting. In January 2021, Aiken and colleagues published research showing
that demand for medication abortion from abroad—​through the online telemedicine
service Women on Web during COVID-​19—​decreased significantly in Great Britain,
which she attributed to the implementation of a fully remote no-​test telemedicine abor-
tion service. In other countries, such as Northern Ireland and Portugal, where abortion
services were provided mainly in person in hospitals, or abortion was unavailable and
international travel was prohibited during lockdown, demand for telemedicine abor-
tion from Women on Web went up significantly.35
Aiken concluded that the evidence for the safety and efficacy of telemedicine abor-
tion was compelling. “We have the outcomes of over fifty thousand medication abor-
tions before and after the service change. It’s a really big sample size and that helps us
to be confident in our estimates. The bigger the sample size, the sharper the estimates
of safety and effectiveness,” said Aiken. “We also were able to account for 85 percent of
all the abortions that took place during our study period. So we feel pretty good about
applying the results of that study to the population because we have such a large and
widespread sample.”36
Research on telemedicine abortion in the United States showed levels of safety and
efficacy similar to the UK study. Gynuity published a study in March of 2021 showing
132 • Abortion Pills

that the TelAbortion services with ultrasounds were just as safe and effective as in-​clinic
medication abortion.37 In August of 2021, the first-​ever study on the safety and effec-
tiveness of new online clinics offering telemedicine abortion without ultrasounds was
published. The research tracked the efficacy and safety of fully remote, asynchronous
medication abortion care provided by the virtual clinic Choix to 141 patients between
October 2020 and January 2021. Among the 110 patients reporting outcomes, 95 percent
had a complete abortion without intervention, 5 percent required medical care to com-
plete the abortion, and no patients reported any major adverse events. The study con-
cluded that this “efficacy rate is similar to in-​person provision, suggesting that abortion
provided via telehealth is feasible and safe.”38 The study’s lead author Ushma Upadhyay,
an ANSIRH researcher and associate professor at University of California, San Francisco,
stated, “This study shows that abortion can be as simple and private and autonomous as
having a telehealth consultation with a clinician and having medications mailed directly
to you at your home or your friend’s home.”39 Upadhyay hoped her research would
encourage more providers to offer telemedicine abortion: “This research means provid-
ers can assess whether a patient is eligible just by a simple conversation with her about her
medical history. That opens the door for so many additional clinicians that can offer this
service, campus student health centers, rural nurses and doctors, family practice physi-
cians. This study is one step towards making medication abortion more normalized and
integrated into primary health care.”40 Upadhyay hoped her research would convince the
FDA to remove their in-​person distribution requirement for mifepristone.
Other researchers spoke out about the importance of telemedicine abortion as well.
In July of 2021, the journal Contraception published a special issue on the mifepristone
REMS.41 Articles included in the issue described the REMS as “needless and unlawful
barriers to care,” noting the disproportionate burdens of the REMS on vulnerable pop-
ulations and several advocated for removing the in-​person dispensing requirement.42
Advocates submitted this new research to the FDA as it considered whether to perma-
nently remove the REMS on mifepristone.43

FDA Loosens REMS Restrictions on Mifepristone

In light of the research showing the safety of abortion pills and telemedicine abor-
tion as well as the growing restrictions on abortion access in many states, members
of the US House of Representatives took action to support medication abortion. On
August 17, 2021, Reps. Carolyn Maloney (D-​NY), Diana DeGette (D-​Colo.), Barbara
Lee (D-​Calif.), and Ayanna Pressley (D-​Mass.) jointly announced a resolution to sup-
port “equitable, science-​based” policies governing access to the abortion pill. “Patients
should be able to receive medication abortion in the way that makes most sense for
them, from the provider of their choosing, whether that is at a health center, their local
pharmacy, or delivered to their home,” the resolution stated.44
 Chapter 4: Eroding Abortion Rights and Self-Managed Abortion • 133

The resolution had seventy-​five original sponsors and soon gained another ten.
“Mifepristone is extremely safe—​the FDA’s own data confirms this,” said Maloney,
who was chairwoman of the Committee on Oversight and Reform. “It’s time that we
trust the science and ensure access to safe, legal abortion, particularly for communities
where abortion care has been historically pushed out of reach.”45 The resolution was
endorsed by more than forty medical, reproductive rights, reproductive justice, and
legal advocacy organizations, including ACOG, Physicians for Reproductive Health,
and NWHN. Nevertheless, anti-​abortion states continued to pass further restrictions on
the medication, often falsely claiming the laws would protect women’s health. Around
this time, Dr. Daniel Grossman and other researchers published a study showing that
medication abortion care with mifepristone dispensed by pharmacists was effective,
with a low prevalence of complications, and patients were satisfied with pharmacists
dispensing the medication.46
Even as state restrictions on abortion were tightening, the FDA moved in the
other direction, to a degree. On December 16, 2021, the FDA partially lifted the
REMS restriction by removing the longstanding rule that healthcare providers must
dispense mifepristone to patients in person. Advocates applauded this change. “The
FDA’s decision to permanently remove the in-​person pill pick-​up requirement is a
major step forward that will enable many more patients to get this safe and time-​
sensitive medication as soon as they are ready, without travel-​related expenses and
delay,” said Georgeanne Usova, senior legislative counsel at the ACLU. “From the
person living in a rural community hundreds of miles from the nearest clinic to the
patient who wants to access this essential care in the privacy and comfort of their
home, the FDA’s decision will come as a tremendous relief for countless abortion and
miscarriage patients.”47
Kristin Moore of EMAA also applauded the decision. “Today, after reviewing
years of evidence on the safety and effectiveness of medication abortion care, the FDA
removed some outdated barriers. The in-​person dispensing requirements on medica-
tion abortion care have proven to be unnecessary during the pandemic, and the FDA
did the right thing today by lifting them. Certified prescribers no longer have to be
both doctor and pharmacist—​meaning they can just write a prescription and have that
prescription filled by a pharmacy.”48
Politicians spoke out in support of the FDA change. “For too long, patients have had
to jump through burdensome hoops just to get medication abortion that we know is
safe and effective,” said Senator Patty Murray from the state of Washington. “For some
women, that’s meant finding time off from work or finding childcare to travel long dis-
tances to a clinic, and being harassed as they enter the provider’s facility—​all to take a
pill that is safe to take at home. That’s why I’m so relieved that today the experts at the
FDA are lifting some of these restrictions and making it easier for patients to get and
take medication abortion.”49
134 • Abortion Pills

Despite lifting the in-​person distribution requirement, the FDA kept mifepristone
within its highly restrictive REMS drug safety program. Under the REMS restrictions,
healthcare providers still had to register with the drug manufacturer to become certi-
fied to prescribe mifepristone. Advocates condemned the restriction as unnecessary
and contrary to medical science. “The FDA’s failure to remove all of the restrictions
on mifepristone ignores the science and smacks of political interference,” said Elisa
Wells.”50 Kristin Moore agreed that the FDA should remove the REMS: “More change
is needed. With access to abortion hanging by a thread nationwide, the FDA must per-
manently lift all the restrictions on medication abortion care so people can get the
care they need in the way that makes sense for them, including by going to their own
healthcare professional.”51
Advocates pointed out the negative impact the remaining restrictions would have
on marginalized people. Destiny Lopez, co-​president of All* Above All, said:

While the action today will go a long way for people seeking care, other barriers remain
and must be lifted once and for all. At a time when abortion care is under attack like never
before, especially for folks working to make ends meet, we can’t afford partial solutions. The
FDA must permanently lift all restrictions on medication abortion and states with politically
motivated bans on medication abortion, particularly via telehealth, must reverse these poli-
cies so people can get care in a way that makes sense for them.52

Francine Coeytaux argued that the prescriber certification requirement had been a
significant barrier to increasing the number of clinicians who could offer medication
abortion, noting that many providers could not become certified because they worked
within institutions that would not allow them to apply.
FDA made another change in the REMS, however, that would reduce the bur-
den on clinicians who prescribe mifepristone: they announced they would for
the first time allow brick-​ and-​­
mortar pharmacies to dispense the medication.
Advocates hoped this would mean more medical providers would be willing to
apply for certification and prescribe abortion pills in the future. Some envisioned
a larger impact. In their 2021 book Controlling Women, Kathryn Kolbert and Julie
F. Kay dreamed about the potential impact of pharmacy distribution of mifepris-
tone: “CVS has over 1,100 MinuteClinics that already offer contraceptives, pregnancy
and STI testing, and primary care to patients in over thirty-​three states. Imagine the
possibilities.”53
But the FDA still blocked the abortion pill from being available in pharmacies in
the same way that any other drug was, instead requiring pharmacies to register with the
drug manufacturer and become certified in order to dispense mifepristone. Dr. Daniel
Grossman of ANSIRH said, “The FDA has not yet issued guidance about what this cer-
tification process will entail. But why is it necessary? Viagra is riskier, yet pharmacies
 Chapter 4: Eroding Abortion Rights and Self-Managed Abortion • 135

aren’t certified to dispense that.”54 Coeytaux pointedly condemned the pharmacy certi-
fication requirement in stronger terms:

It’s purely political. These pills should not only be in pharmacies, they should be available
over-​the-​counter. But instead, years later, we’re still in a place where people think of this as
a drug that is so dangerous it has to be in a black box. We’re supposed to be happy. I don’t
feel like we should accept these crumbs anymore. We’re supposed to celebrate the crumbs,
when in fact, it’s egregious. The FDA is supposed to be ruling based on data and evidence,
not politics.55

The FDA began a year-​long negotiation process with the drug manufacturers Danco
and GenBioPro about how the pharmacy certification process would work.
Other bureaucratic barriers also slowed access to telemedicine abortion. While the
FDA allowed telemedicine, they maintained the requirement that clinicians obtain a
patient agreement form, which for large online medical systems could be difficult, said
Dr. Godfrey. “We haven’t been able to launch telemedicine for a number of reasons.
One reason is the patient agreement form. It’s very difficult to do electronically in big
health systems that have contracts with medical records providers that are in place for
decades. They’re not nimble. They can’t just contract with DocuSign,” said Godfrey.
“You have to remember these huge medical systems are run by lawyers and there’s just
no flexibility in the system.”56
Nevertheless, the partial removal of the FDA REMS restriction opened the doors
to expanded telemedicine abortion access in many states. By March 2022, twenty-​four
states and the District of Columbia had telemedicine abortion access (see Figure 4.6).
Telemedicine abortion providers could continue to provide the service in states where
it was allowed.
But even with the more relaxed FDA rule, many people still faced state-​level barriers
to accessing medication abortion. At the time, nineteen states still required the pre-
scribing clinician to be physically present when prescribing the abortion pill, thereby
blocking telemedicine for abortion. “Eliminating the in-​person dispensing require-
ment may reduce the distances patients will have to travel—​but they will still need to
be in a state that allows telemedicine medication abortion to have the pills mailed to
them,” said Grossman.57 Three states banned mailing abortion pills to patients outright,
and mailing bans in another three states were blocked by courts.58 But even in states
banning the mailing of abortion pills, people could still obtain them from Aid Access
and from online distributors based outside the country.
The FDA decision to allow telemedicine abortion spurred anti-​abortion lawmak-
ers to introduce new restrictions on medication abortion. In the first three months of
2022, lawmakers introduced eight measures that would ban medication abortion out-
right, nine measures that would prohibit the mailing of abortion pills, eleven measures
136 • Abortion Pills

Figure 4.6: States with telemedicine abortion access in March 2022 (courtesy of Guttmacher).

that would restrict the administration of abortion pills to physicians, and five mea-
sures that would limit the provision of abortion pills to a specific point in pregnancy.59
Reproductive rights lawyers, including the ACLU, argued that these laws were pre-
empted by the December 2021 FDA decision and would later file lawsuits challenging
measures that conflicted with the FDA rules.60 In the face of growing restrictions, advo-
cates continued to expand avenues for accessing abortion pills outside of the formal
medical system and develop resources to support people self-​managing their abortions,
but not without resistance.

Spreading the Word About Abortion Pills

In response to conservative states passing abortion bans and the impending Supreme
Court ruling in the Mississippi abortion ban case, Plan C began a nationwide public-
ity campaign to get the word out about abortion pills. In April of 2022, Plan C teamed
with reproductive health, rights, and justice advocates in New York City to plaster the
subway system with information about how to find abortion pills and access free legal
advice about using them. From Queens to the Bronx, in Brooklyn and Manhattan—​
including Times Square—​over 250 posters shared abortion pill information in English
and Spanish with the millions of people passing through subway stations and riding
 Chapter 4: Eroding Abortion Rights and Self-Managed Abortion • 137

Figure 4.7: Plan C and If/​When/​How advertise abortion pill information in the Nassau Ave subway
station in New York City (courtesy of Plan C).

the trains each day (see Figure 4.7).61 “As politicians and courts continue their assault
on abortion access, we are spreading the word that these medically safe and effective
pills are available by mail in all fifty states,” said Elisa Wells. “Everyone deserves access
to this modern medical technology, and we provide the information that people need
to take back control of their reproductive autonomy.”62
At each location there were two posters—​one with information about how to access
abortion pills through Plan C’s online Guide to Abortion Pills, and another poster with
information on how to access free legal help via the Repro Legal Helpline. “As more
and more states are enacting restrictions on access to abortion care, which should be
basic, accessible medical care, we want people to know that there are alternative routes
of access to these pills in all fifty states,” said Wells. “A lot of people don’t even know
about abortion pills, let alone that they can be available very conveniently and quickly
through an online consultation that may or may not involve a video visit, and with the
pills mailed directly to your home.”63 She explained:

Even in a state that has mainstream telehealth medication abortion services, there might
be some people who prefer to obtain pills from alternate sources—​maybe they’re undocu-
mented, maybe they don’t want any record of this on their credit card or they don’t want
parents knowing about it for whatever reason. There might be people who just prefer to keep
it more private and self-​managed. So we want them to know about this.64
138 • Abortion Pills

Plan C also began a program to train people as “ambassadors” to distribute informa-

tion in their communities about abortion pills and Plan C’s guide to pills.
The rise in self-​managed abortion was reflected in an increased number of calls
to the Miscarriage and Abortion (M+​A) Hotline. In January 2021, the M+​A Hotline
answered 109 calls and twenty-​three text messages. In January 2022, they answered
149 calls and 426 text messages. By March of 2022, M+​A Hotline had over forty volun-
teers, including physicians, nurses, and midwives, who came from across the country.
“People are doing this safely, but we’re just here to provide reassurance that they’re doing
what they need to do. And that it’s a safe process that they can take care of at home,”
explained the M+​A medical director April Lockley in March of 2022. “Unfortunately,
people in more restrictive states, people that are poor, people of color, they have an even
more difficult time accessing abortion services, especially since it’s more stigmatized in
certain areas. And so the anonymity of being able to ask their questions through a hot-
line, and a resource that we provide without having to provide their name or talk face to
face with anyone is a good resource for many people in the community.”65
Groups promoting self-​managed abortion experienced resistance to their work,
including censorship on social media. When Reproaction posted graphics with medi-
cally accurate information about abortion pills in the fall of 2021, Facebook removed
these posts. “Facebook said that we had violated their community guidelines,” said
Kara Mailman, Reproaction’s senior research analyst. “They didn’t explain how or what
guideline we had specifically violated and we have not been given recourse for appeal.”66
A month after removing Reproaction’s graphics, Facebook was still blocking the orga-
nization from purchasing ads to share crucial information about medication abortion
with patients in need. “Facebook is letting anti-​abortion organizations take out abor-
tion pill reversal ads, while suppressing our fact-​based posts about abortion pills,” said
Mailman. “This ongoing bias shows that Facebook doesn’t have an interest in fairly
moderating according to their own community guidelines.”67
SASS also experienced censure of their social media posts. Meta removed two posts,
one on Facebook and one on Instagram.68 In both cases, SASS appealed the removal of
the posts and both were put back up. “What really stood out for me was the innocent
nature of the posts—​just the graphic saying you can have an abortion at home,” said
SASS’s media team coordinator Peggy Cooke. “I don’t understand why Facebook reacts
so quickly to things like that but then so slowly or not at all to actual horrible things
that people say to each other.”69 Cooke explained how the posts’ removal interfered with
SASS’s mission to get accurate information about abortion pills to people. “We are a
volunteer team. It costs time and energy to appeal it, and check to see if it got put back
up. If one person or twenty people see that post, that makes a difference,” said Cooke.70
The Center for Countering Digital Hate and Reproaction both called on Facebook
to stop spreading abortion pill misinformation and blocking medically accurate infor-
mation about medication abortion. The Center for Countering Digital Hate started
 Chapter 4: Eroding Abortion Rights and Self-Managed Abortion • 139

a petition urging the tech giants to enforce their policies against ads with misleading
health claims, to refuse ads from organizations that repeatedly violate their rules, and
to contribute their revenues from “abortion pill reversal” ads to reproductive health
charities. They also called on social media platforms to ensure that users known to have
been exposed to misinformation received accurate information.71 Reproaction also had
a petition telling “Facebook and Instagram that censoring vital, fact-​based medical
information about abortion pills is unacceptable” and encouraged people to contact
Meta to complain.72 “Allowing the promotion of unscientific anti-​abortion propaganda
while removing information about a safe, common medical procedure is wrong,” said
Mailman.73
Advocates for self-​managed abortion also experienced resistance from medical
professionals and even some reproductive rights advocates who were uncomfortable
with Plan C’s increasingly visible advocacy of Aid Access and self-​managed abortion.
Francine Coeytaux explained:

We were trying to shake abortion pills free from the gatekeepers—​the medical gatekeep-
ers and the legal gatekeepers and the activist gatekeepers of safe abortion, who have, to
their credit, made abortion safe in our country, but are watching their agency, their locus of
control, their power dissipate because they are no longer needed. Abortion pills are so safe
they should be over the counter. If you take that statement to its logical conclusion, over the
counter means you don’t need a gatekeeper that gives you a prescription. You don’t need a
gatekeeper that asks you a whole bunch of questions before granting access to the pill. Our
premise with Plan C from the get-​go was that these pills are so safe and effective, they should
be over the counter. If you go with that premise, we need to just get out of the way.74

Advocates split on how to react to the six-​week abortion ban in Texas. While repro-
ductive rights groups like Planned Parenthood and National Network of Abortion
Funds insisted the movement should invest in creating ways for people to travel out
of Texas to get abortions, Plan C advocated for sharing information about how peo-
ple can obtain abortion pills from Aid Access, from websites selling pills and from
telemedicine providers in the United States using mail forwarding. Some medical
providers and advocates expressed concern about the safety of abortion pills out-
side of the formal medical system, while reproductive justice advocates expressed
concern about potential criminalization of people using abortion pills outside of the
formal medical system.

Legal Risks of Self-​Managed Abortion

Advocates generally agreed that the risks for self-​managing early abortion were low,
but that women of color and low-​income women faced higher risks. In fact, only one
140 • Abortion Pills

state at the time explicitly prohibited self-​managed abortion—Nevada—and only

after twenty-four weeks. Dr. Beverly Winikoff, president of Gynuity Health Project,
said she did not know of any successful prosecutions of women who self-​managed
an abortion using pills in early pregnancy. Elisa Wells said she knew of twenty-​one
prosecutions of people for self-​managing abortion later in pregnancy out of the tens of
thousands of people who have successfully self-​managed their abortions in the previ-
ous twenty years. “When you do the math—​dividing twenty-​one prosecutions by the
tens of thousands of people who have managed their own abortions—​you can see that
the risk is actually very, very small,” said Wells.75 ”If you order a drug by mail and take
it early, in the first trimester, and nobody finds a fetus somewhere, you are much less
likely to get in trouble than if you do it in the second trimester,” said Winikoff.76
By misapplying and misusing laws, however, some district attorneys were find-
ing ways to prosecute people who self-​managed their abortions. One of the earliest
prosecutions on record for self-​managing abortion with abortion pills occurred in
Massachusetts in 2007, and there were two cases in New York in 2011—​all under
criminal abortion laws that were later overturned.77 Abortion pill advocates advised
people who self-​managed their abortions about steps they could take to reduce their
chance of legal problems. They told them that in the very rare case that they had to
seek medical help, they did not need to say that they used abortion pills. The symp-
toms of abortion with pills were very similar to a natural miscarriage. At the time,
there was not yet a reliable and accessible test to tell the difference78 and the treatment
was the same for both conditions. If they used abortion pills as directed by the World
Health Organization (under the tongue or in the cheek), there was no residue that
might be observed by medical professionals (vaginal use of the abortion pill may leave
an observable residue). The few cases in which women were criminally prosecuted
for self-​managing their abortions usually involved a situation where the woman told
a doctor or nurse that she had used abortion pills, cases in later pregnancy where
there was some sort of physical evidence, and/​or when someone who knew the woman
reported her.
By the middle of 2021, states were adopting a record-​breaking number of abortion
restrictions, the Supreme Court had allowed a six-​week abortion ban to go into effect in
Texas, and the court had agreed to hear a case involving a fifteen-​week abortion ban in
Mississippi. The Guttmacher Institute reported that lawmakers across forty-​seven states
had introduced 561 provisions restricting abortion since January of that year, including
165 abortion bans. A staggering eighty-​three of those restrictions were enacted across
sixteen states, including ten bans.79 Seeing the writing on the wall, Plan C worked to
expand options for people to obtain abortion pills by mail. While importing drugs into
the United States for personal use was generally illegal, the FDA made some exceptions,
including in situations when “the drug is for use for a serious condition for which effec-
tive treatment is not available in the United States.”80 In fact, the FDA had a policy of
 Chapter 4: Eroding Abortion Rights and Self-Managed Abortion • 141

non-​enforcement toward importation of medicines for personal use up to ninety days.

Elisa Wells explained how Aid Access protected itself from prosecution: “Aid Access is
set up to comply with all the requirements in the places that they operate: Dr. Gomperts
is licensed as a physician, so providing care legally. She writes a prescription for the
patient, who then submits it to the pharmacy. The pharmacy is licensed to fill the pre-
scription. And, because the doctor and pharmacy are both offshore, they feel protected
from prosecution in the states that don’t allow telemedicine abortion.”81
While legal consequences for self-​managing abortion were rare, dozens of women
had been investigated and sometimes prosecuted for ending a pregnancy.82 For exam-
ple, in 2011, prosecutors in Idaho charged an unemployed mother of three, Jennie
McCormick, with unlawful abortion after she used abortion pills purchased online to
end a late second trimester pregnancy. A judge later dismissed the charges as uncon-
stitutional, and a federal appellate agreed.83 While there have been no successful pros-
ecutions of women who self-​managed an abortion using pills in early pregnancy,
prosecutors disproportionately targeted low-​income women using Medicaid, immi-
grant women, and women of color with these kinds of charges.84 There had, however,
been the successful prosecution of Ursula Wing in 2020 for distributing abortion pills
(see chapter 2).
In June of 2021, If/​When/​How’s executive director Jill Adams reported that by
the end of 2020, they were fielding ten times as many inquiries on their Repro Legal
Helpline as they were at the start of the year.85 “Whether someone self-​manages an
abortion because they were unable to access clinical care, or because it was the care
that felt right for them, no one should be punished for ending their own pregnancy,
or helping someone else do so,” said Rafa Kidvai, If/​When/​How Legal Defense Fund
director. Melissa Torres-​Montoya and Sara Ainsworth at If/​When/​How raised concerns
about the criminalization of people self-​managing abortion before the American Bar
Association and worked for a resolution against the criminalization of self-​managed
abortion and pregnancy loss, which the American Bar Association finally adopted on
February 21, 2021.86
To ensure anyone targeted with criminal prosecution received legal representation,
If/​When/​How: Lawyering for Reproductive Justice launched a nationwide Repro Legal
Defense Fund in June of 2021—​a first-​of-​its-​kind resource to support women and oth-
ers investigated, arrested, or prosecuted for self-​managed abortion. The fund began
providing money for bail, legal representation, expert witness fees, or other expenses of
litigation. “We’ve seen political attacks on clinical abortion care ramp up significantly
in recent months, making it more critical than ever that we protect and defend peo-
ple who self-​managed abortions,” said Kidvai.87 If/​When/​How also pledged to educate
healthcare providers about the law to discourage reporting of people using abortion
pills, noting that leading medical organizations had said that reporting people causes
tremendous harm.88
142 • Abortion Pills

Elisa Wells emphasized that people should be able to make their own decisions
about legal risk: “Of course, I don’t want to in any way trivialize the traumatic impact
these unjust prosecutions have had on the women who have been charged. But, people
who are seeking abortion pills are looking for a solution, and I would guess that most
would consider the benefit of having access to the pills to far outweigh any very small
legal risk they might face.”89 Pamela Merritt, co-​founder of Reproaction, noted how
legal risks were higher for people of color, but there were also risks in not being able
to access an abortion: “There are risks on both sides, but I believe that people have to
make their own decisions about what is right for them and their families and their cir-
cumstances. I think we need to respect the intelligence of pregnant people.”90
In response to concerns about criminalization of self-​managed abortion, advo-
cates also began to educate people about how to maintain their privacy while search-
ing for abortion pills online. The Digital Defense Fund advised people to use virtual
private networks like Tor, which blocked trackers and ads and automatically cleared
search history. They also advised people to turn off face ID, talk in person or over the
phone, delete any period or fertility apps, leave their phones at home when they can,
and keep online purchases discreet by using cash or online currency such as Bitcoin
(see Figure 4.8).
Fears about criminalization of people self-​managing abortion with pills flared when
on Thursday, April 7, 2022, Texas police arrested a woman and charged her with mur-
der for allegedly self-​inducing an abortion using pills. The woman, twenty-​six-​year-​old
Lizelle Herrera who lived near the Texas–​Mexico border, was held in Starr County jail

Figure 4.8: How to protect your privacy when searching for abortion pills on your phone (courtesy of
Digital Defense Fund).
 Chapter 4: Eroding Abortion Rights and Self-Managed Abortion • 143

on a $500,000 bond. The murder charge was in direct conflict with the constitutional
right to abortion established in Roe v. Wade in 1973. Texas did not have a law mak-
ing self-​inducing an abortion a crime and two recent laws restricting abortion in the
state—​S.B. 8 and S.B. 4—​explicitly exempted pregnant women. Despite these explicit
exemptions, prosecutors obtained an indictment from a grand jury and the Starr
County Sheriff ’s Office arrested and jailed Herrera “on the charge of murder after [she]
did then and there intentionally and knowingly cause the death of an individual by self-​
induced abortion.”91
Reproductive justice advocates in the community, led by the Frontera Fund, orga-
nized a protest at the Starr County Jail on Saturday morning and urged people to call
the jail demanding the release of Herrera. Calls poured in from across the country. By
Saturday afternoon, If/​When/​How’s Repro Legal Defense Fund paid Herrera’s bail and
she was released. Advocates then urged people to call the Starr County District Attorney
Gocha Ramirez, demanding that he drop the charges. The next day, Ramirez issued a
press release, stating that the arrest was improper and he would file a petition to drop
the charges, which he did on April 11. Ramirez reportedly apologized to Herrera in a
text sent to her lawyer, Calixtro Villarreal on Sunday, saying Ramirez should never have
been charged.92 A law professor at University of Texas, Austin, Stephen Vladeck, com-
mented at the time: “There are two possibilities. Either this was a really unforgivable
accident or it was a deeply malicious and cynical ploy. I continue to be deeply troubled
by the universe in which so many people are willing to brush aside fairly basic proposi-
tions about how our legal system is supposed to work.”93
Herrera’s case was part of a longstanding pattern of politically motivated pros-
ecutors stretching the law in order to criminally prosecute pregnant women for the
outcomes of their pregnancies, said Lynn Paltrow, executive director of the National
Advocates for Pregnant Women, which fights criminalization of pregnant people. “This
arrest was inevitable,” Paltrow said. “It’s been inevitable ever since Texas passed its so-​
called Prenatal Protection Act, which amended its murder laws to reach the ‘unborn.’
It’s inevitable every time a state passes one of those laws, even when it includes an
explicit statement that it may not be used to arrest the pregnant woman herself.”94 The
Prenatal Protection Act, enacted in Texas in 2003, created a new crime of feticide by
expanding the definition of an “individual” under the criminal homicide law to include
a fetus and an embryo. Advocates of the law claimed they wanted to protect pregnant
women, and they explicitly exempted prosecution of pregnant women under the stat-
ute, but the laws became a way to redefine when life begins. “What we know, whatever
their intent, is that laws that equate pregnancy termination with murder, which is what
the Texas Prenatal Protection Act is, are used against pregnant women, not for them,”
said Paltrow.95
The Texas law was part of a wave of feticide laws passed in the early 2000s in response
to the murder of Laci Peterson, who was eight months pregnant, by her husband Scott
144 • Abortion Pills

Peterson in 2002. Congress passed the “Unborn Victims of Violence Act,” signed by
George Bush on April 1, 2004, creating a new federal crime for causing the death or
injury to an “unborn child” during the commission of a crime against a pregnant
woman. By 2022, thirty-​eight states have feticide laws and at least twenty-​nine of these
laws apply to the earliest stages of pregnancy. Most, but not all, explicitly exempt preg-
nant women, as the Texas law did, but prosecutors still used these laws against them.
“Vigilante prosecutors all across the country have been deliberately misusing existing
law to arrest people for their pregnancy outcomes, including abortion,” said Paltrow.
“Whoever presented Hererra’s case to the grand jury absolutely had an obligation to
know what the law says. And the law in Texas very, very clearly says on its face it does
not permit prosecution of the pregnant person.”
Paltrow published extensive research on criminal prosecution of pregnant women
across the country and within the state of Texas under feticide laws as well as laws against
manslaughter, child endangerment, and distribution of drugs to minors (through the
umbilical cord).96 “Prosecutors who bring cases like this are trying to groom people in
the United States to think of those who have abortions as criminals,” said Paltrow. “That
stigma, eventually, is likely to stick and results in efforts to throw them in jail.”97
Paltrow lauded local advocates who organized protests shortly after Herrera’s arrest.
“The immediate response from Frontera Fund and South Texans for Reproductive
Justice brought attention to the misuse of this law by the police and prosecutor,” said
Paltrow. “That misuse of law happens often, but it’s only after a public outcry that pros-
ecutors are prevented from abusing their authority to subject people to prosecution for
nonexistent crimes.”98 Paltrow also believed that the Herrera case would undermine
public health. “Somebody who went for help in a medical setting was turned over to the
police. The last thing we should be doing if we want to protect public health is make
people afraid to go to their healthcare providers and speak honestly with them.”99
While the Texas feticide law, as well as S.B. 8 and S.B. 4, explicitly exempted pregnant
individuals from prosecution under these laws, advocates worried that could change if
the Supreme Court overturned the constitutional right to abortion established almost
fifty years ago in Roe v. Wade. “I think that has always been a political calculus by
the anti-​abortion supporters in the Texas Legislature,” said Vladeck. “It’s a lot easier
to build consensus around these measures when the putative offenders—​the villains
in the story—​are not the pregnant individuals, who may in many cases be pregnant
for reasons beyond their control, rather than providers. The providers are much bet-
ter boogeymen for the legislature than the individuals. Indeed, when S.B. 8 was going
through the legislature, a sustained effort was made to say ‘we are not punishing the
pregnant person.’ ”100
But many believed that would change in the absence of Roe. The National Association
of Criminal Defense Lawyers published a report in August of 2021 calling attention
to the dramatically increasing criminalization of reproductive health in recent years.
 Chapter 4: Eroding Abortion Rights and Self-Managed Abortion • 145

The report highlighted current criminalization of pregnant women and the threat of
increasing criminalization if the Supreme Court overturned abortion rights in Dobbs
v. Jackson Women’s Health Organization. “A close analysis of existing and emerging state
law belies the common perception that enforcement will be limited to abortion provid-
ers and irrefutably shows that erosion of a precedent that has stood for nearly half a
century may well open the floodgates to massive overcriminalization,” wrote National
Association of Criminal Defense Lawyers executive director Norman Reimer in the
report’s preface.101
On May 5, 2022, someone at the Supreme Court leaked a draft opinion in the
Mississippi abortion ban case, sending shock waves across the country. Authored by
Samuel Alito, the ninety-​eight-​page draft opinion, dated February 10, indicated the
Court was preparing to fully reverse the half-​century-​old precedent of constitutional
abortion rights established in Roe v. Wade (1973) and reaffirmed in Casey v. Planned
Parenthood (1992). Abortion rights advocates expressed concerns that overturning Roe
would increase discrepancies in access to abortion health care across the country. “In
a post-​Roe world, we would become a country of haves and have-​nots—​where some
people have access to legal abortion and others do not,” said Elisa Wells of Plan C. “In
restricted states, abortion would become almost impossible to obtain—​except through
self-​managed options, which would likely put people at legal risk, especially those who
are already marginalized due to their skin color, economic status, or gender identity.
In states without these restrictions, abortion is likely to continue to be readily avail-
able through modern, safe telemedicine and clinic-​based services.”102 Shortly after the
opinion leaked, traffic on the websites of Plan C and Aid Access surged.103 In the weeks
after the Supreme Court leak, Honeybee Health saw an 80 percent increase in demand
for abortion pills.104
In response to the leaked opinion, Los Angeles-​based filmmaker Jessica Sarah
Flaum released her film, Abortion: Add to Cart, about self-​managed abortion. The film
provided a roadmap for how people could have safe abortions post-​Roe—​even in states
that ban abortion. “With the recent leak from SCOTUS [Supreme Court of the United
States], we decided to release our film publicly to be a resource in preparation for an
upcoming post-​Roe world,” said Flaum, who made the film available on YouTube.105
The film featured two abortion storytellers and interviewed activists from the organiza-
tions Plan C and If/​When/​How.
In June, as the Supreme Court decision came closer, a coalition of over seventy
reproductive health, rights, and justice organizations created a new campaign,
Abortion on Our Own Terms, to educate the public about the safety and effective-
ness of self-​managed abortion using medications, supported in part by the Packard
Foundation and Hewlett Foundation. On their website, Abortion on Our Own Terms
explained what self-​managed abortion was, provided educational resources, and gave
several ways to get involved and take action, including readymade stickers, GIFs, short
146 • Abortion Pills

informational videos, and infographics for supporters to download and share.106 “These
Supreme Court justices can’t put abortion pills back in the bottle,” said Erin Matson, co-​
founder and executive director of Reproaction and a steering committee member of the
Abortion on Our Own Terms coalition.107 The campaign’s primary focus was on educa-
tion and culture change. “Our long-​range vision includes abortion pills on the shelf,
abortion pills for free on college campuses, abortion pills in vending machines. I hope
that we get to a point where people can keep abortion pills in their medicine cabinet in
case they need them. We’ve got to build cultural acceptance and get out the word about
how to self-​manage abortion with pills because folks are looking for the information
and states are failing to allow clinic-​based access.”108
With the Supreme Court decision in Dobbs looming, advocates anticipated that
people from states banning abortion would flock to states where it was still legal and
clinics would be inundated with patients, creating long waits for in-​clinic abortion care.
To address this anticipated influx of patients, California-​based Women’s Reproductive
Rights Assistance Project (WRRAP) created a new “abortion pills by mail” program
to fund telehealth abortion providers in twenty states. They believed that telehealth
providers could absorb a lot of the demand and free up brick-​and-​mortar clinics to
focus on providing in-​clinic procedures. “WRRAP is expanding access by intentionally
choosing friendly states to abortion access,” said Sylvia Ghazarian, executive director of
WRRAP. “The reality is that SCOTUS will probably severely weaken or overturn Roe.
Medication abortion will become more critical in the delivery of care to many people
unable to access or afford care in a clinic.”109
By June 2022, WRRAP was working with nine telehealth abortion providers that
offered services in twenty states, including Forward Midwifery, Pills by Post, Choix, and
carafem. In creating their new abortion pills by mail program, WRRAP worked closely
with Plan C. Unlike most abortion funds that required patients to call them directly for
assistance, WRRAP funded abortion providers directly, which meant faster, more confi-
dential care. “We wanted to streamline the process. It alleviates a lot of steps and makes it
a smoother experience for the patient,” said Ghazarian. “Telehealth abortion care is the
wave of the future in terms of being able to provide access to the largest number of patients
across the US. We want to support these services,” said Ghazarian.110
Meanwhile, new research added to evidence showing the safety of telemedi-
cine abortion. A study with a sample of over four thousand patients from fourteen
clinics—​the largest US-​based study of the no-​test approach to date—​showed that
medication abortions without an ultrasound or pelvic exam were just as safe as those
with them111 and that medication abortion after ten weeks was safe and effective,
although slightly less effective than earlier in pregnancy.112 The WHO endorsed the
use of abortion pills through twelve weeks of pregnancy in 2022.113 Based on this
research, many abortion providers in the United States extended their telemedicine
abortion service up to twelve weeks of pregnancy.
 Chapter 4: Eroding Abortion Rights and Self-Managed Abortion • 147

While advocates expanded their support for telemedicine abortion and self-​managed
abortion in response to the impending decision in Dobbs, they also pursued a much
more ambitious dream: over-​the-​counter abortion pills. In February 2022, research-
ers at ANSIRH released a study finding that pregnant women seeking abortion care
were overwhelmingly interested in having over-​the-​counter access to medication abor-
tion.114 The researchers surveyed 1,687 pregnant people seeking abortion care at seven
abortion clinics in six states (Alabama, California, Florida, Illinois, North Dakota, and
Texas) between October 2019 and March 2020. They proposed a scenario where peo-
ple could buy abortion pills legally without a prescription. The pills would come with
detailed information about how to take them and a twenty-​four-​hour telephone num-
ber to call with questions. The scenario allowed patients to ask a pharmacist any ques-
tions they might have and then go to a clinic afterwards to make sure the abortion was
successful. “Our research finds that people are really interested and supportive of an
over-​the-​counter model of abortion care,” said lead author of the study Dr. M. Antonia
Biggs, associate professor at ANSIRH. ”They perceive it to have the advantages of being
safe, convenient, affordable, and private.”115
The survey found that 83 percent of abortion patients were in favor of over-​the-​
counter medication abortion, a significantly larger proportion than the 37 percent
reported in a similar 2017 survey.116 Participants highlighted several advantages of
over-​the-​counter medication abortion, including privacy (69 percent), earlier access
to care (69 percent), and convenience (65 percent).117 “There are many restrictions on
abortion in general,” said Biggs. “People often live far away from clinics. If you had
over-​the-​counter access without a prescription, you could go to any pharmacy. Most
people live near a pharmacy. Many said that they thought it would also be more private
and more convenient. They prefer to have an option where they could manage their
abortion on their own at home.”118
Cost was also an important factor for respondents. The average cost of in-​clinic
medication abortion in the United States was over $500, while the medications them-
selves cost less than $100. “People are really in need of an affordable option,” said Biggs.
“It’s very likely that over-​the-​counter medication abortion would be cheaper than an
in-​person option, particularly if it’s covered by insurance. At the very least, it would
reduce the cost of travel to clinics that are often many miles away. We found that the
people who were most interested were those who had experienced financial barriers
accessing care.”119
Biggs hoped that the FDA would one day approve over-​the-​counter access to abor-
tion pills, but emphasized that insurance coverage for the medications would be criti-
cal. “What will be really important as we move forward is to ensure that people can have
affordable access to this option, and that it be covered by insurance—​that it doesn’t leave
people out. Affordability is really critical to increasing access to abortion.”120 Research
on demand was a required step in the process of making medication abortion available
148 • Abortion Pills

over the counter. “One of the important pieces of the research is to demonstrate that
there is interest,” said Biggs, who noted the next step in the research—​a label com-
prehension study—​was already underway. Previous research had shown that clinician
support for a less medicalized model of medication abortion—​without ultrasounds or
blood tests—​had increased in response to a strong safety record for abortion pills as
well as the rise of telemedicine during the COVID-​19 pandemic. Biggs and her col-
leagues at ANSIRH hoped the FDA would one day approve over-​the-​counter access to
abortion pills. “You have to be visionary,” said Biggs. “I don’t know when it will happen.
But we have the research to show that it’s safe. The more evidence we have, the more
likely it is that we’re going to make a change.”
Meanwhile, advocates prepared for a post-​Roe future. After the FDA permanently
removed the in-​person dispensing requirement in December 2021, telemedicine abor-
tion expanded significantly. As Texans traveled to states with legal abortion, telemedi-
cine abortion played an important role in helping to meet demand, and served as proof
of concept for a post-​Roe future.
 CHAPTER 5

“Mail Those Pills No Matter What”:

The End of Roe Spurs Efforts to
Expand Abortion Pill Access

If we can’t get laws passed, we may need to be proactive anyway, because people
desperately need our care. We may just need to mail those pills no matter what.
I don’t think the optics of doctors going to jail because they are getting medications
to people who need and want them will win the Republicans votes. Those of us in
the blue states really need to step up and be proactive.
Dr. Linda Prine1

On June 24, 2022, a conservative supermajority of the United States Supreme Court
issued a sweeping decision erasing a half century of federal protection for abortion
rights and opening the door to state restrictions and bans on abortion health care.
Some states had “trigger” laws, designed to go into effect immediately. Other states
had pre-​Roe abortion bans that went into effect. Abortion rights advocates filed suits
in many states to stop abortion bans and succeeded in obtaining stays on bans in
some states. By November 2022, twelve states had banned abortion at fertilization; one
had a six-​week ban and two more had fifteen-​week bans. Another fifteen states had
highly restricted access to abortion, including bans on telemedicine abortion. Dobbs
v. Jackson Women’s Health Organization made a bad situation worse. Under Roe and
Casey, abortion had been hard to access for many women, especially those living in
rural areas or on reservations, and those relying on federal health insurance programs.
The Hyde Amendment blocked coverage for abortion care, with only narrow and
rarely used exceptions for cases of rape, incest, and life endangerment. Indian Health
Services, for example, rarely provided abortion services, including abortion pills, even
for these exceptions.2 While Indigenous women always had to travel long distances to
access medication abortion, the situation became more dire as clinics closed in many
states.
150 • Abortion Pills

With the end of Roe, reproductive rights advocates shifted into high gear, develop-
ing new strategies and pushing legal boundaries to increase access to abortion pills.
Several states passed provider shield laws covering telemedicine abortion services.
While some abortion providers began mailing abortion pills to people living in states
with bans, others did not agree with this strategy and believed that the legal risks were
too high for patients and providers. In states where abortion was still legal but abortion
pills were restricted, advocates challenged those restrictions. In states where there were
no restrictions, advocates pushed for expanded access, including legislation requir-
ing public universities to offer abortion pills in student health clinics. Advocates also
worked at the federal level to expand access, including filing a citizen petition challeng-
ing the FDA REMS restrictions on mifepristone. Outside of the medical system, activ-
ists developed grassroots community networks offering free abortion pills to people
living in states banning abortion. Finally, activists pursued creative strategies to combat
abortion pill stigma and ensure ongoing access to abortion pills post-​Dobbs. This chap-
ter describes these important initiatives in the period right after the Supreme Court
overturned constitutional abortion rights.

The Immediate Aftermath of Roe’s Fall

Within weeks of the Supreme Court’s overturning of Roe v. Wade, the Biden adminis-
tration quickly acted to protect abortion access. On July 8, 2022, President Biden issued
an executive order on “Protecting Access to Reproductive Healthcare Services,” which
directed the Secretary of the Department of Health and Human Services (HHS), Xavier
Becerra, to submit a report within thirty days identifying potential actions to protect
and expand access to abortion, including medication abortion.3 Reports of pharmacists
refusing to fill prescriptions for misoprostol led HHS Secretary Xavier Becerra to issue
guidance on July 13 to pharmacies explaining that withholding medications because
they might cause miscarriage or abortion violated section 1557 of the Affordable Care
Act.4 Then on August 3, 2022, Biden issued another executive order directing HHS to
do more to ensure access to reproductive health services, and misoprostol in particular,
because women were being denied this medication for miscarriages.5
Overall, the official number of abortions dropped 6 percent in July and August of
2022, with over ten thousand fewer abortions reported in those months.6 But the rates
were vastly different across states. Reported abortion in states with restricted access
dropped 32 percent between April and August 2022, while reported abortion in states
with protected access increased by 11 percent. Evidence suggested, however, that self-​
managed abortions soared after Dobbs.7 Before the Supreme Court’s abortion decision
leaked on May 2, requests for abortion pills to Aid Access averaged around eighty-​three
a day. After the leak, that number jumped to 137. After the court decision on June
24, the daily average increased to nearly 214. Over July and August, that amounted to
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 151

13,268 requests; most were filled. Together these studies indicated that many people
living in restrictive states were accessing abortion by traveling to states where abortion
was legal, or were self-​managing their abortions by ordering abortion pills online.8
Despite new abortion restrictions, abortion pill advocates vowed to help people find
ways to access medication abortion, both inside and outside of the formal US medical
system.9 “No matter what happens to laws, abortion pills aren’t going anywhere—​and
information about how they work belongs to everyone,” said Reproaction’s executive
director Erin Matson shortly after the fall of Roe. Advocates shared resources for finding
and safely using abortion pills, including Plan C, SASS, Aid Access, the M+​A Hotline,
and Repro Legal Helpline. Detailed instructions for how to take abortion pills were
available in twenty-​seven languages at HowToUseAbortionPill.org. A young venture
capitalist from Boston, Nathaniel Horowitz, formed Mayday Health, to share informa-
tion about how to access abortion pills through Aid Access.10 “As we continue to navi-
gate the national crisis of abortion bans, more people are seeking to self-​manage their
abortion with pills,” said Kimberly Inez McGuire, executive director of URGE: Unite
for Reproductive & Gender Equity. “They know where and how to get the medication,
and they’re choosing it because it provides control over their reproductive lives.”11
While the largest increase in requests to Aid Access came from states with restricted
access to abortion, every state had increased requests for abortion pills during the
post-​leak and post-​decision periods. In states with total abortion bans, 31.4 percent
of respondents cited “current abortion restrictions” as a reason for their request pre-​
decision, versus 62.4 percent after the decision. In states with no current restrictions,
12.5 percent of respondents cited “possible future legal restrictions” versus 35.5 per-
cent post-​decision in states with no current restrictions on abortion.12 “The increases
indicate that while abortion bans create access barriers that lead to more people self-​
managing their abortions, self-​managed abortion is also a method of choice for some,”
said lead researcher Dr. Abigail R.A. Aiken of the University of Texas at Austin. “The
increase in the visibility created by the Dobbs decision means that more people are
aware of self-​managed abortion as an option. However, interest in self-​managed abor-
tion is not new. It has existed for centuries, and now self-​managed abortion with pills is
backed up by studies proving its safety and effectiveness.”13
In addition to Aid Access, a Mexico City-​based telemedicine abortion clinic—​
Telefem—​began serving people from the United States in July 2022. Telefem offered
telemedicine abortion services to US residents and then mailed abortion pills to secure
pickup locations along the United States–​Mexico border for $150.14 The Mexican
Supreme Court had decriminalized abortion in September 2021. Mifepristone and
misoprostol were legal in Mexico and doctors were allowed to prescribe them across
state lines. Telefem opened its doors to Mexicans in November 2021, but soon people
from other countries began contacting them for help. They realized they could serve
people from other countries who could travel to Mexico and pick up abortion pills in
152 • Abortion Pills

a safe location near Mexico’s borders, such as Guatemala to the south and the United
States to the north. Once patients received their package, Telefem providers walked
them through the entire process by telemedicine (text, phone call, or videoconference).
Telefem recommended that people take the pills in Mexico rather than carrying them
back to the United States because of risks of carrying controlled medications across the
border. People could be asked to show proof they needed those medications. In case
of complications, Telefem referred patients to a network of doctors and clinics along
the Mexico border. Telefem director and midwife Paula Rita Rivera described their
service: “It’s very important to us that people who don’t have access or who don’t know
what to do can find Telefem. We follow a personalized method, giving attention to each
woman. We care about the person that is seeking our services.”15
For women living in states with abortion bans who wanted to receive pills promptly
from US-​based telemedicine providers, some used mail forwarding, but concern about
the legal risks to patients and providers grew post-​Dobbs. In March of 2023, several
telehealth clinicians spoke anonymously to Ms. magazine about what they wished
their patients knew about mail forwarding. “If patients are doing mail forwarding, or
if they’re having a friend get the package, it’s not really something that we can know
about as clinicians, because we really can only be prescribing to the states where we’re
licensed,” said one telehealth clinician.16 They explained:

For example, if a clinician serves California, the patient should be in California and receiv-
ing mail in California. Now, if it’s someone who lives in Texas, and they’ve set up mail for-
warding in California, or a friend is going to take that package in California and then mail
it on to them, they could say something like, “I’m traveling to California to pick up this
package.” That’s fine, as long as it’s not blatantly obvious that they won’t be in the state where
they are receiving it.17

If a patient told their clinician they were located in a different state during the con-
sultation or that they were using mail forwarding, telehealth clinicians may not feel
they could serve them. “We want to help you, but we can’t know that you’re doing
mail forwarding,” said one telehealth clinician. Another clinician summed it up con-
cisely: “Don’t ask, don’t tell.” One telemedicine abortion virtual clinic, Abortion on
Demand, required a videoconference consultation and checked patients’ IP addresses
to ensure they were physically located in a state where the clinician was licensed to
practice. Most clinicians, however, did not do that. “We shouldn’t know if patients are
doing mail forwarding, because it tells us that they’re not in the state where they say
they are and where we are licensed,” said another clinician.18
Some telehealth clinicians were careful to stay within the most conservative inter-
pretation of the law, but others were less worried about trying to insulate themselves
from any potential legal repercussions, especially when women were desperate for
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 153

medical care in the face of unjust restriction on abortion access. “There’s too much
time spent worrying about the ‘what ifs?’ instead of ‘what now?’ ” said one telehealth
abortion clinician. “It comes down to risk tolerance. We all have different risk toler-
ances. The way I look at risk is, ‘What’s the worst thing that can happen if I get caught,
and how likely is it?’ Those two things make me do things that a lot of people would be
too nervous to do.”19 Clinicians were already allowed to serve their established patients
by telemedicine when the patients were traveling in states where the clinician was not
licensed, but generally clinicians were only allowed to serve new patients located in
states where they were licensed. Some advocates argued that the law of the state where
the telehealth provider was located should apply rather than the law of the state where
the patient was located. But in the absence of clear law on that point, telehealth clini-
cians who knowingly served patients located in states where they were not licensed
risked losing their medical licenses.
While telehealth and mail forwarding worked for many people, several providers
and Plan C reported that some mail forwarding services refused to forward abortion
pills. “They open it because they say it’s a suspicious package. I think they know exactly
what the packages look like, even though they’re just a FedEx package,” said one clini-
cian. “Then they send an email to the patient and say, ‘Per our policy, we can’t forward
this to you.’ They say you can come pick it up in person if you want, but I don’t recom-
mend that anyone go in person to do that. These refusals to forward have been very few,
but it’s still something people should know about.”20 Another clinician said she believed
it’s “still relatively uncommon” that mail forwarding services are opening people’s pack-
ages, but wanted patients to know about this possibility. “If we talk to them on the
phone, we subtly tell people to use a friend rather than one of the mail forwarding
places,” said the clinician.21
On the legal risks of forwarding abortion pills for a friend, one clinician noted, “I’m
not aware of a single case of someone being caught forwarding abortion pills for someone
else. We need to lower everyone’s fear levels because fear makes things seem abnormal,
and they’re not.”22 For patients, self-​managed abortion was not against the law in most
states. Only Nevada explicitly prohibited self-​managed abortion. However, reproductive
justice advocates worried about increasing criminalization post-​Dobbs and increasing
surveillance by anti-​abortion police and prosecutors, especially for communities of color
who were already over-​surveilled. In 2022, If/When/How published updated research
showing that between 2000 and 2020, sixty-​one people were investigated and/​or pros-
ecuted for self-​managed abortion. Of those sixty-​one, just over half involved abortion
pills. There were no known cases of people investigated or arrested for using abortion
pills early in pregnancy. Healthcare providers notified law enforcement in 45 percent
of the sixty-​one cases and acquaintances in just over a quarter of the cases. Most cases
(87 percent) led to arrest and 92 percent proceeded through the criminal court process,
with 44 percent pleading guilty and 9 percent resulting in a guilty verdict after a trial. Of
154 • Abortion Pills

the sixty-​one cases, 44 percent were non-​Hispanic white and 41 percent were minori-
tized racial and ethnic groups (15 percent were not reported). Over half (56 percent)
lived in poverty.23 A 2023 study on the criminalization of pregnancy by the organization
Pregnancy Justice found sixteen cases of criminal prosecution for self-​managed abortion
between 2006 and 2022.24
New York telehealth abortion clinician Linda Prine expressed skepticism about
claims that ordering abortion pills by mail was legally risky, noting that the number
of people ordering abortion pills online has “gone through the roof since Roe fell.” Yet
she has heard of no one who had been arrested for getting pills in the mail and using
them in early pregnancy.25 In March 2023, an ex-​husband sued three Texas women
for wrongful death because they helped his ex-​wife obtain abortion pills to end her
pregnancy.26 Republicans also introduced bills in several states to criminalize the use or
distribution of medications for abortion, but they did not pass.27
If/​When/​How legal support counsel Rebecca Wang admitted that the legal risks
for people ordering or forwarding pills were minimal, but varied depending on the
particular laws of the states where people were located, whether people were talking to
others about the activities they were engaging in, and personal identity factors because
people of color tended to be more heavily surveilled by law enforcement. “If people are
receiving medications from a valid telemedicine service and a licensed provider within
the United States, the likelihood that they’re going to face legal risk for receiving those
services or those pills is very, very low,” said Wang. “If a provider is comfortable with
absorbing some legal risk, any patients they see are not going to face legal risk for using
those services.”28 In September of 2023, however, The New York Times reported that
scientists in Poland had developed laboratory tests to detect abortion drugs in people,
creating new worries for advocates of self-​managed abortion.29
In addition to telemedicine abortion, activists also developed new community net-
works to share abortion pills. Soon after Dobbs, activists in the United States connected
with global feminists who had for years run accompaniment networks to provide abor-
tion pills and support to people living in countries banning abortion. Ibis Reproductive
Health described the accompaniment model as follows:

Abortion accompaniment is characterized by activist-​driven, community-​based strategies to

facilitate use of de-​medicalized approaches to widely available medications. Accompaniment
follows a shared understanding of safe abortion as not only evidence-​based but also a prac-
tice that is caring, autonomous, and free of violence, stigma, and judgement. Feminist
accompaniment groups promote horizontal peer-​to-​peer learning, and take great care to
center the needs, desires, and empowerment of the aborting person.30

Relying on guidance from the World Health Organization, accompaniment groups

trained volunteers to provide medication abortion counseling and guidance as well
as emotional and physical support over the phone, through secure digital platforms,​
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 155

or in person. In addition, they provided information about how to access health care,
sometimes collaborating with supportive clinicians and they informed people how
to avoid legal scrutiny. Research showed that accompaniment is extremely safe and
97 percent effective without surgical intervention through thirteen weeks of preg-
nancy.31 Accompaniment groups also supported second-​trimester abortions, which
research showed were over 76 percent effective during the second trimester of preg-
nancy and 95 percent effective with additional medical interventions.32 In 2022, abor-
tion accompaniment groups and networks operated in approximately fifty countries
around the world, including the Mobilizing Activists around Medication Abortion
(MAMA) Network in Africa and the Red Compañera in Latin America.33 In Mexico,
there were over 350 regional networks, many of which were set up over the previous
two decades by Las Libres.34 According to Ibis Reproductive Health, accompaniment
“seeks to affirm abortion as a valid and valued reproductive choice, in which people
who have abortions are enabled as the protagonists of their own abortion process.”35
Even before Dobbs, as legal restrictions limited abortion access in the United States,
Las Libres began providing support to women in the United States, at first in immigrant
communities and then more widely.36 Las Libres activists organized a series of meetings
with activists on both sides of the border. Americans in Mexico as well as volunteers
inside the United States formed a US project to support people in the United States
with self-​managed abortion. Inspired by this work and the global movement for self-​
managed abortion, activists inside the United States began creating their own organi-
zations to support people with self-​managed abortion, such as Red States Access and
We Save Us. By April 2023, Red States Access offered free abortion pills to women in
over ten states banning or heavily restricting abortion, including Alabama, Arkansas,
Florida, Idaho, Louisiana, Missouri, Oklahoma, South Dakota, Utah, and Wisconsin.
We Save Us offered free abortion pills to women in Indiana, Ohio, and Kentucky.37 The
organizations also provided doula support for people using abortion pills. The Plan C
Guide to Pills indicated the states served by each group. At that time, Aid Access also
served people living in states with abortion bans, but they shipped the medications
from a pharmacy in India, which could take two to three weeks. To speed delivery
of pills to people in states with bans, Francine Coeytaux worked with Aid Access to
find distributors within the United States, including harm reduction organizations, so
patients could receive their medications within days instead of weeks.38 At the same
time, they developed a plan to allow US-​based clinicians in states protecting abortion
rights to serve patients in states restricting abortion.

The Push for Telemedicine Abortion Provider Shield Laws

To protect telemedicine abortion clinicians who offered care to patients from out
of state, abortion rights advocates pushed for provider shield laws that included
telemedicine. While several states passed provider protections, most of these laws
156 • Abortion Pills

did not apply to telemedicine providers. But on July 29, 2022, Massachusetts passed
the nation’s first provider shield law that covered clinicians sending abortion pills
directly to people who were physically located in states with abortion bans.39 The
law had robust protections for healthcare workers who provided abortion services
to patients living outside the state—​both those who traveled to Massachusetts for
care, and those who received care in their home states from Massachusetts providers
via telemedicine. The Massachusetts law meant people living in states with abortion
bans could receive telemedicine abortion care from US providers and obtain FDA-​
approved abortion pills promptly by mail, rather than having to order pills from out-
side of the country.
To shield healthcare workers from criminal investigation and prosecution by police
and prosecutors from anti-​abortion states, the new law prohibited the extradition of
Massachusetts providers who lawfully provided abortion care in Massachusetts to a
resident of a different state where the procedure was illegal. The law also prevented
Massachusetts law enforcement officers or employees from providing information or
assistance to any federal or state law enforcement agency or private citizen in relation to
an investigation or inquiry into protected reproductive healthcare services. To protect
healthcare workers from civil suits, the law created a new civil remedy for clinicians in
Massachusetts to countersue if they were the subject of criminal prosecution or civil
lawsuits filed by someone outside of the state, enabling them to recover an amount
equal to the damages assessed in these out-​of-​state lawsuits. The law also protected
providers’ professional licenses and access to malpractice insurance, even if they faced
out-​of-​state civil lawsuits for providing lawful abortion care in Massachusetts.40
These protections meant people living in states with abortion bans or telehealth
abortion restrictions could still receive telehealth abortion care from Massachusetts
providers. The law also increased abortion access for minors, since Massachusetts did
not require parental consent or notification for minors aged sixteen and seventeen.
Therefore, teenagers who did not want to involve their parents but who lived in states
with parental notification or consent requirements could receive confidential telehealth
abortion care without informing their parents.41 Legal scholars questioned the consti-
tutionality of telemedicine provider shield laws, arguing that they “strike at the heart
of basic, fundamental principles of law in our federalist system—​interstate comity and
cooperation.” They also noted that the law did not protect providers if they left the state,
or cover patients or those helping them in their home states.42 By January of 2023, one
Massachusetts clinician was offering telemedicine abortion services to people in states
with restrictive abortion laws.43
After the law was signed, Vice President Kamala Harris traveled to Massachusetts
and met with lawmakers and advocates in Boston. At this meeting, Harris described
Massachusetts as “a national model for protecting reproductive rights on the state
level,” and she encouraged the leaders to support state legislators across the country
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 157

who were fighting for abortion protections.44 Telemedicine abortion clinicians also
celebrated passage of the Massachusetts law. “The Massachusetts shield law is a huge
breakthrough for getting pills to women in restricted states,” said Dr. Linda Prine, tele-
medicine abortion advocate and co-​founder of the Miscarriage and Abortion Hotline.
“Clinicians now have the backing of their state laws, protecting their license and prac-
tice, as well as the federal protection of prescribing an FDA-​approved medication. We
are hopeful that other pro-​choice states will soon follow suit.”45
In early 2023, Dr. Linda Prine, Dr. Maggie Carpenter, and reproductive rights attor-
ney Julie F. Kay formed the Abortion Coalition for Telemedicine Access to advocate for
telemedicine provider shield laws to enable licensed providers to serve people anywhere
in the United States, so that healthcare providers in blue states could help people in red
states obtain abortion medications by telemedicine. Another organization, Healthcare
Across Borders, run by Jodi Jacobson, was also working to pass telemedicine provider
shield laws.
On January 9, 2023, New York state Senator Shelly B. Mayer (D) introduced a law
to protect New York clinicians providing telemedicine abortion services to patients
located in states banning or severely restricting medication abortion.46 The bill passed
out of committee on January 17 and was then introduced in the Assembly by member
Karina Reyes (D). The law shielded clinicians and pharmacists throughout the state
from criminal prosecution, extradition, loss of license or malpractice insurance, and
from subpoenas of their medical records for prescribing and sending abortion pills to
people who needed them anywhere in the United States.47 Prine explained how the law
would solve a piece of the abortion access problem:

Before Roe fell, 75 percent of people got their abortions under eight weeks. Early abortion
is safer, and people want to get their abortion right away. Now, it’s really hard in all of
these red states. If you can get an abortion at all, it’s hard to get it early. This law doesn’t
help people with fetal anomalies who are thirteen-​plus weeks. It doesn’t help when peo-
ple need procedures and can’t have them. But this would at least allow people to go back
to having a really early abortion in the safety of their own home. It would be a big step
towards alleviating the suffering.48

Prine organized a campaign urging New Yorkers to contact their state legislators and
ask them to protect telemedicine abortion across state lines.49 Some expressed con-
cerns that states might criminally prosecute people receiving abortion pills, which
Prine vigorously disputed:

There was this narrative that this might be dangerous to people in the South if we started
mailing pills there. And we’re like, wait a minute. People need their pills. The laws so far
are against the providers of pills, not the patients. Patients are getting pills where they can,
158 • Abortion Pills

but they’re getting them later in pregnancy than they should be getting them. Now they
will have the option of quickly getting their pills from a licensed clinician. And there’ll be
FDA-​approved pills instead of paying a lot to get them from an overseas pharmacy with no
directions on how to take them. This is harm reduction. What we’re doing is not adding risk.
We are reducing risk.50

Nevertheless, Prine admitted there was legal risk for physicians doing this work. At
seventy-​one, she said, “doctors like me who are at the end of our careers, we should be
the ones to step up” to take the chance.51
Others expressed concerns that providers offering this care would not be guaran-
teed protection from criminal and civil lawsuits in red states. Prine countered:

Lawyers are telling us, you’re still at risk. Bad things can happen to you. We’re like, look,
abortion doctors are always at risk. We signed up for that. We know that that’s part of doing
this work. Maybe this is increasing our level of risk, and maybe it’s a different kind of risk,
but we’re used to being at risk and we’re okay with that. So let us decide the risks we want
to take. Just give us the best law you can and we’ll run with it because people need it. People
really, really, really need it. They needed it months ago.52

Prine called for creative approaches to increase reproductive healthcare access now.
“We learned from the November election that people in our country really want abor-
tion to remain accessible. Yet despite that, the red states remain on the offensive and
plan to pass more restrictive laws. Thus, those of us in blue states need to become
equally proactive and get positive things done,” said Prine, who advocated for even
stronger laws:

We should also think about more radical laws we could pass, like making mifepristone
over the counter or available via “standing orders” for pharmacists or nurses, or legalizing
advanced provision. Blue states should pass laws that challenge the FDA regulations just like
red states have done when they make this federally approved medication illegal. Let’s make
it more accessible. We would actually be following the science to do so.53

In addition to New York, the Abortion Coalition for Telemedicine Access pushed for
telemedicine abortion provider shield laws in other states, including in Washington
state, California, Vermont, Colorado, Maryland, and New Jersey.54
On April 27, 2023, the state of Washington enacted a provider shield law protect-
ing medical professionals in the state offering telemedicine abortion to people out of
state.55 Within days, a Washington doctor was offering this service to people in Idaho
and Utah,56 joining a doctor in Massachusetts offering telemedicine abortion to people
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 159

in other restrictive states under the protection of the Massachusetts telemedicine pro-
vider shield law. Then Colorado and Vermont passed telemedicine provider shield laws
and clinicians from those states began serving patients in states with abortion bans or
restrictions on telemedicine abortion.57 In June of 2023, New York passed a telemedi-
cine abortion provider shield law and providers immediately started providing services
to people living in states banning abortion.58 In October of 2023, California passed a
telemedicine abortion provider shield law.59
Telemedicine providers promptly began serving patients in states with bans from
states with shield laws. In June 2023, Aid Access set up operations in shield law states
in order to avoid shipping from outside of the country and customs delays that would
sometimes take up to three weeks.60 Aid Access offered telehealth abortion for $150
or less to people in all fifty states with delivery in two to five days. In the first month
of operation, they mailed abortion pills to 3,500 people in states banning abor-
tion, and to fifteen thousand people total across the country.61 “It’s nice to be play-
ing offense, not defense,” said a New York physician working with Aid Access.62 Aid
Access served women who were up to thirteen weeks pregnant and applied the law of
the state in which the providers were located. New York, for example, did not have a
parental consent law so clinicians there could serve people of any age from any state.63
A second company, Abuzz Health, also began offering telemedicine abortion for $0
to $150 to people in thirty states with delivery in one to five days. This company also
operated from within shield law states. According to Wells, by July of 2023, there were
over a dozen clinicians in shield law states offering telemedicine abortion to people
in restricted states.64 Women in Mississippi, for example, were receiving telemedi-
cine abortion care from clinicians in states with provider shield laws, according to
Michelle Cohen of SHERo.65 By October of 2023, Aid Access was serving over 5,500
people a month in banned or restricted states.66
Telemedicine providers also provided services along the borders of states with
bans. Hey Jane, for example, saw a 164 percent increase in patients, with a 301 percent
increase in patients in Illinois, a 231 percent increase in patients in Colorado, and a
178 percent increase in patients in New Mexico—​all border states. Hey Jane reported
that people were coming to them earlier in pregnancy after Dobbs: the average ges-
tational age of their patients went down to around six weeks pregnant at the time of
intake.67 In October of 2023, the Massachusetts Medication Abortion Access Project
began offering telemedicine abortion to people in all fifty states.68 By offering care ear-
lier in pregnancy, virtual clinics relieved pregnant women of the discomforts of ongo-
ing pregnancy symptoms.
These mission-​driven clinicians offered telemedicine abortion services for sliding
scale fees. In 2023, three clinicians—​Christie Pitney, Julie Jenkins, and Ruchi Kaul—​
formed the Abortion Freedom Fund to support telehealth abortion. Another abortion
160 • Abortion Pills

fund, WRRAP, also supported telehealth. But neither of these funds would support Aid
Access clinicians serving people in states with abortion bans. By fall of 2023, approxi-
mately three-​quarters of Aid Access patients were located in states with bans and approxi-
mately a third of those clients needed financial aid, which amounted to $20,000–​25,000 a
month per clinician, an unsustainable burden.69
Another obstacle was that clinicians serving states with bans had to dispense
the medications themselves, which meant stocking, packaging, and mailing medica-
tions. After California passed its telemedicine provider shield law, advocates hoped
Honeybee Health would dispense abortion pills to people in states with bans.70
Legal experts predicted anti-​abortion states would file legal challenges to these
telemedicine provider shield laws. “The interjurisdictional abortion wars are com-
ing,” said David Cohen, Greer Donley, and Rachel Rebouché in The Columbia Law
Review.71 They argued shield laws were a way for the abortion rights movement to
“pivot from defense to offense,” and that they helped women for whom travel is not
possible. But providers offering abortion services to people in states with bans could
be subject to extradition if they were to leave the protective states. These legal risks led
some groups to not prioritize these types of shield laws, such as the New York Civil
Liberties Union and Planned Parenthood in New York. “You don’t want to send pro-
viders false assurances that they are totally protected by the law,” said Katharine Bodde
at New York Civil Liberties Union.72 On the other hand, Julie Kay of the Abortion
Coalition for Telemedicine Access believed the new telemedicine provider shield laws
stood on very firm constitutional and legal grounds. “They don’t conflict with consti-
tutional law or interstate law. They’ve been very well researched and carefully crafted
by law professors and reproductive rights attorneys and legal counsel of the state gov-
ernments,” said Kay. “The amount of kicking the tires and looking under the hood that
went on in New York alone has been significant, and certainly way more than a lot of
other legislation that has been passed.”73
In addition to supporting the passage of shield laws, Abortion Coalition for
Telemedicine Access works to implement these laws. “We help medical providers get
up and running, such as getting medical malpractice insurance, setting up electronic
medical records, and explaining how to ship pills,” said Kay. “Telemedicine shield laws
are excellent, but there is still some legal risk for providers, so Abortion Coalition for
Telemedicine Access advises them on how to minimize that risk,” said Kay. Abortion
Coalition for Telemedicine Access also worked to decrease stigma. “The stigmatiza-
tion is magnified because it’s abortion, because it’s medication abortion, because it’s
telemedicine, and because it’s across state lines,” said Kay. “We’ve gotten a lot of resis-
tance, even from providers and practitioners that support abortion politically but who
are not fans of the model of telemedicine abortion. The medical profession tends to be
conservative with a small ‘c,’ but these medications have been proven safe and effective
for decades. So part of our work is educating providers and the general public.”74 Kay
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 161

said they also experience resistance from lawyers in the reproductive rights movement.
She explained:

Lawyers are trained to be super double cautious. Globally, in places where abortion has been
banned or severely restricted, you have to work within that context. One year after Dobbs,
we’re still having a really hard time adjusting to that in the United States. It’s a luxury that we
may have as activists, but certainly people who are seeking abortion services in ban states
don’t have. Our mission is to provide reproductive health care as a human right. If we’re not
taking a risk, we are shifting the risk onto the people who are the most vulnerable.75

In these and other ways, activists sought to make abortion pills a safe, convenient, and
private way to end an early pregnancy.

Litigation and Legislation to Expand Abortion Pill Access at

the State Level
In addition to pushing for telemedicine provider shield laws, abortion advocates
challenged state restrictions on medication abortion. By mid-​2022, nineteen states
imposed in-​person dispensing requirements and many imposed other restrictions
that went beyond FDA requirements, such as only allowing physicians to dispense
the medication, requiring the patient to consume the medication in the presence of a
provider, and requiring multiple in-​person visits to obtain the medication. In October
2021, Texas had banned clinicians from prescribing abortion pills after seven weeks of
pregnancy—​three weeks before the FDA time limit of ten weeks. Legal scholars and
advocates questioned the constitutionality of these additional restrictions on abor-
tion pills.76 In March 2023, Wyoming specifically banned abortion pills—​becoming
the first state to do so. In late June, a federal court blocked the law before it was sup-
posed to go into effect on July 1.77 Six states banned mailing abortion pills, but courts
blocked the laws in all the states but for Arizona.78
University of Pittsburgh law professor Greer Donley argued that state bans of an FDA-​
approved abortion medication may violate the supremacy clause of the Constitution.
The supremacy clause established that federal laws take precedence over state laws that
are in conflict and prohibits states from interfering with matters that are exclusively
entrusted to the federal government—​such as the regulation of medications. “To get
an FDA approval for a drug, it can take decades and can cost hundreds of millions of
dollars to produce the amount of research and data that’s required,” said Donley. “That
comes with a license to sell the product in fifty states. If states could just ban different
types of products that are FDA approved, you can imagine that pharmaceutical com-
panies would be quite upset about that because that is really curtailing their market for
their product, which they worked so hard to be able to sell.”79
162 • Abortion Pills

Professor Donley cited a 2014 case where the Massachusetts governor issued an
emergency order banning the prescribing and dispensing of the FDA-​approved opi-
oid Zohydro. The producer of the drug sued in federal court and the court ruled that
the emergency order was preempted by federal law under the supremacy clause. The
court blocked the order and allowed sale of the drug. The court ruled that allowing the
law to stand would “undermine the FDA’s ability to make drugs available to promote
and protect the public health.”80 Temple University law professor Rachel Rebouché and
others argued that banning abortion medications similarly usurped the power of the
FDA because it in effect takes mifepristone off the market.81 Shortly after the Supreme
Court overturned Roe v. Wade, Attorney General Merrick Garland issued a statement
saying that state restrictions on mifepristone were preempted by federal law. “The FDA
has approved the use of the medication mifepristone. States may not ban mifepristone
based on disagreement with the FDA’s expert judgment about its safety and efficacy,”
said Garland.82
GenBioPro challenged state restrictions on mifepristone in October 2020, when the
company sued Mississippi in federal court for its restrictions that went beyond the FDA
rule, including a law allowing only physicians to dispense the drug and requiring in-​
person dispensing.83 After Dobbs, they withdrew this case, but filed another in a federal
court in West Virginia in January 2023. The second lawsuit argued that the state’s abor-
tion ban and specific restrictions on medication abortion violated the supremacy clause
and the commerce clause of the Constitution. “Congress subjected [mifepristone] to
a substantial and detailed federal regulatory program with which West Virginia law
interferes. That state law must give way to the comprehensive federal regime Congress
enacted and the Food and Drug Administration implemented,” the complaint stated.
“West Virginia’s ban and restrictions impermissibly restrict patients’ access to mifepris-
tone and GenBioPro’s opportunity and ability to market, promote, and sell the medica-
tion in the State.”84 Representing GenBioPro, Skye Perryman, the president and CEO of
Democracy Forward, argued, “Our case makes clear that nothing in the Court’s deci-
sion last year in Dobbs displaced Congress and FDA’s role in deciding whether medi-
cations are safe and effective and determining which regulations should be imposed
on mifepristone. States cannot substitute their medical and scientific judgments for
judgments FDA has made, and doing so undermines not only access to medication,
but the country’s entire drug regulation system.”85 In August of 2023, the federal district
court dismissed GenBioPro’s challenge to the West Virginia abortion ban, which the
company appealed to the Fourth Circuit.86 The district court, however, also ruled that
a law restricting doctors from prescribing mifepristone via telemedicine was “unam-
biguously preempted” by FDA regulation of mifepristone because Congress had allo-
cated to the FDA alone the right to dictate the manner in which mifepristone may
be prescribed. This ruling had the potential to help people in states that still allowed
some abortions but blocked telemedicine abortion, such as Arizona, Florida, Georgia,
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 163

Iowa, Kansas, Montana, Nebraska, Nevada, North Carolina, Ohio, Pennsylvania, South
Carolina, Utah, and Wisconsin.
In another federal case filed in January 2023, a North Carolina doctor named Amy
Bryant challenged her state’s laws imposing medically unnecessary restrictions on
physicians prescribing mifepristone to their patients. North Carolina required doc-
tors to dispense mifepristone in person in a specially certified surgical facility after
state-​mandated counseling and a mandatory 72-​hour delay. “We know from years
of research and use that medication abortion is safe and effective,” said Dr. Bryant.
“There’s no medical reason for politicians to interfere or restrict access to it, or for
states to force doctors to comply with mandates not supported by medicine or sci-
ence. These burdensome restrictions on medication abortion force physicians to
deal with unnecessary restrictions on patient care and on the healthcare system.”87
Bryant’s lawyer Eva Temkin of King & Spalding explained: “Congress has made clear
that FDA is tasked with establishing regulatory controls for this drug to ensure safety
and patient access in the least burdensome way. State politicians cannot stand in the
shoes of the FDA to impose restrictions on medication access that FDA has deter-
mined are not appropriate and that upset the careful balance FDA was directed by
Congress to strike.”88 Other states had similar restrictions on medication abortion
(see Figure 5.1).89

Figure 5.1: Contrary to FDA regulation, many states required physicians to dispense mifepristone
directly to patients and required patients to have an in-​person visit with the physician (courtesy of
Guttmacher Institute).
164 • Abortion Pills

On April 30, 2024, the federal court ruled that some of the state’s restrictions placed
on dispensing abortion pills that went beyond the controls set by federal regulators
were unlawful, including prohibiting healthcare providers other than physicians from
prescribing the drug; requiring in-​person prescribing, dispensing, and administering;
mandating the scheduling of an in-​person follow-​up appointment; and requiring non-​
fatal adverse event reporting to the FDA. However, the court ruled that North Carolina
could impose requirements that had not been expressly considered and rejected by the
FDA or that focused more on the practice of medicine and a patient’s informed consent.
This included the state’s requirements for an in-​person advance consultation, use of an
ultrasound, an in-​person examination, blood type testing, and adverse event reporting
to state health authorities.90 Advocates vowed to keep fighting for FDA preemption of
state restrictions.91
In addition to challenging laws restricting medication abortion, abortion pill advo-
cates pushed for new state laws to expand medication abortion access. Following
California’s lead,92 advocates in Massachusetts pushed for legislation to require university
campus health centers to offer medication abortion.93 For many college students, access
to abortion health care was critical for continuing their education, but unnecessary bar-
riers placed heavy burdens on students seeking this care. Although student health insur-
ance plans covered the cost of abortion in Massachusetts, campus health services did not
provide this service. This forced students to travel off campus to obtain abortion pills,
sometimes requiring them to travel long distances on public transportation because of
the limited number of abortion providers in the state, leaving large geographic gaps.
Research on how many students were likely affected by the lack of medication abor-
tion services on campuses and what burdens they experienced showed that between
forty and sixty-​four public university students in Massachusetts were obtaining medi-
cation abortions each month, amounting to 480 to 768 students each year. The study
then measured the distance from each of Massachusetts’s thirteen four-​year public uni-
versity campuses to the nearest abortion clinic, and calculated the distance and travel
times by public transportation between the campuses and nearest clinics. The results
were that students had to travel between two and forty-​two miles to obtain abortion
pills at off-​campus clinics. If a student had to use public transportation, this travel could
take between eighteen and four hundred minutes one way to reach the closest abor-
tion clinic. As many as 93 percent of students at these universities were more than
thirty minutes from the closest abortion facility via public transportation. Students
from University of Massachusetts Amherst—​the state flagship public university—​had
to travel twenty-​five miles to reach the closest abortion provider, Planned Parenthood
of Western Massachusetts in Springfield. If they had to take public transportation, the
bus ride was two hours and eighteen minutes one way. To travel to the clinic, obtain
the health care they needed, and travel home by bus took almost a full day—​time few
students had to spare between classes, jobs, and other activities.94
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 165

Advocates argued that the burdens caused by forcing students off campus to obtain
abortion pills fell disproportionately on women of color, lower-​income students, and
those with other family or work responsibilities that placed demands on their time and
finances. These students were less likely to have the resources to travel long distances
to obtain the health care they needed. Advocates also argued that increasing access to
medication abortion was critical for gender equity as well as racial and economic jus-
tice for Massachusetts college students. According to the Guttmacher Institute, almost
40 percent of women seeking abortion health care did so because having a child would
interfere with their education. Research showed that access to contraception and abor-
tion improve women’s educational attainment. Women who had a child while in college
were less likely to graduate than those who did not, and 89 percent of students said that
having a child while in school would make it harder to achieve their goals.95 Advocates
argued that students should not have to get on buses and travel long distances to pick
up abortion pills from unfamiliar clinicians. Students deserved to have a familiar place
to access the abortion health care they needed with nurses and doctors they already
knew and who had their medical records. They also warned about making students
have to hunt for abortion clinics to get the health care they needed. They noted that on-​
campus health services varied in the amount of information they provided about how
to find abortion health care off campus, often leaving students in the position of having
to figure out how to obtain care on their own and putting them at an increased risk of
reaching out to one of the many anti-​abortion centers masquerading as reproductive
health clinics, which targeted college students and could delay or even prevent access
to real health care. In July of 2022, shortly after the Dobbs decision, the Massachusetts
legislature passed a law requiring public colleges in Massachusetts to provide medica-
tion abortion services in campus health centers.96
Advocates in other states pushed for similar measures. In December of 2022, stu-
dents from Columbia University’s Reproductive Justice Collective, Barnard College,
City University of New York (CUNY) and State University of New York (SUNY)
rallied at the Women’s Health Protective Association Fountain in Riverside Park.
Students called on New York state lawmakers to pass a bill to make medication abor-
tion available on all eighty-​nine CUNY and SUNY campuses across the city and state.
Joined by sponsors of the bill, Assembly members Harvey Epstein and Senator Cordell
Cleare, the young demonstrators also called on New York Governor Kathy Hochul
to support the bills and incorporate funding for them into her first executive budget.
“In this post-​Roe landscape, it’s critical we ensure young people can get on-​demand
access to medication abortion we need,” said Niharika Rao of the Reproductive Justice
Collective and a youth abortion activist with Advocates for Youth. “We cannot let
extremists politicize abortion care—​yet today restrictions exist that are based in poli-
tics and not on the science. Medication abortion is common, extremely safe, and just
like other services offered in primary care settings.”97
166 • Abortion Pills

At the time, health centers at many public university campuses in New York did not
offer medication abortion. “Students rely on their health centers for medical care,” said
Epstein. “Abortion is medical care, yet far too many schools do not provide access to
abortion services at their health centers. As we face an increasingly hostile environment
for civil rights, in New York we’re fighting back to guarantee not only the right to abor-
tion but access to it for a population that has limited time, resources and transportation
options.”98 Students faced other obstacles accessing abortion care as well, such as lack
of information about how to find abortion providers. “On-​campus provision actually
makes insurance coverage easier, reduces precious travel time for students, and can
help to increase young people’s awareness about their options,” said Rao.99 “Far too
often, students seeking abortions have to travel off campus and potentially face aca-
demic and financial losses—​sometimes with the added emotional toll of having to seek
care completely on their own,” said Sean Miller, Northeast regional director for Young
Invincibles, a national nonprofit dedicated to amplifying the voices of young adults.100
Offering medication abortion on university campuses was also a social justice issue,
said Miller, because the lack of abortion access was “disproportionally harming young
women from low-​income, Black and brown families.”101
Advocates expressed concern that laws banning abortion in other states would force
people to travel to New York to get care, increasing wait time at clinics in the state and
putting pressure on local abortion funds and doctors. “New York is a destination state.
Our clinics are being overwhelmed. It’s becoming harder to get appointments,” said
one student at the rally. “Additionally, it’s becoming harder when the alt-​right here in
New York, upstate and in the city, have been emboldened and have increased their
tactics of harassing and intercepting patients at clinics.”102 The proposed legislation
required CUNY and SUNY campuses across the city and state to provide access to
medication abortion at student health centers that served over half a million students,
57 percent of whom were women. Schools would also have the option to contract with
a third party to provide the services. Schools that demonstrated they could not fulfill
the mandate would be required to provide referrals off campus to hospitals or clinics.
The legislation also established a “public college and public university student health
center abortion by medication fund” jointly overseen by the State Comptroller, health
commissioner, and chancellors from SUNY and CUNY. “As New York becomes a des-
tination state for abortion access, we must reduce wait times and funding pressure by
making on-​campus abortion pills available to students,” said Rao.103 On April 28, 2023,
New York enacted a law requiring public universities in the state to offer medication
abortion through campus health centers.104
While the legislation only applied to public universities, advocates hoped the legis-
lation would influence private colleges and universities to also offer medication abor-
tion in their on-​campus health centers. In October of 2022, Barnard College became
the first private college in New York to pledge to offer medication abortion at its student
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 167

health center. “Health care is a human right and an essential aspect of making this prin-
ciple manifest is ensuring that comprehensive care is available in a direct, unfettered,
and accessible way,” said Senator Cordell Cleare. “For the hundreds of thousands of
college students in New York State, campus health centers are the first, best, and only
option for timely medical care and attention. Our legislation is needed because these
centers must provide a full scope of services, including medication abortion, which will
ensure the health, safety and well-​being of students.”105 The New York law passed in
May of 2023.106

Federal Initiatives to Expand Abortion Pill Access

In addition to state-​level initatives, advocates worked at the federal level to increase
access to abortion pills. In Congress, Rep. Cori Bush of Missouri introduced the
Protecting Access to Medication Abortion Act (H.R. 767), Rep. Kathy Manning of
North Carolina introduced a resolution declaring the authority of the FDA to approve
drugs for abortion care (H.R. 309), and Rep. Patrick Ryan of New York introduced a
measure declaring that state restrictions on dispensing medication abortion were pre-
empted by federal law (H.R. 2573). Across the aisle, anti-​abortion legislators pushed
restrictions on abortion medications. For example, in September of 2023, Rep. Andy
Ogles of Tennessee introduced The Ending Chemical Abortion Pill Act (H.R. 5806).
In a deadlocked Congress, none of these measures advanced.
Reproductive health providers and advocates, however, pressed the FDA to expand
access to mifepristone by focusing on a non-​abortion use for the drug: miscarriage
treatment. ACOG, the American Medical Association, and forty-​seven other organiza-
tions representing reproductive healthcare providers, researchers, and advocates filed
a citizen petition, urging the FDA to approve mifepristone for treatment of incomplete
miscarriages.107 In combination with misoprostol, mifepristone was known as the best
treatment for miscarriage, but abortion bans created barriers to accessing the medica-
tion. “The confusion that the opposition has sown with all their legislation plus the risk
of criminalization equals chaos. And that just leads to cruelty. That’s what we’re seeing.
People are being denied care in real time and lives are totally upended,” said Kirsten
Moore at the EMAA Project, which joined the petition.108 The FDA had approved mife-
pristone for pregnancy termination, but did not explicitly label the drug for use in mis-
carriage care. The citizen petition asked the FDA to modify the drug’s label to add an
indication for miscarriage treatment and to remove requirements that clinicians and
pharmacies be certified to prescribe and dispense the drug, which created barriers to
access for miscarriage. Advocates noted that approximately 25 percent of all pregnan-
cies ended in miscarriage.
To treat a miscarriage, some clinicians took a wait-​and-​see approach, with active
monitoring in case symptoms such as infection developed and required intervention.
168 • Abortion Pills

Other clinicians offered medications to complete the miscarriage or manually emptied

the uterus. For patients choosing medication, the well-​established standard of care was
mifepristone in combination with misoprostol. Clinicians could prescribe mifepristone
for miscarriages as an off-​label use, but only if they were a certified prescriber because
of the FDA’s REMS restrictions. Because of this restriction, many clinicians in medical
offices and emergency rooms could not prescribe the medication. As a result, the most
commonly used medical protocol for miscarriage management was misoprostol alone,
but research showed that the combination of mifepristone and misoprostol was faster
and more effective for miscarriage care as well as less painful than misoprostol alone.109
The lack of mifepristone labeling for miscarriage was also making the medication vul-
nerable to bans in states hostile to abortion. They noted that lawmakers in Alabama
and Arizona had introduced legislation to ban mifepristone.110 “These are wholesale
bans on mifepristone for any use and, if enacted, will prevent clinicians from providing
the gold standard miscarriage care in their communities of practice, harming public
health,” said the citizen petition. “Even without a wholesale ban on mifepristone, clini-
cians in states that ban abortion may be hesitant to prescribe a drug that has only been
approved for abortion even for a legal, off-​label use, like miscarriage management.”111
Advocates hoped that adding miscarriage management to the label would legiti-
mate this important use and make it harder for states to ban the drug. “The FDA has the
authority delegated by Congress to regulate the safety of drugs and what should be on
the market and how it can be on the market. States should not be able to override FDA
authority,” said Moore.112 In addition to relabeling mifepristone, the petition asked the
FDA to eliminate the requirement of clinician certification to prescribe and dispense
mifepristone. “ACOG is encouraging doctors to become certified prescribers if they
wanted to do miscarriage treatment, even if they don’t want to do abortions. But they’d
have to certify and say that they themselves were an abortion doctor, and that is a hur-
dle,” said Moore.113 Requiring providers to become certified to prescribe mifepristone
was not only an administrative burden, but it could open them up to risks of violence
and harassment because of the medication’s association with abortion. The petition
cited research showing that physicians who only planned to prescribe mifepristone for
miscarriage care still feared becoming targets of anti-​abortion protesters.114
The citizen petition also asked for removal of the pharmacy certification requirement,
arguing the requirement was unnecessary and created barriers to access, especially for
poor and rural women. The petition asked the FDA to remove a requirement that patients
receiving mifepristone sign an informed consent form saying they are using the drug
for abortion. “Asking a miscarriage patient to attest to having an abortion will confuse
patients at best, but due to the prevalence of abortion stigma, it might also add emotional
harm to their miscarriage experience,” said the citizen petition.115 Moore emphasized the
urgency of these changes so that patients could access the best care possible in a time
of crisis. “If you’re talking about someone who’s seeking treatment for miscarriage, they
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 169

want to go to their own healthcare provider and get their prescription filled as quickly as
possible,” said Moore.116
On January 5, 2023, the FDA rejected the citizen petition, stating that Danco would
have to submit an NDA for the FDA to change the label on the mifepristone and that the
request to use enforcement discretion to remove the REMS was not properly the subject
of a citizen petition under FDA’s regulations.117 On February 1, 2023, eight US senators
sent an open letter to Danco Laboratories, urging them to submit an application to the
FDA to add miscarriage management to the medication’s label. “Currently, access to
abortion has been restricted, or will likely be restricted, in twenty-​four states. Not only
do these laws take away the reproductive rights of women, but they also endanger the
lives of people experiencing early-​pregnancy miscarriage,” said the senators.118 Because
of legal concerns about mifepristone, they noted, healthcare providers were instead pre-
scribing high doses of misoprostol to ensure effectiveness, resulting in severe cramp-
ing, “making it a longer, more dangerous, and psychologically taxing process.” “People
experiencing miscarriage deserve access to safe and effective treatment, without added
and unnecessary pain,” said the lawmakers. “Women in need of mifepristone for early-​
pregnancy miscarriages are experiencing barriers to effective and safe treatment because
this drug is commonly used in medical abortions. Updating mifepristone’s label will
make this drug accessible for miscarriage management without fear of criminal action
against healthcare providers.”119 The senators implored Danco to submit a request to the
FDA to add miscarriage management as an indication to the mifepristone label.
In the letter, the senators cited research showing that over one million women
in America experienced a miscarriage every year—​as many as 26 percent of all
pregnancies—​noting that miscarriage was more common among Black and low-​
income women. Research showed the combination of mifepristone and misoprostol
significantly improved the management of early pregnancy loss, resulting in fewer
complications and reducing the likelihood of patients needing an additional procedure.
Yet a 2023 study found that between 2016 and 2020, only 1 percent of over twenty-​two
thousand patients nationwide who took medication to treat miscarriages received the
recommended two-​drug protocol. Misoprostol on its own was much less effective than
the two-​drug combination, requiring follow-​up surgery to complete the miscarriage
in roughly 25 percent of cases.120 “Patients experiencing an early miscarriage should
have access to the most effective medication available,” said Kirsten Moore. “Given the
uncertain and hostile legislative climate in some states, it is vitally important to add
miscarriage to the mifepristone label.”121
While the FDA did not act on ACOG’s citizen petition nor the senators’ letter, they
did announce, on January 3, 2023, the new certification process for brick-​and-​mortar
pharmacies to become eligible to sell mifepristone—​a process the FDA negotiated with
the abortion pill manufacturers Danco and GenBioPro after the agency announced
it would make this change in December of 2021. Before that, certified providers had
170 • Abortion Pills

to stock and dispense the pills themselves, or rely on mail order pharmacies that dis-
pensed the medication. With the new certification process, providers could just write
a prescription and have it filled by certified brick-​and-​mortar retail pharmacies, mak-
ing it more quickly and conveniently available to patients. Reproductive rights advo-
cates celebrated the change, hoping it would expand access to abortion pills.122 “Today’s
announcement means that people who live in states that have not banned medication
abortion care may soon be able to walk into their neighborhood pharmacy and walk
out with their medications in hand,” said Kirsten Moore. “By allowing brick-​and-​mor-
tar pharmacies to dispense medication abortion care, the FDA is treating medication
abortion like the safe, effective, time-​sensitive care that it is.”123
But advocates were concerned that the FDA created barriers to mifepristone being
available in pharmacies by requiring pharmacies to register with the drug manufacturer
in order to dispense the drug, despite the fact that mifepristone was safer than many
over-​the-​counter medications, including Tylenol. “Even as the FDA drops one onerous
restriction, it adds another—​a certification requirement for pharmacies, which is not
supported by medical evidence and could present a large enough hurdle that will dis-
suade some from dispensing [mifepristone],” said Upadhyay at ANSIRH. “With abor-
tion restricted in large parts of the country, we need our public health policies to follow
the science so people can have access to this essential medication.”124
Advocates expressed concern about whether busy pharmacies would be willing
to take on the extra work to become certified to dispense abortion pills. “This is just
a bunch of paperwork that doesn’t add any value,” said Moore. “These certification
requirements unfairly limit the pools of prescribers and pharmacies for no good reason.”
Moore nevertheless hoped pharmacy distribution would mean more medical provid-
ers would be willing to become certified and prescribe abortion pills in the future. “We
are moving this product from what used to be a very niche category with a very small
circle of players into the mainstream,” said Moore.125 Pharmacy access was important
to normalizing abortion pills and making them more accessible. “Today, we celebrate
this progress and tomorrow, we’ll continue to work towards a world with no restrictions
on medication abortion care,” said Moore.126 Several retail pharmacy chains, including
Walgreens, CVS, and Rite Aid, announced they would seek certification to sell abortion
pills in states where legally permissible.
In response, anti-​abortion groups organized a national day of protests on February
4 targeting chain pharmacies to discourage them from dispensing mifepristone. The
protests were organized by a group calling themselves the Progressive Anti-​Abortion
Uprising (PAAU). The group claimed to be peaceful and progressive, but its mem-
bers had repeatedly broken the law to achieve their goal of intimidating, harassing,
and blocking women from accessing reproductive health care. PAAU planned protests
for February 4 at pharmacies across the country, including in Boston, New York City,
Washington, DC, Chicago, Los Angeles, and San Francisco.127
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 171

The February 4 action was co-​ sponsored by two other anti-​ abortion groups:
Survivors of the Abortion Holocaust and Live Action, which on January 26 disrupted
a Walgreens shareholder meeting in Newport Coast, California. Two anti-​abortion
extremists broke into the building where the meeting was to take place and hid out in
a closet for nine hours waiting to ambush and disrupt the meeting. “These extremists
are infamous for stalking physicians, invading clinics, and bullying patients and clinic
staff,” said duVergne Gaines, director of FMF’s National Clinic Access Project. “Groups
like PAAU, the Survivors, and Live Action are doing their best to grab headlines and
terrorize pharmacies out of providing critical access to the abortion pill, but they must
be stopped.”128 According to Gaines, members of PAAU had connections to violent,
anti-​abortion extremists. PAAU director of activism Lauren Handy, who claimed to be
a feminist, was trained by one of the leading extremists in the anti-​abortion movement,
Jeff White, founder and leader of Survivors of the Abortion Holocaust. White, who
had been arrested dozens of times for blockading clinics, disorderly conduct, stalking,
and more, served time in federal prison for defrauding numerous state Affordable
Care Act programs of over $27 million. Handy studied and worked with White for
two years in California, according to Gaines.129 Handy faced criminal charges in sev-
eral states, including Michigan, DC, Virginia, and Ohio. Among other convictions, a
Michigan jury found Handy guilty of trespassing and resisting police during a protest
at an abortion clinic in Flint in 2019.
On January 22, 2023, President Biden issued a presidential memorandum direct-
ing the Secretary of HHS, in consultation with the Attorney General and the Secretary
of Homeland Security, to consider new guidance to support patients, providers, and
pharmacies who wished to legally access, prescribe, or provide mifepristone—​no
matter where they lived. The president called for new actions to ensure that patients
could access reproductive health care and abortion medications free from harassment,
threats, or violence.130 “Americans support abortion, period, and pharmacy access to
the abortion pill is long overdue,” said Gaines. “Pharmacies need to stand firm against
this fringe group, and law enforcement must be vigilant against these extremists to
ensure safe access to all pharmacies—​and abortion clinics.”131
On March 2, Walgreens announced that it would not dispense mifepristone in
twenty US states, including several where abortion remained legal—​like Alaska, Iowa,
Kansas, and Montana. Amidst an ever-​changing set of laws regarding abortion care,
pharmacists said they were struggling to navigate “blatant contradictions between state
and federal law that make it very challenging to identify what is legal and what is not
legal,” according to E. Michael Murphy, a spokesperson for the American Pharmacists
Association. “We are very concerned…because we as pharmacists want to ensure
the patients have access to the best possible care that’s informed by evidence.”132 The
announcement was a response to a letter sent to Walgreens in February by nearly two
dozen Republican state attorneys general, who threatened legal action if Walgreens
172 • Abortion Pills

dispensed the drugs. The attorneys general sent similar letters to CVS, Albertsons,
Rite Aid, Costco, Walmart, and Kroger. After significant backlash, Walgreens walked
back its plan not to dispense abortion pills in states where abortion was still legal. In a
statement on March 6, the pharmacy chain vowed to offer mifepristone where it was
still possible to do so. “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,” Walgreens said in its statement. “Providing legally approved med-
ications to patients is what pharmacies do.”133 Many remained skeptical about whether
Walgreens would in fact do so.
In early October 2023, GenBioPro announced on their website the names of eigh-
teen brick-​and-​mortar pharmacies that were dispensing mifepristone. The pharma-
cies listed included independent community drugstores, university-​affiliated outlets,
and compounders located in nine states: Arizona, California, Maryland, New York,
Pennsylvania, South Carolina, Washington, Wisconsin, and Texas. There were no
chain pharmacies on the list, although CVS and Walgreens assured the public they still
planned to dispense the medication.134 The same month, New York City’s public hospi-
tals began offering telemedicine abortion.135

Expanding Abortion Pill Access Outside of the Medical System

and the Law
In addition to groups working to expand legal access to abortion, grassroots networks
expanded to provide extralegal access to abortion pills for people living in the United
States. AccessMA, WeSaveUs, ARTogether, IdahoAccess, and OKAccess formed after
Dobbs to mail abortion pills for free to people living in states with abortion bans (see
Figure 5.2). Red State Access (see Figure 5.3) provided information on how to access
abortion pills for free through these community networks.136
By July of 2023, twenty-​five US-​based distributors located across the country were
mailing mifepristone and misoprostol to people living in states with bans. Community
networks were able to obtain the medications from overseas suppliers, bring them into
the country, and then mail them from within the United States so that people received
the medications promptly. Depending on their supply and people’s preferences, they
would mail the pills loose in bubble wrap (for confidentiality purposes) or send them
in blister packs. They served people of all ages, at all gestational stages, using different
protocols for people in later pregnancy and offering doula support, either in person
or virtually. They provided detailed information about how to use the pills by email,
with e-​learning tools, and ensured that people were within thirty minutes of emergency
care in the rare event that they needed it. They urged people to flush any misopros-
tol they did not use. They were careful to use encrypted apps and aliases. In the first
year, these organizations mailed abortion pills to over twenty thousand people. These
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 173

Figure 5.2: Red State Access Instagram post indicating what states are served by different US-​based
networks as of November 7, 2023 (designed by Lara I. for Red State Access.).195

organizations received contributions from small donors and large ones, although as
they ramped up their work and became higher profile, large donors withdrew from
supporting them for fear of legal risks. Advocates in these groups accepted the legal
risks of doing this work because they knew that many people could not travel out of
state to obtain abortion care, and felt strongly that no one should be forced to give birth
against their will. These organizations did not advertise, but spread the word by word
of mouth and through Plan C. Some people within the movement were uncomfortable
with their operations and spoke out against them. Sometimes their shipments of pills
from abroad were confiscated, but most of the time they reached their destinations.137
In addition, accompaniment networks in Mexico expanded their work in the
United States. Mexico-​based networks serving people in the United States included
Las Libres,138 Colectiva Bloodys, Marea Verde, Matamoros Decide, and Red Necesito
Abortar. Providing support to thousands of women self-​managing their abortions all
over the United States, these organizations emphasized “the guiding principles of wom-
en’s autonomy, horizontality, dignity, and safety.”139 They trained volunteer community-​
based activists about how to support people using the pills outside of clinical settings and
how to handle medical complications remotely. By May of 2023, Las Libres had trained
about fifty networks of women in the United States to provide abortion assistance.140 At
Figure 5.3: Red State Access image used on social media (courtesy of Red State Access).196
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 175

the time, Las Libres in Mexico alone was receiving two hundred to three hundred calls
each day from the United States and claimed to have served over twenty thousand
people since they began working with people in the United States. “A year ago, there
was a lot of fear in the U.S., but now we know there are many abortion networks in
the U.S. and that they have been multiplying,” said Verónica Cruz Sánchez, director
of abortion assistance organization Las Libres.141 Las Libres helped US-based activists
create their own networks in the US. While Mexico-​based Las Libres activists used
social media to communicate, US-​based Las Libres activists concerned about security
and criminalization used encrypted apps like Signal, especially after the Nebraska case
where prosecutors used Facebook messages to charge a mother and daughter for self-​
managed abortion. Whereas in Mexico misoprostol was widely available over the coun-
ter, that was not the case in the United States so US activists had to help people obtain
abortion medications. Accompaniment occurred both virtually and in person. The US-​
based networks often maintained relationships with physicians in the community who
were willing to respond to emergencies, or provide follow-​up care, although they did
not usually participate directly.142 By November 2023, Las Libres in the United States
reported they had already served approximately ten thousand people.143
Red State Access and its partners struggled to maintain funding. They spent about
$10 per package, most of which was shipping, but they couldn’t accept any individual
donations without revealing their personal identity. They also couldn’t send money to
the mailing volunteers without leaving a trail. They often ran out of money and had to
pause services, especially as the donations after Dobbs tapered off.144 For example, on
October 10, 2023, AccessMA had depleted funding for its free program in ten states so
they were only able to send medications to people who were undocumented, unbanked,
advanced gestation, minors, and domestic violence clients. They directed other clients
in affected states to two low-​cost online vendors on Plan C. According to one researcher,
“a significant portion of people reaching out to these networks are in controlling envi-
ronments, can’t leave a financial trail, can’t leave the house without the partner/​parents
noticing etc. There’s definitely been an uptick of these cases since the price drop on Plan
C. Now, only people in really desperate situations reach out.”145 Despite these setbacks,
Red State Access continued to help develop new partners, including Mississippi Access,
Louisiana Access, and Texas Red Transfronteriza.146 Another organization, TSA Health,
formed to provide “free religious telehealth abortion care” in New Mexico, with plans
to expand to states banning abortion. TSA Health was founded by The Satanic Temple,
known for challenging abortion bans based on First Amendment religious arguments.147
In addition to community support networks providing free abortion pills to people
living in states with bans, dozens of companies offered abortion pills online for as little
as $25, with prompt delivery in all fifty states.148 For example, in July of 2023, a website
called MTP Pharmacy delivered abortion pills in three days for $37 to people living in
any US state or territory. Another group called Private Emma delivered abortion pills in
176 • Abortion Pills

three to four days for $49. Safeabortiononline.com delivered abortion pills in four days
for $50. Plan C, which tested websites selling abortion pills, including conducting prod-
uct testing of the medications, listed the top twenty-​five online suppliers in order of
cost on their website, regularly updating the list with the latest prices, which led to price
competition. “They’re all looking at our list and they’re saying, ‘How can I get a higher
ranking above this other one,’ ” said Wells. “So they set their price just a little bit below
and then the next one contacts us and says, ‘Okay, well, I want to be a little bit below
that price.’ It got really outrageous at one point, where one of them went down to like
$25.”149 None of these suppliers required a prescription and many provided abortion
pills in advance so people could have them on hand in case they experienced an unin-
tended pregnancy. “We welcome these price reductions by the online retailers because
we know the base cost of the product is quite low” said Wells, who estimated that the
pills cost the suppliers about $2 to $3. Online sellers charged hundreds of dollars before
Dobbs. “We recognize the price gouging that was going on previously, so we’re glad that
competition in the marketplace is resulting in more affordable products for people who
need them.”150 According to Wells, several of the companies were longstanding phar-
macies that offered many medications, whereas others were newly formed, indepen-
dent, mission-​driven companies created by reproductive health advocates wanting to
ensure access to abortion pills, such as Private Emma, An Idle Timer, Medside 24, and
ybycmeds. Wells noted the competition was fierce among these companies, so much so
that she had to send out a code of conduct companies had to comply with in order to
be listed.151
While most websites did not do any sort of medical screening of customers for eligi-
bility to use the medications, one claimed to: Private Emma. Private Emma began selling
abortion pills in the United States in November 2022. A representative of the company
claimed they were a charitable organization that had for years provided “sanitary prod-
ucts” to women in Africa. They claimed to have a medical director who screened each
customer to ensure they were eligible to use abortion pills. By July of 2023, Private
Emma had mailed mife/​miso combi packs to close to eight thousand people in the
United States. The company had two warehouses inside the United States so they were
able to mail medications promptly to their customers. Their medications came from
India and were brought into the country by mail or courier. They initially charged $105
for the mife/​miso combi pack, but they were eventually able to drop their prices to
$49 as they increased their efficiency and volume over time. They were able to get the
medication for between $2 and $3, plus shipping from India of about $1 per package.
Priority mail cost $10, and they had costs of rent on the warehouses, payments to couri-
ers, and employee costs (they had five employees). In their first nine months of opera-
tions, they had five thousand combi packs confiscated during shipment. An employee
of Private Emma described the risks they faced doing this work: “People are putting
their livelihoods on the line because people could go to prison for doing something like
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 177

this. We’ve got people involved in India, in Africa, and in the States. Everyone is risking
something to be involved in this organization to be able to make it more affordable and
make it more accessible.”152
The work of organizations providing information about and access to abortion pills
had an increasingly significant impact as more states restricted access to abortion in
the medical system. Between April of 2022 and April of 2023, the Plan C website had
2.4 million visits, over three times as many as the previous year, when they had 719,000
visitors. The day after the Dobbs decision alone had 559,000 visits. By May of 2023,
Plan C had seven to eight thousand visitors to their website each day. Legislation intro-
duced in Texas to suppress abortion pill information specifically mentioned Plan C.153
Aid Access, listed on Plan C’s website, served over 300,000 people between 2021 and
2023.154 Many other people were ordering pills through websites.155 The SASS website
received around thirteen thousand visits each month, and the organization conducted
an increasing number of abortion pill trainings. In 2022, SASS train-​the-​trainer sessions
reached at least 983 people across the United States, including in states with abortion
bans and severe restrictions on access. SASS worked with Advocates for Youth to reach
at least an additional 132 people, most of whom were located in Texas, where abortion
was completely banned with very limited exceptions. They also had a dedicated social
media team that spread information about abortion pills on the internet.156 According
to Ariella Messing, executive director of the Online Abortion Resource Squad, posts on
their abortion subreddit increased to more than 1,300 posts a day by May of 2023.157
On the other hand, people in organizations inside states with abortion bans had
to be careful about how they shared information. “I cannot say anything dealing with
how to get the abortion pills,” said Michelle Cohen of SHERo Mississippi. “It’s unfor-
tunate that I cannot post Plan C information, but I definitely personally support Plan
C and their mission.” Instead, Cohen posted links to other organizations with general
information about abortion pills. “I post on all of our social media handles the people
who are trusted folks that you can go to for information, but it can’t be just information
about where to get pills. That’s how I can save myself. I have to be real clear not to post
any images of the pills because the anti-​abortion lawmakers can come at me and say,
‘Oh, you’re advertising where people can get pills.’ There’s a fine line that I have to walk
here in Mississippi when it comes to even discussing abortion pills.”158 Reproaction
co-​founder Pamela Merritt spoke about the importance of sharing information about
abortion pills, particularly in communities where people need it most:

I think more people know about pills now than they did before Dobbs, but it’s whether the
right people know about pills—​the people who need them as opposed to people who would
like them. I don’t feel that in North St. Louis city folks know about being able to access medi-
cation abortion at online pharmacies or any of that. So how are activists reaching those peo-
ple? I would say the best way to reach them is through information sharing in an intimate
178 • Abortion Pills

setting, where people can ask questions and be respected and feel comfortable receiving and
sharing the information. I know there are organizers who are doing that. It’s just a little tricky
finding people in states with abortion bans to go out and do that.159

Merritt said that while information sharing is protected by the First Amendment, she
knew there were legal risks. “The reality is that the Attorney General in the State of
Missouri is absolutely unhinged, and is somebody who wants to throw people in jail.
By the time you litigate the First Amendment protection, you’ve been through hell.”160
Merritt however said she was willing to take those risks. “I’ve structured my life so that
I can take risks that other people don’t. You know a lot of the folks who are best suited
to go into certain communities are also folks who are incredibly vulnerable to that
kind of prosecution. That said, there are activists on the ground who are doing it.”161
Merritt also said people were likely getting abortion pills through the street economy.
“One of the things I learned from volunteering for five years in North St. Louis is
that the street economy is real and people get everything that they need through a
completely separate economic system. That includes diapers, formula, and probably
misoprostol.”162
Merritt, however, expressed frustration with activists who talked about abortion
pills as if they would solve the problem of abortion access. “This is not the cure to all
that ails us,” said Merritt, who explained that many people don’t live in circumstances
where they can self-​manage an abortion:

The reality on the ground is that self-​managed abortion with pills from an online pharmacy
is probably the best thing for somebody at Washington University in St. Louis who misses
a period. Awesome, fantastic. But for the sisters who are on the North Side or in Bootheel,
we are at the exact same crux that we were on abortion access without Medicaid abortion
coverage. Access was good for them but not for me. It bothers me when people are like,
“Oh, it’s gonna be great! It’s just this wonderful thing.” And I’m just like, you obviously have
never lived in a house with three other families in a one-​bedroom, one-​bathroom situation
while you’re self-​managing your abortion after thirteen weeks because you weren’t sure how
pregnant you were because you didn’t go to the doctor, and then somebody calls the police
because they were just tired of you being on the sofa. There’s not a lot of privacy when you’re
poor. It frustrates me. But I think that when I first began work on self-​managed abortion
with pills versus now, there’s more of an acknowledgment that it is not going to make every-
thing okay.163

Merritt said she knew many young people who did not have a permanent place to live
and did not have a reliable and confidential address to receive abortion pills by mail.
In October 2023, the Society for Family Planning reported that abortion actually
increased the year after Dobbs by 2,200 abortions. While abortions plummeted in states
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 179

banning abortion, they increased dramatically in states where abortion was still legal.164
These numbers did not include abortions accessed outside of the formal medical sys-
tem, which were likely happening in great numbers. Other research showed that tele-
health abortion in particular made timely abortion care possible, especially for younger
people, those experiencing food insecurity, rural residents, and those living far from an
abortion facility.165 American women discovered, as women knew across the globe in
countries where abortion was illegal, that they could not wait for permission to have
abortions, but they were also not going back to the days of dangerous, coat-​hanger abor-
tions. The internet and abortion pills had created a new reality. “A lot of us local people,
local activists, organizers, and local groups were not waiting around for a national plan
or a national strategy,” said Michelle Cohen of SHERo in Mississippi. “There were a lot
of us who had been doing this work, and so there were plans in place and folks helping
their communities because the government does not give a damn about us and the legal
system does not give a damn about us.”166

Reframing Abortion Pills and Early Abortion

Anti-​abortion advocates had had tremendous success in stigmatizing abortion and
framing abortion pills as dangerous and hard to use. In response, abortion advocates
developed creative strategies to counter anti-​abortion rhetoric and images saturat-
ing the internet and political discussions portraying embryos in early pregnancy as
fully formed miniature human beings. New abortion restrictions passed by legis-
latures across the country referred to embryos as “babies” and claimed there was a
“fetal heartbeat” at six weeks of pregnancy. In response, the MYA Network developed
the Issue of Tissue Project, which showed what tissue removed during early abor-
tions looked like.167 “There’s a lot of misinformation out there and many people have
come to believe it,” said MYA Network co-​founder Dr. Michele Gomez, a family care
physician in Burlingame, California. “There’s also accurate information out there but
mostly in the form of highly magnified embryos at these early stages. People have a
right to know and understand that they are magnified.”168
Advocates argued that before nine weeks of pregnancy, when 80 percent of abor-
tions take place, the embryo was not visible with the naked eye in the pregnancy tissue
removed during an abortion. There was no “heartbeat” at six weeks of pregnancy, only
the electrical activity of cells before an actual heart is formed, said Gomez. “The anti-​
choice movement has been showing inaccurate and graphic pictures for a long time,
and these images shock us so they tend to stick with us,” said Gomez. “Without fac-
tual images to counter the inaccurate images, many people just accept the only things
they’ve ever seen, which is completely understandable. Seeing actual images of early
pregnancy tissue, as seen with the naked eye, can help people replace the graphic and
inaccurate images they may have come to accept as true.”169
180 • Abortion Pills

MYA Network’s Issue of Tissue Project shared accurate images of early pregnancy
tissue. After manual aspiration abortions, they rinsed the blood from the tissue removed
from the uterus and photographed it for pregnancies of five weeks through nine weeks.
After an egg joins with a sperm at fertilization, it’s called a zygote. After five days of
development, it’s called a blastocyst. The blastocyst embeds in the uterine wall and
becomes an embryo at around ten to twelve days after fertilization. At around the tenth
week of pregnancy it becomes a fetus.
In the MYA Network pregnancy tissue photos, the embryos were too small to see
with the naked eye. At five weeks of pregnancy, the tissue is about one-​quarter-​of-​an-​
inch wide. At six weeks of pregnancy, the tissue is a little over half-​an-​inch. At seven
weeks of pregnancy, the tissue is one-​inch wide. At eight weeks of pregnancy, the tissue
is two-​and-​a-​half inches wide. At nine weeks of pregnancy, the tissue is about three-​
inches wide, while the fetus is 7/​8 of an inch (see Figure 5.4). Gomez said the MYA
Network’s decision to share these images grew from their own experiences as clini-
cians. “Many of us in the MYA Network provide in-​office abortions by manual uterine
aspiration, which is a simple, non-​surgical procedure that takes five to ten minutes to
complete and can be done with only ibuprofen for pain control,” she said. “We’ve often
had the experience of a patient asking to see the pregnancy tissue after the procedure,
and then being very surprised by what they see.”170
They argued that seeing the tissue resulting from pregnancy termination could dispel
the myths surrounding abortion, help clear up confusion and misunderstandings result-
ing from anti-​abortion misrepresentations, and combat abortion stigma and shame. “In
my experience, pregnant people and their partners have felt some relief when they see
the tissue, because it doesn’t look like what they’ve seen in anti-​choice imagery,” Gomez
continued. “We in the MYA Network discussed this, and decided that as clinicians we
wanted our patients to have more information, so they could be better informed.”171
On their website, the MYA Network shared recordings of patients speaking about
their surprise and relief after viewing their own pregnancy tissue after an abortion.

Figure 5.4: These photos show pregnancy tissue extracted at five to nine weeks of pregnancy, rinsed of
blood and menstrual lining. The images show the tissue in a petri dish next to a ruler to indicate its size.
The tiny embryo is embedded in the tissue (courtesy of MYA Network).
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 181

One woman explained, “It wasn’t what I expected at all. It was so small…and seemed
a lot less scary.” Others spoke about how seeing their pregnancy tissue relieved feel-
ings of guilt. “It just looked like mucus, it was just a little thing…nothing that made us
feel guilty,” said another patient after viewing her pregnancy tissue.172 After the MYA
Network published the images, TikTok influencers used them to raise awareness about
early abortion and point out the absurdity of this early pregnancy tissue having more
rights than the actual person who is pregnant.173 “A lot of people are comforted by
seeing these images—​they’re just so different from what they’d previously seen,” said
Gomez. “People need and deserve facts, love, and compassion to make decisions about
their own bodies and their own lives.”174 Advocates as far back as 1995 had argued for
showing women abortion tissue to demystify abortion and relieve anxiety and fear.175
Other reproductive health clinicians developed a different, innovative strategy to
expand access: “missed period pills.” For patients who had missed a period and did not
want to be pregnant, clinicians began prescribing “missed period pills” or “late period
pills” without prior pregnancy confirmation. The pills were the same regimen for medi-
cation abortion—​200 milligrams of mifepristone and 800 micrograms of misoprostol.
Misoprostol could also be used alone to restore menstruation. “If people want their
periods to return and do not want to be pregnant, these medicines provide a benefit
for them, regardless of their pregnancy status,” said Dr. Teresa DePiñeres, a physician
who advocated for missed period pills and worked with the organization Period Pills.
“Offering more options for fertility control is a good thing,” said DePiñeres.176
Advocates said some people preferred not to know if they were pregnant and others
simply wanted to avoid waiting to confirm a pregnancy or schedule an abortion. The
pills could be taken even if menstruation was just a few days late. Period pills could
relieve the anxiety of waiting for a period to come, and the stress of taking a preg-
nancy test when a person didn’t want to be pregnant. Gynuity research showed period
pills provided psychological and emotional benefits, especially in social contexts where
abortion-​related stigma exists.177 “There’s not a right or wrong way. It’s just another
option for getting the care we need, and to practice bodily autonomy,” said DePiñeres.
“Most studies show that when people have options, they feel more satisfied with the
care they receive.”178 DePiñeres noted that people often chose to take medicines that
they may not need in order to prevent an unwanted condition, such as emergency con-
traception after unprotected sex or anti-​malarial pills if they travel to a country with
malaria cases. These medications had the psychological benefit of reducing stress and
anxiety about an unwanted condition.
Research indicated strong interest in missed period pills. A 2020 study of 678 people
in two states found that 70 percent of those who did not want to be pregnant said
they would prefer period pills instead of a test to confirm pregnancy. “If such a service
were available, demand could be substantial,” they concluded.179 The researchers noted
missed period pills could alleviate the impact of restrictive social norms and abortion-​
related stigma, which is associated with “increased anxiety, stress, depression, social
182 • Abortion Pills

isolation, negative self-​evaluation and somatic symptoms.”180 By fall of 2022, period

pills were available via telemedicine in six states—​California, Colorado, Massachusetts,
New Mexico, Oregon, and Washington—​and in the District of Columbia as part of a
pilot study run by the University of California, San Francisco. The National Working
Group on Period Pills advocated for making period pills more accessible in the United
States. Formed in 2019, the group had twenty-​one members by 2022, including medical
clinicians, lawyers, reproductive justice leaders, and researchers. The working group
also had fourteen organizational members, including five universities.181
Researchers at the University of California, San Francisco, began a clinical trial
on missed period pills to evaluate women’s experiences of using misoprostol alone to
bring back a missed period. In the trial, participants took misoprostol after missing
a period but without knowing whether they were pregnant. The study’s goal was to
assess “the feasibility and acceptability of this traditional concept of menstrual regula-
tion.”182 Advocates hoped period pills could help avert the negative consequences of
new abortion bans, in effect in over a dozen states across the country. “In the United
States, we are going to see increased maternal mortality because there are going to be
more unwanted pregnancies under conditions that are not safe,” said DePiñeres. “More
people are going to need abortions in places where they don’t have that option. This is
a way to potentially mitigate or circumvent some of that.”183
Abortion pill advocates pursued other forms of research to increase abortion pill
access. Aid Access founder, Dr. Rebecca Gomperts, began testing mifepristone for
contraception, with the goal of making a weekly 50-​milligram dose of mifepristone
available over the counter on pharmacy shelves within ten years. In May 2022, the
Moldovan Department of Health gave approval for the clinical trial of mifepris-
tone for contraception. More than fourteen medical centers, including seven hospi-
tals, committed to participate in the study. Researchers began enrolling patients in
Moldova in August 2023 and then expanded the study to the Netherlands, working
with Leiden University Medical Centre. Researchers planned to include 949 women
who would use mifepristone weekly for a year. Gomperts hoped that easy access to
mifepristone as birth control would then make it available for abortion if neces-
sary. Approval of mifepristone for contraception would also make it available as a
morning-​after pill, for use within 120 hours after unprotected intercourse. “It would
allow us to move flexibly between the medicine’s different indications as weekly
contraceptive, as an on-​demand method used before or after sexual intercourse
or as an early medical abortion method, depending on our life circumstances,”
said Gomperts.184
In order to understand how to increase access, advocates also studied atti-
tudes toward abortion pills in particular communities. In May of 2023, research-
ers at the National Asian Pacific American Women’s Forum and Ibis Reproductive
Health published a study about barriers to medication abortion for people within
 Chapter 5: The End of Roe Spurs Efforts to Expand Pill Access • 183

Asian American, Native Hawaiian, and Pacific Islander communities. The study
was funded by the Society of Family Planning. Barriers included community stigma
toward abortion, sexual, and reproductive health care, a lack of family support, and
the unavailability of language support for limited-​English or non-​English-​speak-
ing patients at abortion clinics.185 To address the digital divide, a new organization,
Reproductive Health Initiative for Telehealth Equity & Solutions, formed in 2022 to
better understand and remedy unequal access to the internet and telehealth-​capable
devices, as well as digital literacy.186
Other activists worked to destigmatize abortion by challenging myths about abor-
tion being difficult or traumatic. When activist and artist Jex Blackmore appeared on
Fox News Detroit on January 23, 2022, with reporter Charlie Langton and anti-​choice
advocate Rebecca Kiessling, they held up a mifepristone abortion pill and swallowed
it with a sip of water, saying “I want to show you how easy and safe it is by taking it
myself.” Blackmore’s Fox appearance went viral on social media, angering critics on
both ends of the political spectrum. Blackmore’s action was a part of a guerrilla cam-
paign for mail-​order abortion pills launched on January 22, the anniversary of Roe
v. Wade, by a group of Detroit activists affiliated with the group Shout Your Abortion.
The campaign included pasting more than one hundred posters on buildings and walls
across the city with the message, “ABORTION PILLS FOREVER,” along with the web-
site address, “shareabortionpill.info,” where people could find information about how
to order abortion pills by mail.187 Within the reproductive health community, the GLC
continued their work to normalize self-​managed abortion by attending and presenting
at conferences of organizations such as the National Abortion Federation, the Society
for Family Planning, the Abortion Care Network, Creating Change, Essence Fest, and
the State Innovation Exchange.188
Public awareness of abortion pills and self-​managed abortion was increased with
the release of a documentary called Plan C by filmmaker Tracy Droz Tragos. Tragos
began working on a film about the work of the organization Plan C in 2019, but after
Dobbs she rushed to finish so she could premiere the film at Sundance Film Festival in
Park City, Utah in January 2023. “Once Roe fell, there was an urgency to get the film
done and get it out there,” said Tragos. “The work of these intrepid activists must be
known.”189 The film featured Francine Coeytaux as well as several telemedicine pro-
viders such as Dr. Julie Amaon of Just the Pill, Dr. Razel Ramen of Pills by Post, and
midwife Christie Pitney of Forward Midwifery. The film also featured the work of
Dr. Rebecca Gomperts of Aid Access. “We have so much more access to abortion pills
today than we did in 2014,” said Coeytaux at the premier. “We can truly say to anybody
no matter what state you live in, you can get abortion pills mailed to you. It’s still not
over the counter. It’s still not in pharmacies. It’s still not $5. There’s a lot of work to be
done, but we’re a hell of a lot closer. Many people now know there are pills for abortion
and that they are safe and effective. We’ve made a huge amount of progress so far.”190
184 • Abortion Pills

In addition to Plan C advocates and clinicians, the film featured advocates from
several other organizations supporting people using abortion pills, including Dr. Linda
Prine of the Miscarriage and Abortion Hotline, and lawyer Farah Diaz-​Tello of the
Repro Legal Helpline. The film also included several interviews with people whose
identities were protected, including two people who ordered pills in states with abor-
tion bans and someone from a US-​based harm reduction organization that mailed pills
to people in states with bans. “The film did a brilliant job of telling the stories of people
who need abortions and the efforts of activists and providers trying to meet that need,”
said Elisa Wells. “The film shows the harm that abortion restrictions are causing people
and the possibility of a different solution that hasn’t been well known in the past, which
is telehealth and abortion pills.”191
While the world was focused on the Supreme Court’s dismantling of constitutional
abortion rights, these activists had been working hard behind the scenes to prepare for
a post-​Roe future by empowering people to access abortion pills no matter where they
lived or what they could pay. “The film tells stories of new models of care, and new and
alternate routes of access,” said Amy Merrill, Plan C co-​founder and digital director.
“We hope the film raises widespread awareness about this very real option and gener-
ates new hope, creativity, and momentum.”192 The film made clear the United States was
increasingly divided between abortion haves and have-​nots, where people in blue states
had increasing options to obtain private, convenient, and affordable telehealth abortion,
while people in red states faced increasing barriers and legal risks to obtaining this care.
To address these disparities, a tight network of committed reproductive health advo-
cates and a growing network of organizations were fighting to create access for people
no matter where they lived. “What we want people to know with this film is that abor-
tion pills are available in all fifty states by mail,” said Elisa Wells. “We know that part of
the narrative is that you can travel to a different state to get care, but you don’t need to
do that. You can get access to these safe and effective pills by mail in all fifty states. We
now need to work on policy to ensure that there’s no risk of criminalization.”193
At its Sundance premiere, Plan C elicited three standing ovations from audience
members, with people laughing and cheering but also squirming uncomfortably in
their seats as they contemplated the struggles people were encountering trying to
access abortion pills post-​Roe. “We hope the film reminds people that they don’t have
to accept reality as it is now,” said Merrill. “Together we can stand up to bullying, use the
digital tools in our pockets to spread information, and build new systems that center
the individual, their decisions, and their rights.”194
Abortion pills were becoming an increasingly accessible, safe, and effective alterna-
tive to clinic-​based care, which was becoming inaccessible because of abortion bans. In
response, the anti-​abortion movement increasingly focused on trying to restrict access
to abortion pills.
 CHAPTER 6

“Putting the Genie Back in the Bottle”:

Post-​Dobbs Attempts to
Block Mifepristone

By April of 2023, thirteen states had banned most abortions. Georgia and Florida
banned abortions at six weeks of pregnancy. Another eight states had bans blocked
by courts.1 A study released in April of 2023 revealed that in the first six months after
the Dobbs decision in June 2022, there were about thirty-​two thousand fewer recorded
clinical abortions than expected in the United States, an average of about five thousand
fewer legal abortions each month than in the months before the ruling—​a drop of about
6 percent. In April and May, there were an average of about eighty-​two thousand abor-
tions each month. From July through December, that fell to an average of seventy-​seven
thousand clinical abortions per month. In the thirteen states with bans, clinic-based
abortions fell more than 95 percent, while the average number of clinical abortions in
other states increased slightly on average. But abortions surged in some states, such as
Minnesota and Kansas, to which people traveled to have legal abortions. The study did
not measure the number of self-​managed abortions, so the actual number was likely
much higher than the reported number.2 In this increasingly fraught political landscape,
where fewer women had access and women without access were seeking to self-​manage
abortions, pills became the frontline of the battle for abortion access.
In April 2023, the conservative Heritage Foundation published the ninth edition of
its strategy blueprint, Mandate for Leadership: The Conservative Promise, where they
laid out their strategy on abortion pills, including to reverse FDA approval of mifepris-
tone, end the mailing of abortion pills by reviving the long-​dormant 1873 Comstock
anti-​obscenity law, limit use of abortion pills to seven weeks gestation, block telemedi-
cine abortion, pressure the FDA to conduct inspections of Danco and GenBioPro as
well as facilities manufacturing pills, and impose burdensome reporting requirements
on clinicians prescribing mifepristone.3 Anti-​abortion groups hoped to take advantage
186 • Abortion Pills

of the many federal judges appointed by the Trump administration, from the Supreme
Court down to district trial courts. These judges emboldened organizations such as the
conservative legal group Alliance Defending Freedom (ADF), which worked to make
abortion illegal nationwide and to roll back health care advances like medication abor-
tion. Anti-​abortion groups, including an expansive network of “crisis pregnancy cen-
ters” (CPCs), attempted to interfere with access to medication abortion by spreading
disinformation about abortion pills. Finally, anti-​abortion prosecutors charged women
for obtaining and using abortion pills. This chapter chronicles these efforts, and how
abortion rights advocates responded.
Across the country, anti-​abortion states made clear their plan to criminally pros-
ecute women using abortion pills and those helping them. In August 2022, shortly after
the Supreme Court released the Dobbs decision, Nebraska prosecutors brought felony
charges against a forty-​one-​year-​old mother and her seventeen-​year-​old daughter for
illegally performing an abortion after the mother bought abortion pills and her daugh-
ter used them to end a pregnancy. Nebraska law enforcement officials subpoenaed
Facebook to turn over messages between the mother and daughter discussing abortion
pills, and Facebook complied.4
Then in January 2023, the attorney general of Alabama, Steve Marshal, announced
that women who used abortion pills were exempt from the state’s feticide law, but could
be prosecuted under other state laws. “The Human Life Protection Act targets abor-
tion providers, exempting women ‘upon whom an abortion is performed or attempted
to be performed’ from liability under the law,” said Marshall, but “it does not pro-
vide an across-​the-​board exemption from all criminal laws, including the chemical-​
endangerment law.” Alabama’s chemical-​endangerment law criminalized anyone who
“knowingly, recklessly or intentionally causes or permits a child to be exposed to, to
ingest or inhale, or to have contact with a controlled substance, chemical substance, or
drug paraphernalia.”5
These two stories raised concerns that anti-​abortion prosecutors would escalate
criminal prosecutions against people using abortion pills post-​Dobbs. While only one
state—​Nevada—​explicitly banned self-​managed abortion after 24 weeks when the
Supreme Court overturned Roe, legislators threatened to pass more bans, but no addi-
tional states did that in the two years after Dobbs. Members of the Texas Right to Life
expressed frustration that the Texas legislature failed to enact new laws encouraging
criminal prosecutions. “While leftist groups traffic abortion pills over our southern
border or ship them to college dorm rooms, politicians failed to address this scourge,”
said Texas Right to Life in a May 29, 2023 email to supporters.6 In May of 2024,
Louisiana legislators introduced legislation to place mifepristone and misoprostol on
the list of controlled substances in the state, but they exempted pregnant women who
possess these medications for their own consumption and allowed people who have
a “valid prescription” to obtain them from pharmacies. There were no exceptions for
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 187

people supporting a pregnant woman.7 Nevertheless, abortion advocates expressed

concerns that prosecutors would increasingly bring criminal charges against people
for self-​managing their abortions, and would disproportionately target low-​income
women and women of color.8
Despite the legal risks of self-​managing abortion, research showed that many women
were willing to use abortion pills, especially those experiencing clinic access barriers.
In a study of 19,830 patients attending forty-​nine abortion clinics in twenty-​nine states,
one in eight considered self-​managing before attending the clinic, and of these, one in
three attempted to do so. Women without access to clinics and those who preferred at-​
home care were more likely to consider self-​managed abortion.9
The criminalization of self-​managed abortion was part of a wider anti-​abortion
campaign to stigmatize abortion pills and discourage people from using them. The
campaign spread disinformation about the safety of abortion pills, advocated danger-
ous “abortion pill reversal” theories through CPCs pretending to be abortion clinics,
and brought a legal challenge to the FDA’s approval of mifepristone. By moving abor-
tion out of brick-​and-​mortar clinics, abortion pills posed a deep threat to the anti-​
abortion movement’s central strategy of physically interfering with access to abortion.
Just as abortion pills were finally becoming more accessible after years of tight restric-
tions by the FDA, the anti-​abortion movement poured tremendous resources into try-
ing to block women’s access to abortion pills.

Abortion Pill Disinformation

To interfere with abortion pills access, the anti-​abortion movement developed a coor-
dinated campaign to spread misleading and false information about the safety and
efficacy of medication abortion. In February of 2022, the right-​wing Family Research
Council (FRC) published a report titled “The Next Abortion Battleground: Chemical
Abortion”.10 Founded in 1983 as a division of James Dobson’s religious right organiza-
tion Focus on the Family, the FRC was one of the far right’s most powerful advocacy
groups, fighting against abortion, stem-​cell research, and LGBTQ equality, and pro-
moting “the Judeo-​Christian worldview as the basis for a just, free and stable society.”11
The FRC’s “chemical abortion” report used inflammatory and misleading language.
For example, they used the phrase “chemical abortion” to make abortion pills sound
dangerous. Throughout the report, they referred to embryos and fetuses as babies, and
they described misoprostol as a drug that “ ‘yanks’ the baby out” of the womb. They
referred to medication abortion as a “violent regimen.” The report repeatedly referred
to the “abortion industry”—​an attempt to make doctors and other clinicians provid-
ing abortion health care sound nefarious and exploitative.
The FRC report inaccurately claimed that abortion pills posed “profound dangers”
to women, citing the rarest and most severe drug reactions from the mifepristone
188 • Abortion Pills

medication guide, and framing them as common. FRC claimed that abortion caused
depression and that medication abortion was “uniquely traumatic” to women, more
so than aspiration abortion—​a claim repeatedly disputed by major medical organiza-
tions, including the American Psychological Association.12 FRC inaccurately claimed
that mifepristone was “subject to the FDA’s drug safety program—​Risk Evaluation and
Mitigation Strategy (REMS)—​because it carries such life-​threatening risks.”13
At the end of their report, FRC called on the FDA to strengthen restrictions on the
abortion pill, prohibit telemedicine abortion, and require doctors to conduct unneces-
sary physical examinations of patients receiving the abortion pill. These barriers would
have significantly decreased access to medication abortion and increased the costs. FRC
also called for the criminal prosecution of Rebecca Gomperts of Aid Access, cracking
down on online pharmacies that sold abortion pills, and shutting down Gynuity Health
Projects’ TelAbortion study.
The FRC talking points proliferated across the anti-abortion movement, appearing
in the materials of anti-abortion CPCs and legal pleadings challenging the FDA’s 2000
approval of mifepristone. FRC’s panicked rhetoric revealed abortion opponents’ fear of
the power and control that abortion pills could give to women. An affordable, widely
accessible abortion pill that women could obtain through the mail and take in the pri-
vacy of their own homes would not only greatly increase access, but would also allow
women to avoid anti-​abortion protesters at clinics.
Taking a bizarre turn in November 2022, Students for Life circulated a petition
claiming that abortion pills caused pollution and supporting legislation to require peo-
ple using abortion pills to collect the products of their abortions and submit them to
their medical providers for disposal.14 Then in April of 2023, Students for Life submit-
ted a citizen petition asking the FDA to prohibit access to mifepristone until the agency
studied whether trace amounts of the pill in wastewater posed any risk to “endangered
or threatened species or designated critical habitats.”15 They claimed the FDA approval
of mifepristone violated the Endangered Species Act, and they threatened to sue the
FDA if the agency did not respond within 180 days.
By 2023, anti-​abortion groups were operating over 2,500 CPCs around the United
States.16 CPCs were designed to discourage pregnant women from having abortions
by claiming to offer unbiased counseling about abortion. In fact, they spread scientifi-
cally inaccurate information and used scare tactics. They often attempted to appear like
medical clinics, even though few were, and they used non-​diagnostic ultrasounds to
falsely signal medical legitimacy, while collecting people’s personal and health informa-
tion, with no privacy protections.17
A primary strategy used by CPCs to stigmatize abortion pills was to promote “abor-
tion pill reversal”—​the idea that giving pregnant women high doses of progesterone
would counteract the effects of mifepristone and stop an abortion. ACOG described
“abortion pill reversal” as “unproven and unethical” and “dangerous to women’s
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 189

health.”18 Clinical trials of the abortion pill reversal procedure ended after participants
experienced dangerous hemorrhages requiring hospitalization.19 “Claims regarding
abortion ‘reversal’ treatment are not based on science and do not meet clinical stan-
dards,” declared ACOG.20
In the fall of 2021, Reproaction and the Center for Countering Digital Hate raised
an alarm about social media companies circulating anti-​abortion groups’ “abortion pill
reversal” claims, while at the same time blocking factual information about abortion
pills from reproductive health groups. The Center for Countering Digital Hate pub-
lished a report titled “Endangering Women for Profit,” which reported that Facebook
and Google accepted between $115,400 and $140,667 for ninety-​two ads promoting
“abortion pill reversal” between January 2020 and May of 2021. Almost all of these
ads—​98 percent—​promoted websites that claimed abortion reversal was “effective.”
These anti-​abortion ads received up to 18.4 million views, including 709,870 impres-
sions from minors between the ages of thirteen and seventeen. By targeting minors,
these ads violated Facebook’s policy against advertisements to minors that promoted
unsafe services or that “exploit, mislead, or exert undue pressure on the age group tar-
geted.”21 Co-​founder of Reproaction Pamela Merritt described “abortion pill reversal”
as part of the long history of white supremacist medical experimentation on Black and
Latinx people. “The abortion pill reversal tactic is another attack on the profession of
medicine. It’s a continuation of the careless disregard for the health of people in mar-
ginalized communities. It’s like experimentation. They know that it’s not been vetted,
but they’re willing to experiment with people’s health and their future fertility.”22
CPCs promoted “abortion pill reversal” online and at their brick-​and-​mortar loca-
tions as well. To lure in unsuspecting people, CPCs mimicked reproductive health clinics,
often intentionally locating these centers next to abortion clinics and using names like
“Center for Pregnancy Choices” and “Your Options Medical.” Despite appearances, these
organizations—​often run by white evangelicals—​used medically inaccurate information
and coercive tactics to obstruct women’s access to abortion, contraception, and even pre-
natal care. A study of over six hundred CPC websites in nine states revealed that one-​
third of CPCs promoted “abortion pill reversal.”23 Almost two-​thirds made patently false
or biased medical claims, including that abortion caused breast cancer and infertility—​
which ACOG states is untrue.24 Many told women that abortion causes depression, a claim
debunked by the American Psychological Association. Many inflated miscarriage rates to
encourage women to delay care until it was too late to use abortion pills or access abortion
legally. Such delay tactics were dangerous, especially for women with ectopic pregnancies
and those who planned to continue their pregnancies and needed prompt prenatal care.25
A range of advocates worked to expose these anti-​abortion centers, including
Reproaction’s Expose Fake Clinics campaign and Abortion Access Front.26 Concerned
about the dangers of “abortion pill reversal,” Colorado became the first state to pass
a law restricting this practice. In April of 2023, the Colorado legislature passed a law
190 • Abortion Pills

subjecting healthcare practitioners who perform medication abortion reversal to disci-

pline unless the state’s medical licensing boards determined that treatment was a “gener-
ally accepted standard of practice.” A Catholic medical center promptly challenged the
law in federal court.27 In October 2023, a federal judge entered a preliminary injunction
against enforcement of the law as a violation of religious freedom.28 Meanwhile, abor-
tion opponents introduced “informed consent” laws requiring healthcare providers to
notify people taking abortion pills about the option of “abortion pill reversal.” As of
2021, fourteen states had these laws, although courts blocked them in several states.29
These laws were mostly in the Midwest and South, but conservative legislators in pro-
gressive states introduced these laws as well.30
When the Supreme Court’s reversal of Roe v. Wade allowed states to ban abor-
tion, advocates expressed concerns that CPCs could share private information about
pregnant women seeking abortion with law enforcement. CPCs appeared to be
local, but many were part of large anti-​abortion, anti-​LGBTQ networks, such as
Heartbeat International, Care Net, and the National Institute of Family and Life
Advocates. Under the direction of these groups, CPCs used sophisticated digital
strategies, including geofencing and menstrual apps, to intercept those seeking abor-
tion, and online data platforms to collect client information. Privacy International
documented how CPCs used centralized platforms such as eKYROS and Next Level
Center Management Solutions to store and share client information. Heartbeat
International boasted its software enabled CPCs to share client information with the
broader anti-​abortion movement.31
Many pregnant women provided their medical information to CPCs without under-
standing that these organizations were not subject to medical records privacy laws and
could share their private information with the anti-​abortion movement. A group of
state-​based women’s rights advocacy organizations called The Alliance: State Advocates
for Women’s Equality and Gender Justice published a report in February 2022, “The
CPC Industry as a Surveillance Tool of the Post-​Roe State.” According to the report, a
“modernized, proliferating and mostly evangelical CPC industry” was collecting “mas-
sive amounts of client data including detailed sexual and reproductive histories through
in-​person ‘counseling,’ centralized chat platforms, and smartphone apps,” stored in a
proprietary anti-​abortion movement “mega-​database.”32 The Alliance warned that the
proliferating web of CPCs was positioned to assist with state surveillance of pregnant
women and enforcement of abortion bans post-​Roe.
While there were over 2,500 CPCs in 2022, health clinics providing abortion had
diminished precipitously, from 2,749 in 1978 to under 780 in early 2022. In some states,
CPCs outnumbered abortion clinics eleven to one. CPCs’ attempts to intercept women
seeking reproductive health care delayed access until it was too late to use medication
abortion or to access abortion care at all in the many states with bans on abortion after
a certain number of weeks.33
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 191

New York-​based privacy group Surveillance Technology Oversight Project (S.T.O.P.)

released a report in May of 2022 titled “Pregnancy Panopticon: Abortion Surveillance
After Roe,” detailing the digital surveillance threats facing pregnant women who seek
abortion information and services, and how these threats could escalate dramatically if
the Supreme Court repealed abortion rights and states criminalized abortion. “Police,
prosecutors and private anti-​abortion litigants will weaponize existing American sur-
veillance infrastructure to target pregnant people and use their health data against
them in a court of law,” concluded the report. “This isn’t speculation—​it’s already
happening.”34
The report explained how anti-​abortion governments and private entities were
using cutting-​edge digital technologies to surveil women’s search history, location data,
messages, online purchases, and social media activities by using geofencing,35 keyword
warrants, big data, and more. “Every aspect of pregnant people’s digital lives will be put
under the microscope, examined for any hints that they sought (successfully or other-
wise) to end their pregnancy,” stated the report.36 The report predicted modern sur-
veillance tools would help states to enforce criminal abortion bans on a scale that was
technically impossible before Roe, posing an unprecedented threat to pregnant women
and those helping them access care. Police could use digital keyword warrants to “cast
digital dragnets” and identify people seeking abortion information online. They could
also purchase data from commercial data brokers—​which they could do without any
court oversight—​and leverage commercial databases that used big data and machine
learning to predictively identify pregnant women. Using these technologies, police
could track anyone who travels out of state for abortion health care and prosecute them
upon their return.
“It will be truly dystopian when police can use modern surveillance to enforce these
backwards abortion bans,” said Albert Fox Cahn, co-​author of the report and executive
director of S.T.O.P, which litigated and advocated for privacy and fought excessive local
and state-​level surveillance. “The Supreme Court may be turning back the clock fifty
years on civil rights, but anti-​abortion policing will bring us an even darker future,”
Cahn continued.

In 1973, police couldn’t use the surveillance tools that have become commonplace today.
Suddenly, every phone, laptop, and smart device will become a potential policing tool, with
pregnant people’s location data and search histories mined for evidence. Even when abor-
tion bans stop at the state line, the surveillance will be national, giving anti-​abortion police
a way to track abortion care coast to coast. Even if the laws are the same as pre-​Roe, the way
they’re enforced will be starkly different.37

S.T.O.P. was concerned that anti-​abortion states would use geofencing to iden-
tify people accessing abortion care. Geofence warrants could enable police to force
192 • Abortion Pills

Google and other companies to identify everyone who comes into a designated area—​
such as an abortion clinic—​during a designated time. As of 2022, only one state—​
Massachusetts—​banned geofencing near abortion clinics. Using these technologies,
police could track women who travel out of state for abortion health care and prosecute
them upon their return, said advocates. “As it stands, anti-​abortion activists already
surveil pregnant people to intimidate them out of exercising their legal reproductive
rights. Police and prosecutors already surveil pregnant people digitally to pursue cases
against them,” said S.T.O.P.’s research director Eleni Manis. “We expect a massive esca-
lation of surveillance targeting pregnant people, their reproductive healthcare provid-
ers, and anyone helping pregnant people access care, including care for miscarriages
and ectopic pregnancies.”38 They also noted that electronic payment records and retail
sales data were potent sources for abortion surveillance, and warned that police were
already using mass extraction technology to download all data on a user’s phone into
a searchable file.
Whereas states operated under some limitations, such as probable cause require-
ments for warrants, private parties do not have to abide by such requirements and could
pursue claims under civil bounty-​hunter laws prohibiting abortion, with much less evi-
dence than is needed to enforce criminal abortion bans. And while bounty-​hunter laws
in force in Texas, Idaho, and Oklahoma barred any enforcement action by state offi-
cials, private bounty hunters and anti-​abortion states would be able to work in tandem
to target pregnant women as well as anyone who helped them find abortion health care.
Some states were already tracking menstruation, pregnancy, and abortion. The
Missouri state health department director, Dr. Randall Williams, testified at a 2019
state hearing that he kept a spreadsheet monitoring the menstrual periods of Planned
Parenthood patients.39 Oklahoma issued an annual “Abortion Surveillance” report with
detailed information about abortions in the state.40 In January 2022, Oklahoma state
senator George Burns introduced Senate Bill 1167, the “Every Mother Matters Act,”
which would establish a government database of pregnant women looking to get abor-
tions in Oklahoma.41
S.T.O.P. recommended that state and federal lawmakers consider steps to protect
people’s privacy, such as targeted bans on electronic surveillance and bans on private-​
sector data brokers from buying or selling information about reproductive health. In
New York, lawmakers proposed legislation to ban geofence warrants, keyword war-
rants, and facial recognition technology, as well as ban police from purchasing geoloca-
tion data from commercial vendors. S.T.O.P. called on tech giants like Apple, Facebook,
and Google to dramatically improve encryption and privacy protections, and to stop
allowing mass police surveillance. S.T.O.P. also urged abortion providers and advocates
to “harden their digital infrastructure” to ensure the privacy of people seeking their help
online by implementing stronger privacy protections into their digital platforms, col-
lecting only data that’s absolutely necessary for their services, retaining it only as long
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 193

as needed, and minimizing third-​party sharing. S.T.O.P. recommended that abortion

providers and advocates should immediately conduct privacy audits of all electronic
communication, including use of third-​party social media and messaging services.
To address these privacy concerns, members of Congress introduced the Stop Anti-​
Abortion Disinformation (SAD) Act on June 23, 2022 to crack down on CPCs. The
bill directed the Federal Trade Commission (FTC) to prohibit deceptive or misleading
advertising related to the provision of abortion services, and authorized the FTC to
enforce these rules by penalizing organizations in violation with fines of up to $100,000
or half of the parent organizations’ yearly revenues. The SAD Act required the FTC
to make a biannual report to Congress on enforcement actions.42 A group of senators
introduced the My Body, My Data Act—​a federal law protecting personal reproduc-
tive health data by minimizing the information that companies can collect and retain,
for example through period tracking apps. The bill would prevent organizations from
disclosing or misusing that information, and create a new national standard to protect
reproductive health data, enforced by the FTC.43 Congressional Republicans blocked
both bills.
While Congress did not act, California lawmakers passed AB 1242 to enhance pri-
vacy protections. On September 27, 2022, the California governor signed the law bar-
ring telecommunications companies incorporated or headquartered in California from
providing records of digital communications related to abortion to law enforcement
officials seeking to use them in an investigation or prosecution for abortion that is legal
under California law.44 The bill aimed to prevent cases like the Nebraska prosecution of
the mother and her seventeen-​year-​old daughter. “California’s AB 1242 could be a huge
step forward in protecting people’s digital privacy as they navigate abortion access in
this post-​Roe world, especially as people increasingly turn to self-​managed abortion,”
said Elisa Wells. “While self-​managed abortion using pills is extremely safe and effective
from a medical perspective, we know that people have been unjustly criminalized for
managing their own abortions and that digital footprints have been used by prosecu-
tors to build cases against people. Plan C welcomes this effort to strengthen digital pri-
vacy. Abortion is normal health care and no one should be investigated or criminalized
for it.”45 The law authorized the California attorney general to sue California corpora-
tions to compel their compliance with the law, and imposed civil liability if the corpo-
ration knew or should have known that the warrant, subpoena, or other legal process
was related to an investigation into an abortion or enforcement of a criminal abortion
law. With many large tech companies based in California, including Google, Apple,
and Meta, which owned Facebook and Instagram, advocates hoped the law would have
a nationwide impact because it protected communications occurring between people
located outside of California.
California lawmakers proposed another bill in February 2023 to protect people
from unconstitutional searches of their data. The law proposed to block police and
194 • Abortion Pills

prosecutors in anti-​abortion states from using “reverse warrants” to require technol-

ogy companies to reveal the names of people who have searched online for abortion or
traveled to a location offering abortion services.46 Normal warrants seek information
about a particular person, such as places they’ve been or the keywords they searched
for online. A reverse warrant seeks the identities of all the people who present at a par-
ticular location or who searched for a particular keyword. These warrants can be used
to conduct broad phishing expeditions for those who seek abortion. Reverse warrants,
geofence warrants, or keyword warrants—​known as “dragnet surveillance demands”—​
enabled local law enforcement in states across the country to compel tech companies to
search their records and reveal the names and identities of all people whose digital data
shows they’ve spent time at or near an abortion clinic or searched for abortion informa-
tion online. “Between 2018 and 2020, Google alone received more than 5,700 reverse
warrant demands from states that now have anti-​abortion and anti-​LGBTQ legisla-
tion on the books,” said Hayley Tsukayama, senior legislative activist at the Electronic
Frontier Foundation, which advocates for digital privacy. “As a worldwide leader in
technology and innovation, California is uniquely positioned to divest from digital sur-
veillance that would target people for having an abortion or seeking reproductive and
gender-​affirming care.”47
The law’s introduction came at a critical time, when Republicans in Arkansas
and Oklahoma introduced bills allowing authorities to criminally prosecute women
who have abortions.48 “Carrying a smartphone, using social media and allowing apps
to know our location has become a part of our daily routines,” said Becca Cramer-​
Mowder, legislative advocate at ACLU California Action, which backed the bill. “But it
means that each of us has a vast data trail that is vulnerable to government abuse. Anti-​
abortion police and prosecutors have used digital data to criminalize people for their
abortion long before Roe v. Wade was overturned, and law enforcement in other states
have already abused reverse warrants to identify people protesting police violence. We
need to put a stop to this type of dragnet surveillance.”49

Anti-​Abortion Campaign to Remove Mifepristone from

the Market
On November 18, 2022, anti-​abortion advocates filed a federal lawsuit—​Alliance of
Hippocratic Medicine v. FDA—​challenging the FDA’s original approval of the medi-
cation mifepristone in 2000, as well as subsequent updates to the approval in 2016,
2019, and 2021. The conservative legal group ADF filed the lawsuit on behalf of four
anti-​abortion medical organizations, several doctors, and a dentist against the FDA
and the HHS. ADF had represented Mississippi in the case that led the Supreme
Court to overturn Roe v. Wade and they had a history of helping draft anti-​abortion
laws adopted in many states. In their 113-​page complaint, the plaintiffs argued the
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 195

FDA unlawfully fast-​tracked the approval of mifepristone in 2000 and did not have
the required research to prove the safety of the drug under the labeled conditions of
use. They argued that mifepristone was a dangerous drug that caused depression and
many deaths.50
ADF chose to file the case in the Amarillo Division of the Northern District of
Texas, where it was assigned to the forty-​five-​year-​old Trump appointee Matthew
J. Kacsmaryk. For five years before becoming a federal judge, Kacsmaryk was deputy
general counsel for First Liberty Institute, a Christian conservative legal organization
that specializes in representing religious groups claiming to have experienced discrimi-
nation.51 In 2015, Kacsmaryk had written an op-​ed for the National Catholic Register
stating his opposition to same-​sex marriage, no-​fault divorce, birth control, abortion,
and sex outside of marriage—​and his support for “complementarianism,” a religious
belief that assigns primary headship roles to men and support roles to women based on
the interpretation of certain biblical passages.52 “He is an anti-​LGBT activist and cul-
ture warrior who does not respect the equal dignity of all people,” said Senator Dianne
Feinstein (D-​Calif.) during his Senate confirmation hearing, reading from a letter of
the Leadership Conference on Civil and Human Rights. “His record reveals a hostility
to LGBT equality and to women’s health, and he would not be able to rule fairly and
impartially in cases involving those issues.”53 Kacsmaryk was the only federal judge in
the district where ADF filed the lawsuit, so he was guaranteed to hear the case, lead-
ing to charges of judge shopping. Texas was within the Fifth Circuit Court of Appeals,
which had a majority of conservative judges—​six of whom were appointed by Trump.54
The ADF lawsuit asked Kacsmaryk to declare the FDA’s 2021 decision to allow
healthcare workers to meet with patients by telehealth and mail abortion pills to them a
violation of the 1873 Comstock Act. Promoted by anti-​vice crusader Anthony Comstock
and described as a “chastity” law, the Comstock Act banned sending obscene literature,
contraceptives, abortifacients, or any sexual information through US mail. After the
Supreme Court ruled in Griswold v. Connecticut in 1965 that people had a fundamental
right to access and use contraception, Congress removed the language concerning con-
traception in 1971, but left the part of the law criminalizing mailing abortifacients and
information about abortion. Before Roe v. Wade, federal courts had ruled this part of
the law applied only to “unlawful” abortions. After the Roe decision, the Comstock law
remained on the books but was not enforced. Since the Supreme Court had reversed
Roe, ADF hoped to bring the law back into effect. Kirsten Moore described the lawsuit
as trying to “put the genie back into the bottle” and “trying to undo progress.”55 Danco,
the manufacturer of the brand-​name mifepristone Mifeprex, filed a motion to inter-
vene in the lawsuit, which Kacsmaryk granted, but GenBioPro did not join the lawsuit.
After Dobbs, in response to a request for clarification from the US Postal Service,
the Department of Justice’s Office of Legal Counsel issued a legal opinion in late
December 2022, stating that the Comstock law does not prohibit mailing abortion pills
196 • Abortion Pills

if the sender does not know that the medications will be used illegally. The Department
of Justice opinion, authored by Assistant Attorney General Christopher H. Schroeder,
argued the law applied only to “unlawful” abortions, citing a long line of cases. Those
sending or delivering pills “typically will lack complete knowledge of how the recipi-
ents intend to use them and whether that use is unlawful under relevant law.” Abortion
was allowed by federal law, Schroeder wrote, and every state allowed abortion in some
circumstances, such as to preserve the life of a pregnant woman. Individuals receiving
abortion pills had “a constitutional right to travel to another state that has not prohibited
that activity and to ingest the drugs there,” the opinion stated—​so “someone sending
a woman these drugs is unlikely to know where she will use them, which might be in
a state in which such use is lawful.” The opinion concluded, “therefore, even when a
sender or deliverer of mifepristone or misoprostol, including USPS, knows that a pack-
age contains such drugs—​or indeed that they will be used to facilitate an abortion—​such
knowledge alone is not a sufficient basis for concluding that [the law] has been vio-
lated.”56 The decision applied to the US Postal Service and other carriers, such as United
Parcel Service and FedEx. While the opinion indicated that federal prosecutors would
not use the Comstock law to bring criminal charges against anyone for mailing abortion
pills, it did not protect people from charges by state prosecutors under state laws.
By February 2023, tension about an imminent ruling in the Texas case was at fever
pitch. On February 16, Senator Ron Wyden (D-​Ore.) called on the Biden administra-
tion and the FDA to defy any ruling restricting abortion pills. “President Biden and
the FDA must ignore it,” said Wyden in an impassioned speech on the floor of the
Senate. “The FDA should go on just as it has for the last twenty-​three years since it first
approved mifepristone. The FDA needs to keep this medication on the market with-
out interruption regardless of what the ruling says. Doctors and pharmacies should go
about their jobs like nothing has changed.”57
One reason for defiance, said Wyden, was that the judge was an anti-​abortion
zealot. Wyden described Kacsmaryk as a “lifelong right-​wing activist. A partisan
ideologue. An anti-​abortion zealot who was hand-​picked by Donald Trump and the
Federalist Society to feign impartiality on the bench and deliver favorable rulings on
the cases his fellow right-​wing ideologues funnel his way.”58 Kacsmaryk had made
several extreme rulings in other cases. In November 2022, he ruled that the Biden
administration wrongly interpreted a provision of the Affordable Care Act as bar-
ring healthcare providers from discriminating against LGBTQ+​Americans. Then in
December, he ruled that teens must have parental consent to obtain birth control,
overturning a decades-​long precedent allowing minors to access birth control.59 “He
has issued constitutionally dubious and extraordinarily contentious opinions, has
defied precedent on protecting LGBTQ employees, and attacked the right to contra-
ception by restricting minors’ access to it,” said Wyden, who called Kacsmaryk “the
most lawless judge in the country.”
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 197

Wyden suggested anti-​abortion extremists had rigged the system to get an extremist,
anti-​abortion judge appointed to their abortion pill challenge. “Because of how judges
in this federal district in Texas are assigned, the plaintiffs were able to use a procedural
loophole and hotwire the judiciary. They could ensure Kacsmaryk was the only judge
who could get the case,” said Wyden. “This judge is not upholding the oath he took. He
is not adhering to the Constitution. He is making a dangerous mockery of the rule of
law. Something needs to be done about it,” said Wyden.60
On the merits, Wyden argued the plaintiffs had no standing to bring the suit
because they could not show any actual harm or injury to demonstrate a direct impact
by the FDA approval of the drug. He also argued it was too late to challenge the FDA’s
approval of mifepristone in 2000 because the statute of limitations allowed challenges
to FDA procedures for only six years. Finally, Wyden argued the FDA had not unlaw-
fully fast-​tracked the approval of mifepristone in 2000 and that they had the required
research to prove the safety of the drug that year and in subsequent updates to the
approval in 2016, 2019, and 2021, when the agency began allowing clinicians to mail
abortion pills to their patients. Wyden cited a 2018 Government Accountability Office
report concluding that the FDA had “followed its standard review process when it
approved the application…for the drug Mifeprex” and “based its approval on reviews
of peer-​reviewed published studies, articles, and other information submitted by
Mifeprex’s sponsor.”61 He noted the FDA also conducted extensive reviews of mife-
pristone’s safety in 2016.
Wyden argued the ADF complaint restated many of the objections anti-​abortion
groups had already raised to the FDA’s 2021 modification of its mifepristone approval.
In response, the FDA had published a forty-​page rebuttal letter to these objections,
which ADF failed to address in their complaint.62 “Congress long ago empowered the
FDA, a body made up of scientists and clinicians, to approve or disapprove the use
of new drugs—​not states and certainly not activist judges,” said Wyden. “The FDA
approved Mifepristone twenty-​three years ago. For those looking to challenge that
approval, well, it’s too late. The statute of limitations allows challenges to FDA proce-
dures for only six years.”63 In an impassioned conclusion, Wyden called for defiance
of any Texas court ruling restricting mifepristone, noting that the judge had no way to
enforce his ruling:

The power of the judiciary begins and ends with its legitimacy in the eyes of the public.
It does not have the military backing of the executive branch or Congress’s power of the
purse. A judge’s rulings stand because elected leaders and citizens have agreed that abiding
by them is right and necessary to uphold the rule of law. That’s part of the social contract
in America. But the judiciary must uphold its end of the social contract too. It must follow
the rule of law and earn the confidence of the American people continually, every day, every
month, every year. Recently that confidence has eroded, and it’s no secret why. Look at the
198 • Abortion Pills

Dobbs decision overturning Roe. Look at what is happening in Texas right now. Parts of
the judiciary have morphed into a mob of MAGA [“Make America Great Again”] extrem-
ists, conspiring with and willing to do the bidding of every right-​wing group or former
President that appears before it, no matter the cost to life and liberty. There are moments in
history where Americans and their leaders must look at circumstances like this one and say,
“Enough.” Not “let’s see how the appeals process plays out,” or “Let’s hope Congress can fix
this down the road.” Just, “Enough.”64

Other lawmakers, including Rep. Alexandria Ocasio-​Cortez, joined Wyden’s demand

that the FDA ignore the Texas judge’s opinion if he tried to remove abortion pills from
the market.
Meanwhile, panicked newspaper headlines stated the Texas judge could and likely
would end access to mifepristone. A Washington Post headline read, “The Texas judge
who could take down the abortion pill.”65 USA Today feverishly warned, “A Texas judge
could soon force a major abortion pill off market nationwide.”66 A Denver Post headline
ominously declared, “One Texas judge will decide fate of abortion pills used by millions
of American women.”67 Legal experts pushed back against these claims, arguing that the
Texas judge did not in fact have the power to ban abortion pills nationwide. “Actually,
one Texas judge is not the final decision-​maker on medication abortion,” wrote David
Cohen of Drexel Kline School of Law, Greer Donley at University of Pittsburgh School
of Law, and Rachel Rebouché of Temple Law School in an article in Slate magazine.
“Despite the barrage of predictions that this case could ban mifepristone and take it off
the market, there are several basic legal principles suggesting that Judge Kacsmaryk’s
power is limited and that a ruling for the plaintiffs will not necessarily change much at
all with medication abortion,” wrote Cohen, Donley, and Rebouché.68
The experts noted judges could bind only the parties before the court, in this case
the FDA and Danco, not GenBioPro. They noted that the plaintiffs were asking only for
the judge to declare that approval of mifepristone was unlawful and that there was no
mechanism for him to ban a medication. “They can’t ask him to take it off the market.
That’s not in his authority. He can’t go into any warehouse and confiscate anything. The
FDA can, but that’s up to the FDA, just like it’s up to a police officer to enforce laws
against going fifty-​five when I’m driving sixty,” said Cohen, who noted that Congress
had provided a specific procedure in the Food, Drug, and Cosmetic Act for withdraw-
ing drug approvals. “He may order the FDA to follow the withdrawal process, but that
withdrawal process leaves the final decision in the FDA’s hands,” said Cohen. “So if
there’s any wiggle room in the judge’s order, they could interpret the ruling as a require-
ment to start this process. And then they start that process. That can be a lengthy pro-
cess with them as the final decision maker.”69
Cohen said that if the judge declared the drug was unlawfully approved, it would
be an unapproved drug, but it would be up to the FDA to enforce that. Judges couldn’t
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 199

tell the agencies to enforce their laws. The FDA could decide whether they were going
to go after the distributor of the unapproved drug, or not. “And if you look at their
website, there were multiple documents that talked about unapproved drugs. The FDA
had a risk assessment strategy in enforcing their laws. They don’t have the capability or
the resources to go after every unapproved drug that’s out there, just like a police offi-
cer goes after someone who’s recklessly driving sixty miles an hour, but not me if I’m
safely driving sixty miles an hour,” said Cohen. The FDA could use their enforcement
discretion to not enforce the law against Danco based on the safety of mifepristone. He
noted that doctors were not parties to the Texas case, would not be bound by any deci-
sion, and that most states allowed doctors to prescribe unapproved drugs as a matter
of course. The FDA’s authority is to go after the distributor, not doctors. “Unapproved
drugs are a part of American medicine. It does raise risks for malpractice lawsuits if
you are prescribing unapproved drugs. I’m not saying this is something that is without
any legal risk, but it’s not against FDA law for doctors to prescribe unapproved drugs.
It would be up to their state law.” Cohen emphasized that despite newspaper headlines,
“this judge does not have the power to ban prescription of the drugs. He does not have
the power to actually take it off the shelves.”70
Meanwhile, advocates reminded the public that misoprostol alone was safe and
effective for ending a pregnancy and would remain accessible no matter what hap-
pend in the lawsuit. For years studies from around the world had shown self-​managed
abortion with misoprostol alone to be 93 to 99 percent effective and very safe. Because
of the widespread availability of mifepristone, the use of the misoprostol alone for
abortion had not been studied in the United States.71 On February 6, 2023, research-
ers at the University of Texas at Austin published peer-​reviewed research on the use of
misoprostol alone for abortion. The research found that misoprostol alone was over
88 percent effective, with few incidents of serious adverse events or signs of poten-
tial abortion complications.72 “This is the first US-​based study on misoprostol alone
for self-​managed abortion and it’s coming at this critical time where we don’t know
what’s going to happen with access to mifepristone,” said the study’s lead author, Dana
M. Johnson, a PhD candidate in public policy and demography at the University of
Texas at Austin and a senior associate research scientist at Ibis Reproductive Health.
“Our contribution with this study is to add to the broad evidence base we have from
the international space on how safe and effective misoprostol is.”73
The research was based on data from Aid Access, which provided telemedicine
abortion services with pills in all fifty states. Due to pandemic-​related challenges ship-
ping mifepristone, Aid Access prescribed misoprostol alone to over one thousand US-​
based patients in June of 2020. Aid Access physicians either mailed misoprostol directly
to patients or sent prescriptions to local pharmacies for pick-​up. “We took a very con-
servative approach by including just the people who had a totally confirmed, complete
abortion at four weeks and didn’t get a surgical intervention,” said Johnson. “That is
200 • Abortion Pills

why our finding is 88 percent effectiveness, which is much lower than the SAFE Study
from Ibis, which showed 98 percent effectiveness.”74
Published in November of 2021, the SAFE Study—​which stands for Studying
Accompaniment Feasibility and Effectiveness—​showed that 98.8 percent of those who
used the misoprostol-​alone regimen had a complete abortion without surgical inter-
vention.75 “Self-​managed abortion with misoprostol only is highly effective, and war-
rants renewed attention,” it concluded, calling it “no longer a second-​tier method, but
one that offers similar effectiveness, and often greater accessibility, than the mifepris-
tone and misoprostol regimen.”76 This research showed that while misoprostol alone
was a little less effective than the combination of mifepristone and misoprostol, extra
doses of misoprostol could increase efficacy. “We did take this conservative approach,
but our findings were really, really good. There were very few people who had a serious
adverse event. There were very few people who had any kind of treatment for that or a
symptom of a potential complication,” added Johnson.77
Johnson conducted follow-​up interviews with the research participants to under-
stand their experiences of using misoprostol alone, which could be more difficult than
the combination of mifepristone and misoprostol because the misoprostol-​alone regi-
men calls for multiple doses of the medication, as opposed to one dose if combined with
mifepristone. Those who used misoprostol alone could experience stronger cramping
as well as nausea, fever, chills, vomiting, and diarrhea, which can be more severe when
taking misoprostol alone because of the higher dosage.
Johnson found in her research that women’s experiences of using misoprostol were
shaped by their mindset and how prepared they felt. Many found information on
Reddit. The abortion subreddit, R/​abortion, was curated by OARS (Online Abortion
Resource Squad), which trained volunteers to “ensure that every Reddit post asking
for abortion-​related help gets a quality, accurate, compassionate answer and referral
to resources.”78 “People asked a lot of questions and that brought a sense of comfort
because if you know that you can prep your hot water bottle or your ibuprofen or your
chamomile tea, you’re going into it with a little bit more of a mindset that you can man-
age this pain,” said Johnson. Research from other countries had shown that patients can
have positive abortion experiences with misoprostol alone when they had access to the
information they needed, felt prepared for what they would experience, and were sup-
ported through the process.79
In response to attempts by abortion opponents to remove mifepristone from the
US market, abortion advocates suggested providers could prescribe misoprostol off
label to patients in states where abortion remained legal. Many telemedicine abortion
providers pledged to do this, including Abortion on Demand, Aid Access, carafem,
Choix, Forward Midwifery, Hey Jane, and Just the Pill. Planned Parenthood has also
said they would offer this service.80 NAF’s clinical practice guidelines suggested offering
misoprostol alone where the mifepristone combination was not accessible. The World
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 201

Health Organization also had guidelines for misoprostol alone as a safe and effective
option for abortion care.81 According to these guidelines, women in the first twelve
weeks of pregnancy should dissolve four 200 milligrams of misoprostol between their
gum and cheek, three times at three-​hour intervals.82 “With clinical options for abortion
severely limited post-​Dobbs, these guidelines are important in affirming self-​managed
abortion as a safe and essential practice that can be empowering for those seeking to
end a pregnancy,” concluded the University of Texas at Austin study authors. “There is
potential for its use in the U.S. as a method of ensuring reproductive autonomy, espe-
cially for populations who have been systematically cut off from safe, affordable and
non-​coercive reproductive healthcare services.”83 Even in states with legal abortion,
people were using misoprostol alone, which they could obtain over the counter at some
pharmacies, said Dr. Carolyn Westhoff. “In our community here in Upper Manhattan,
lots of people are buying misoprostol basically over the counter from pharmacies and
self-​administering. They may only come into the clinic if they’re not sure whether it
worked or not. There are a lot of pharmacies that will sell you whatever you want as
long as it’s not a scheduled drug, and as long as you’re not trying to get insurance to pay
for it,” reported Westhoff.84
Despite the misoprostol-​alone contingency plan, reproductive rights advocates
fought to keep mifepristone on the market. On February 24, Democratic attorneys gen-
eral from over a dozen states filed a federal lawsuit in Washington state, asking the
court to declare that mifepristone was safe and effective and that the FDA’s approval
of mifepristone was lawful and valid. The attorneys general asked the court to block
the FDA from taking any action to remove mifepristone from the market or reduce
its availability, and to require the FDA to remove several current restrictions on the
medication. The plaintiffs included attorneys general of Washington, Oregon, Arizona,
Colorado, Connecticut, Delaware, Illinois, Michigan, Nevada, New Mexico, Rhode
Island, and Vermont.85 The attorneys general noted the FDA had placed mifepristone
in the REMS drug safety program designed to regulate dangerous or addictive drugs,
such as fentanyl and other opioids, certain risky cancer drugs, and high-​dose sedatives
used for patients with psychosis, and had imposed REMS on only sixty medications out
of the more than twenty thousand prescription drugs approved for use in the United
States. Subjecting mifepristone to the REMS program gave the impression mifepristone
was a risky or dangerous drug when, in fact, it was very safe. “The federal govern-
ment has known for years that mifepristone is safe and effective,” said Washington state
attorney general Bob Ferguson. “In the wake of the Supreme Court’s radical decision
overturning Roe v. Wade, the FDA is now exposing doctors, pharmacists, and patients
to unnecessary risk. The FDA’s excessive restrictions on this important drug have no
basis in medical science.”86
The attorneys general noted that the mifepristone REMS program required medi-
cal providers prescribing mifepristone to register with the drug manufacturer, required
202 • Abortion Pills

pharmacies to go through a certification process in order to dispense mifepristone, and

required patients to sign an agreement attesting that they had chosen to take the medi-
cation to terminate a pregnancy, even when they were using the medication for mis-
carriage. “FDA’s decision to continue these burdensome restrictions in January 2023
on a drug that has been on the market for more than two decades with only ‘exceed-
ingly rare’ adverse events has no basis in science,” stated the complaint. “It only serves
to make mifepristone harder for doctors to prescribe, harder for pharmacies to fill,
harder for patients to access, and more burdensome for the plaintiff states and their
healthcare providers to dispense.”87 The plaintiffs argued that the FDA has exceeded its
authority by continuing its “unnecessary and extremely burdensome” restrictions on
mifepristone, exposing patients to needless anguish and confusion and violating the
Fifth Amendment equal protection guarantees of the Constitution. “Through the 2023
REMS, FDA reduces access to a critical and time-​sensitive healthcare service needed by
pregnant people. And FDA treats providers, pharmacists, and patients who prescribe,
dispense, or use mifepristone worse than providers, pharmacists, and patients who pre-
scribe, dispense, or use nearly every other medication. FDA’s actions are irrational and
violate the Fifth Amendment under any standard of review.”88
The states also argued that the REMS requirement that providers register with the
drug manufacturer could compromise their privacy and safety, and result in them
being targeted by anti-​abortion violence, noting that abortion opponents made 182
death threats against abortion providers in 2021 alone. The certification requirement
for providers and pharmacies might discourage them from offering mifepristone, espe-
cially in light of the increased criminalization of providing abortion services in many
states. “The certification requirement for providers and pharmacists opens them up to
potential liability if they serve patients from other states like Idaho that have restrictive
abortion laws, even if the provider is in full compliance with Washington law,” accord-
ing to a press release from Ferguson’s office. “In addition, healthcare providers who
may move to other states in the future to practice might think twice about completing a
certification to prescribe mifepristone, as it may expose them to liability or professional
consequences in the future.”89
Finally, the lawsuit objected to the FDA requirement that patients must fill out
a patient agreement form, which must be included in their medical records, and for
women from states banning abortion, could be viewed by providers in their home states.
“While safeguards exist to protect the privacy of medical records, the patient agreement
documentation required by the FDA creates an added risk for patients—​particularly
for those patients who travel to Washington for medical treatment from states where
their abortion is illegal. The documentation of their abortion remains in their medical
records, and can be viewed by providers in their home state,” said Ferguson.90
Ferguson expressed concern about hackers compromising the confidentiality of
these patient agreement forms. “Abortion providers have been targets for hackers seeking
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 203

to steal information about both patients and providers. In 2021, for example, hack-
ers accessed data of roughly 400,000 patients from Planned Parenthood Los Angeles.
Providers in Washington report frequent cyberattacks aimed at illegally obtaining
information about patients and providers. This is especially concerning because abor-
tion providers and patients can be targeted for harassment and extremist violence.”91
According to the complaint by the attorneys general, “the REMS require burdensome
documentation of the patient’s use of mifepristone for the purpose of abortion, making
telehealth less accessible and creating a paper trail that puts both patients and provid-
ers in danger of violence, harassment, and threats of liability amid the growing crimi-
nalization and outlawing of abortion in other states.”92 Experts saw the lawsuit as an
attempt to produce a contrary ruling from the Texas judge so that the FDA could refuse
to remove the medication from the market until the Supreme Court ruled, preserving
access to the medication at least until that time.93
On Friday, April 7, 2023, federal judges in both Texas and Washington state issued
contradictory rulings on mifepristone. Federal judge Matthew Kacsmaryk ruled that the
FDA improperly approved mifepristone in 2000 and said he would void the approval,
with a stay until April 14 to give the Justice Department an opportunity to appeal. He
ruled the FDA had rushed the approval of mifepristone and that the FDA did not have
adequate evidence of the drug’s safety. He also ruled that the FDA’s 2021 decision allow-
ing clinicians to mail abortion pills violated the 1873 Comstock Act. Kacsmaryk cited
studies purporting to show negative mental health effects of mifepristone. He cited a
study based on several dozen anonymous blog posts from abortionchangesyou.com, a
website run by the anti-​abortion Institute of Reproductive Grief Care.94 Kacsmaryk did
not mention that bloggers on an anti-​abortion website are a self-​selected group that is
far from a representative sample of women who have obtained abortions. Kacsmaryk
also cited a disputed 2002 study by David C. Reardon, an anti-​abortion activist asso-
ciated with the Lozier Institute, claiming that women who had abortions were more
likely to experience depression and commit suicide, attributing this to “self-​destructive
tendencies, depression, and other unhealthy behavior aggravated by the abortion expe-
rience.”95 Finally, Kacsmaryk cited a Finnish study he described as finding that the
“overall incidence of adverse events is ‘fourfold higher’ in chemical abortions when
compared to surgical abortions.” One of the study’s authors, gynecology professor
Oskari Heikinheimo, later challenged how Kacsmaryk portrayed the study, stating the
study showed serious complications from mifepristone were remarkably low and most
of the “adverse events” were uterine bleeding.96
In his sixty-​seven-​page decision, Kacsmaryk referred to mifepristone as “chemical
abortion” ninety-​three times. He used inflammatory and medically inaccurate anti-​
abortion language, such as repeatedly calling fertilized eggs, zygotes, and embryos
“unborn children,” and saying the FDA “mandates…mifepristone to kill the unborn
human.” He called women who had never given birth “mothers” because they were
204 • Abortion Pills

pregnant and he called clinicians “abortionists.”97 He even cited the Sesame Street jingle
“One of these things is not like the others” to support one of his arguments.98 The Texas
judge ruled the FDA had rushed the approval of mifepristone in 2000. In fact, anti-​
abortion political interference delayed FDA approval for twelve years. The FDA’s review
of the drug maker’s application for approval of mifepristone took over three times lon-
ger than for other drugs: fifty-​four months to approve mifepristone, compared to an
average wait time of fifteen months for approval of other medications at the time.99
Less than one hour after the release of Kacsmaryk’s ruling, a federal judge in the
Eastern District of Washington, Thomas O. Rice, issued an injunction blocking the FDA
from “altering the status quo and rights as it relates to the availability of mifepristone”
in the plaintiff states and the District of Columbia.100 As a result, the FDA was under
contradictory federal court orders regarding its approval of mifepristone—​with one
court saying the FDA approval of mifepristone was invalid, and another saying it must
maintain its approval of mifepristone. The Department of Justice immediately appealed
Kacsmaryk’s ruling and also filed a request for clarification with the Washington state
court, describing the court’s ruling as in “significant tension” with the Texas abortion
ruling.101
Despite the Texas ruling, many telemedicine clinicians were determined to con-
tinue providing abortion pills, including mifepristone, to patients by mail. “Let
me be clear: Mifepristone is extremely safe, effective, and still legally available
through Hey Jane,” said Kiki Freedman, co-​founder and CEO of Hey Jane, a tele-
medicine abortion provider. “Our focus remains on our patients and delivering the
best possible evidence-​based, compassionate care and therefore we will continue
providing our current medication abortion protocol of mifepristone and misopros-
tol.”102 In addition, experts said that Aid Access would likely continue to ship generic
mifepristone from India to consumers in the United States. “There will still be
ways to get the two-​pill regimen,” said Abigail Aiken at the University of Texas at
Austin.103
Concerned about abortion pills access, Washington state Governor Jay Inslee
bought thirty thousand doses of mifepristone—​a three-​year supply for that state.104
Then Massachusetts Governor Maura Healey announced her state had bought fif-
teen thousand doses of mifepristone—​a two-​year supply—​to “ride out” the legal chal-
lenge.105 In April, Oregon Governor Tina Kotek directed the state to obtain 22,500
doses of mifepristone.106 In addition, hundreds of pharmaceutical executives, includ-
ing the CEO of Pfizer, signed a letter objecting to the Texas ruling, arguing it could
destabilize the drug market in the United States. “In the face of laws and rulings that
aim to undermine the evidence-​based and legislatively sanctioned authority of fed-
erally mandated institutions such as FDA to protect public interests, and by putting
an entire industry focused on medical innovation at risk, we cannot stay quiet,” the
letter read.107
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 205

On April 13, 2023, in a divided opinion, the US Court of Appeals for the Fifth Circuit
ruled that the Texas plaintiffs had waited too long to challenge the original approval of
mifepristone in 2000, but were timely in their challenges to modifications of the approval
in 2016, 2019, 2021, and 2023. They ruled the FDA did not have adequate evidence
to make these changes, including allowing use of the medication through ten weeks
of pregnancy, lowering the recommended dosage to decrease side effects, allowing all
qualified clinicians to administer mifepristone, decreasing the number of appointments
required to prescribe the medication from three to one, allowing the medication to be
prescribed by telemedicine and mail, approving a generic version of mifepristone pro-
duced by GenBioPro, and allowing certified pharmacies to dispense the medication.
As a result, the ruling only allowed certified physicians to prescribe mifepristone at the
higher dosage level for use up to seven weeks of pregnancy, and they could no longer
send the medication through the mail nor could pharmacies dispense mifepristone.108
The Fifth Circuit decision was written by two Trump-​appointed judges—​Kurt
Engelhardt and Andrew Oldham—​and released just after midnight. A third judge—​
Catharina Haynes, appointed by George W. Bush—​would have fully reversed the Texas
court’s decision. “The Fifth Circuit’s latest ruling shows exactly why courts have no
place interfering in health care,” said Kirsten Moore of EMAA. “This middle-​of-​the-​
night ruling, while keeping mifepristone on the market, rolls back years of medical
progress by reinstating restrictions that were lifted in 2016 and forcing people to go
back to picking up their medications in person, essentially eliminating telehealth access
and forcing people to travel, in some cases hundreds of miles, just to receive care.”109
The morning after the Fifth Circuit ruled, Danco filed an emergency appeal of the Fifth
Circuit decision to the Supreme Court, arguing that the plaintiffs lacked standing, that
the complaint lacked any viable merits claims, and that the 2023 FDA changes were not
even before the Fifth Circuit. They also argued that fairness overwhelmingly favored a
stay because Danco faced substantial, certain, unrecoverable harm, whereas the plain-
tiffs faced no irreparable harm from a stay, and that the public interest favored a stay.110
The next day, the Department of Justice filed an emergency appeal to the Supreme
Court. The appeals went to Samuel Alito, who was assigned to handle emergency mat-
ters from the New Orleans-​based Fifth US Circuit Court of Appeals.111
On April 14, the Supreme Court placed a five-​day stay on the Fifth Circuit ruling
in the mifepristone case, giving the Court until April 19 to rule in the case. The same
day, Judge Rice in Washington issued an order requiring the FDA to maintain full
access to mifepristone in seventeen states plus Washington, DC, “irrespective” of the
Fifth Circuit appeals court. Rice’s order applied to the seventeen states that filed the
lawsuit: Arizona, Colorado, Connecticut, Delaware, District of Columbia, Illinois,
Michigan, Nevada, New Mexico, Oregon, Rhode Island, Vermont, Hawaii, Maine,
Maryland, Minnesota, Pennsylvania, and Washington. Rice declined to apply his
ruling nationwide.
206 • Abortion Pills

As the Supreme Court weighed its options on mifepristone, abortion and women’s
rights supporters across the United States protested the latest efforts to restrict access to
abortion. Protests took place in small and large cities, including Amarillo and Dallas,
Texas; Chicago; Detroit; Los Angeles and Santa Barbara, California; New York City;
Seattle; Sioux Falls, South Dakota; Tallahassee, Florida; and Washington, DC.112 While
203 House Democrats filed an amicus brief to the Supreme Court urging them to ensure
access to medication abortion was based on science not ideology,113 House Republicans
filed a brief urging the Court to uphold Judge Kacsmaryk’s decision undermining the
FDA and access to medication abortion.114
Then on April 18, GenBioPro—​the pharmaceutical company that made a generic
version of mifepristone—​sued the FDA in Maryland federal court, where the agency
was headquartered, seeking an order to compel the agency to allow GenBioPro to con-
tinue to sell the medication in the United States. GenBioPro estimated their generic
medication comprised two-​thirds of the mifepristone sold in the United States.115 The
company argued they had the right to preserve the drug’s availability under the fed-
eral Food, Drug, and Cosmetic Act, the FDA’s regulations, and the company’s rights
guaranteed by the Fifth Amendment of the Constitution. “In the United States, once
a drug has been through the rigorous FDA review process and received approval, fed-
eral law protects the right to market the drug,” said GenBioPro CEO Evan Massingill.
“GenBioPro will use all regulatory and legal tools to protect access to mifepristone for
patients and providers.”116
The Supreme Court extended the stay two more days, then in a decision issued late
on Friday, April 21, 2023, they blocked the Fifth Circuit ruling from taking effect, allow-
ing mifepristone to remain on the market without any limitations while the case was on
appeal, with Clarence Thomas and Samuel Alito dissenting.117 Reproductive rights advo-
cates expressed frustration that the issue was even before the Court. “While SCOTUS
offered temporary relief, the fate of a medication approved by the FDA more than 20 years
ago should have never been before the Supreme Court to begin with,” said Kirsten Moore
of the EMAA Project. “The FDA has the authority and scientific expertise to evaluate
and approve medications—​not politicians, not activists, and not judges. We must now
move forward to ensure access to safe and effective medication abortion care nationwide
without any further interference—​our freedom to make our own healthcare decisions
is on the line.”118 Elisa Wells emphasized the confusion caused by the case: “The longer
this court case continues, the further we travel down a path of legitimizing the baseless
claims of a small group of extremists as something worthy of the court’s attention. A stay
is the correct decision but does not erase the chaos, confusion, and fear that this case was
designed to cause. And, even though mifepristone can remain on the market for now,
access to abortion care is still severely and unjustly restricted in many states.”119
At the time the courts were hearing this case, over one hundred scientific studies
had proven mifepristone to be a safe method for ending a pregnancy. Mifepristone was
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 207

safer than penicillin and Viagra, which were not subject to any REMS restrictions.120
Between 2000 and June 2022, the FDA received reports linking mifepristone to twenty-​
eight deaths out of the 5.6 million people who had used the medication, and information
gaps made it impossible to directly attribute the cause of these deaths to mifepristone.
In some cases, the deaths involved overdoses and coexisting medical conditions.121
ACOG, the American Medical Association, the Society for Maternal-​Fetal Medicine,
and other medical organizations stated in a brief filed in the case, “The risk of death
is almost non-​existent,” citing an analysis by ACOG of hundreds of published studies
finding that “serious side effects occur in less than one percent of patients, and major
adverse events—​significant infection, blood loss, or hospitalization—​occur in less than
0.3 percent of patients.”122 According to the brief, “the scientific evidence supporting
mifepristone’s safety and efficacy is overwhelming. Mifepristone is one of the most stud-
ied medications prescribed in the United States and has a safety profile comparable to
ibuprofen.”123 ACOG, the American Medical Association, and the American Academy
of Family Physicians all issued statements opposing the FDA REMS restrictions and
certification requirements for mifepristone because these restrictions had no basis in
medicine and created barriers to time-​sensitive abortion and miscarriage treatment.124
The Supreme Court sent the case back to the Fifth Circuit, where oral arguments
were held on May 17, 2023. A lot was at stake in this case. If the Fifth Circuit’s ruling
had gone into effect, access to mifepristone would have decreased significantly across
the country, even in states with legal abortion. Such a ruling would have ended tele-
medicine abortion with mifepristone, which had expanded significantly since the FDA
finally allowed it in 2021, particularly for people living in rural areas who had to travel
long distances to find certified doctors. They would have had to make multiple visits
over several days to obtain abortion pills. And doctors would have only been able to
prescribe mifepristone in the first seven weeks of pregnancy (forty-​nine days)—​which
was just five weeks after conception, since pregnancy was dated from the first day of
the last menstrual period. Finally, doctors would have had to prescribe a higher dosage,
which would have caused more side effects. The panel of judges selected to hear the
appeal included two anti-​abortion Trump appointees, James Ho and Cory Wilson. In a
2019 decision, Ho wrote, “abortion is the immoral, tragic and violent taking of innocent
human life.” As a Mississippi state lawmaker, Wilson voted for a six-​week abortion ban.
The third judge was a George W. Bush nominee Jennifer Elrod. During the oral argu-
ments, the judges were openly hostile to the two attorneys representing the FDA and
Danco—​Sarah Harrington and Jessica Ellsworth; and they were friendly to the attorney
representing the plaintiffs—​Erin Morrow Hawley, who was married to the conservative
member of Congress Josh Hawley. Hawley and the three judges were also contributing
members of the conservative legal organization The Federalist Society.
During oral arguments, the judges demonstrated their bias against the FDA and their
basic misunderstanding of the science behind the case. One of the judges suggested that
208 • Abortion Pills

allowing licensed medical professionals who were not doctors to prescribe mifepristone
increased the risk of complications, which is not the case. The judges indicated a belief
that ultrasounds were necessary to determine how far along a pregnancy was, which
was also not true. The judges repeatedly suggested that mifepristone was unsafe, despite
extensive research showing the medication was safer than many over-​the-​counter medi-
cations, including Advil and Tylenol, and far safer than carrying a pregnancy to term.
Confronted with this evidence, the judges refused to believe it. Similar to Kacsmaryk,
the Fifth Circuit judges used polemical anti-​abortion language like “chemical abortion.”
Elrod repeated an anti-​abortion talking point that mifepristone “cuts off nutrition” to an
embryo or fetus. The judges also exhibited basic misunderstandings about the role of the
FDA. The judges seemed to believe that the FDA should dictate the details of how medical
providers should practice medicine, such as how to diagnose how many weeks a patient
is pregnant, which is not the role of the FDA. Elrod also suggested that because some
patients in states with bans may use mail forwarding to obtain medications from tele-
medicine providers in other states, the FDA should restrict the use of the medication—​a
standard that could lead to the removal of almost any drug from the market. Harrington
argued that the FDA’s role was to determine whether a medication is safe and effective,
not whether patients would use the medication in compliance with state law.
The judges did not listen to Harrington and Ellsworth, repeatedly asking them
questions that had already been answered. For example, Harrington argued that the
plaintiffs had no standing because they were protected by state and federal conscience
clause laws from having to provide abortion services they found objectionable. Judge
Ho appeared not to hear or listen to her argument, asking the same question again
and again, despite her direct answers to his questions. The judges also made scolding
comments to Harrington and Ellsworth. Elrod demanded an apology from Ellsworth
for a comment in Danco’s brief characterizing the district court opinion as an “unprec-
edented judicial assault on a careful regulatory process” of the FDA. At one point, Judge
Ho asked Harrington if the federal government would abide by the court’s decision.
Sometimes the judges’ comments verged on the absurd: one suggested that removing
or restricting mifepristone from the market would not harm the drug maker Danco,
which markets only that one product. At another point, when Judge Ho was trying to
argue that the FDA did not have authority to approve mifepristone under a law autho-
rizing an approval process for drugs to address a “disease, illness or condition,” Ho
bizarrely asked Harrington, “When we celebrated Mother’s Day, were we celebrating ill-
ness?” The case got the attention of the pharmaceutical companies, which understood
the threat the case posed to the stability and profitability of their industry. Over seven
hundred pharmaceutical executives signed an open letter objecting to the Texas ruling,
arguing it could destabilize the drug market in the United States. Pharmaceutical com-
panies as well as the pharmaceutical trade association PhRMA also filed amicus curiae
briefs in the case.125
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 209

On August 16, the Fifth Circuit Court of Appeals released a decision in Alliance for
Hippocratic Medicine v. FDA that dismissed the challenge to the FDA’s 2000 approval
of mifepristone, but sharply restricted access to medication abortion nationwide and
eliminated telemedicine abortion. In a ninety-​six-​page decision, the Fifth Circuit
judges ruled that the plaintiffs had waited too long to challenge the original approval of
mifepristone in 2000, but were timely in their challenges to later modifications of the
approval in 2016 and 2021. The court ruled the FDA acted improperly in these later
modifications in several regards, including allowing the use of mifepristone through
ten weeks of pregnancy (from seven weeks approved in 2000), lowering the recom-
mended dosage to decrease side effects, allowing any qualified clinician to administer
mifepristone, decreasing the number of appointments required to prescribe the medi-
cation from three to one, allowing the medication to be prescribed by telemedicine and
mail, and allowing certified pharmacies to dispense mifepristone. The court dismissed
the plaintiff ’s challenge to a 2019 FDA decision to approve a generic version of mifepris-
tone produced by GenBioPro.126 The plaintiffs and the Department of Justice appealed
the ruling, which remained on hold until final review by the US Supreme Court. The
Supreme Court denied the plaintiffs’ appeal, but agreed to hear the Department of
Justice’s appeal. Then, at the eleventh hour, the attorneys general of Missouri, Kansas,
and Idaho filed a motion to intervene in the case, which Judge Kacsmaryk granted
in January 2024, opening the door to ongoing litigation even if the Supreme Court
dismissed the lawsuit.127 During oral arguments on March 26, 2024, several justices
expressed skepticism as to whether the plaintiffs had standing to sue.128 A side effect of
the mifepristone lawsuit was that it significantly increased media coverage about abor-
tion pills. Despite the mifepristone misinformation at the heart of the lawsuit, a June
2023 report by NARAL Pro-​Choice America found that accurate reporting on medica-
tion abortion care outperformed anti-​abortion disinformation by 179 percent in the
first five and a half months of 2023.129
In addition to the Texas case, abortion opponents tried to revive the Comstock law
in other ways. In April 2023, the town of Edgewood, New Mexico, passed an ordi-
nance designed to block the mailing of abortion pills and other abortion-​related items
to Edgewood, citing the Comstock Act. The ordinance allowed residents to sue other
residents for violations. The ordinance violated a New Mexico law that expressly for-
bade local restrictions on abortion.130 Another town, Eunice, sued the New Mexico
Governor Michelle Lujan Grisham and Attorney General Raúl Torrez, arguing that a
new state law prohibiting jurisdictions from restricting access to reproductive health
care, including abortion, was preempted by the Comstock Act. The lawsuit asked the
judge to declare that federal law outlawed all “shipment and receipt of abortion pills and
abortion-​related paraphernalia throughout the United States,” regardless of whether a
customer could legally use them where they reside. Local officials and anti-​abortion
advocates held a news conference in Washington, DC, to announce the filing of the
210 • Abortion Pills

lawsuit.131 Republican members of Congress introduced a 2024 federal budget with rid-
ers revoking the FDA’s decision to allow telemedicine abortion and pharmacy dispens-
ing of mifepristone.132
In other states, anti-​abortion legislators tried to suppress speech about abortion pills.
A model bill drafted by the National Right to Life Committee would make it a crime
to give “information to a pregnant woman or someone seeking the information on her
behalf ” about “self-​administered abortions or the means to obtain an illegal abortion.”
In February of 2023, a group of anti-​abortion Texas legislators introduced a bill to make
it illegal to “provide information on how to obtain an abortion-​inducing drug,” includ-
ing making or maintaining websites or creating and distributing apps on the topic.
This bill required internet service providers like AT&T, Comcast, Charter, and others
to “make every reasonable and technologically feasible effort to block Internet access
to information or material intended to assist or facilitate efforts to obtain an elective
abortion or an abortion-​inducing drug.” Because the law clearly violated free speech
protections of the First Amendment of the Constitution, the legislators made the bill
enforceable by private citizens, similar to Texas’s 2021 S.B. 8 bounty-​hunter abortion
law. The bill encouraged people to notify internet service providers of abortion-​related
content and “request that the provider block access to the information or material” and
granted them “absolute immunity” against lawsuits for agreeing to take down abortion-​
related information.133 Other states succeeded in passing laws enhancing the power of
the state to enforce abortion bans. In May of 2023, North Carolina adopted a law, over
the governor’s veto, that imposed a $5,000 fine against any individual or organizations
that promote the sale of abortion pills by advertising, hosting, maintaining a website,
or providing an internet service “purposefully directed to a pregnant woman who is an
NC resident.”134
Undaunted by legal threats, Mayday Health advertised in states banning abor-
tion. When Mississippi banned abortion shortly after Dobbs, Mayday Health put up
three billboards saying, “Pregnant? You still have a choice,” with a link to their website,
which had information about Aid Access and other ways to obtain abortion pills. The
Mississippi attorney general subpoenaed Mayday Health and the group put up more
billboards.135 In March of 2023, Mayday drove mobile billboards around college cam-
puses in fourteen states with abortion bans.136 While these tactics garnered national
headlines, they were done without consulting with grassroots activists in Mississippi,
who resented Mayday’s actions.137
Finally, following the Heritage Foundation playbook, an anti-​abortion group Life
Legal Defense Foundation filed a whistleblower lawsuit against Danco in January 2021
under the False Claims Act, which allows third parties to file challenges on behalf of
the US government and claim between 15 and 30 percent of the fine if the action suc-
ceeds. On April 12, 2023, in a settlement with the Department of Justice, Danco agreed
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 211

to pay $765,000 to the United States to resolve allegations that from 2011 to 2019 the
company failed to properly label imports of mifepristone as originating in China and
to pay customs duties on imports lacking those labels. Under the deal, Danco denied
the allegations but stated they were settling the case to “avoid the delay, uncertainty,
inconvenience, and expense of protracted litigation.” Life Legal received $116,000 of
the settlement.138
Despite all of these attempts to suppress access to abortion pills, these medications
in fact fueled increased access to abortion post-​Dobbs. In March of 2024, Guttmacher
Institute reported that the number of abortions in the formal healthcare system in the
United States in 2023 topped one million for the first time since 2012 and had increased
10 percent since 2020 (see Figure 6.1). They attributed this increase to broader avail-
ability of telehealth for medication abortion, increased financial support, and state poli-
cies improving protections and access to care in some states.139

Figure 6.1: The estimated number of abortions in the formal healthcare system peaked in the early
1990s and then steadily declined until 2020, when it began to increase, rising sharply in 2023 (courtesy of
Guttmacher).

Notes: 2023 estimate shown with accompanying 90% uncertainty interval. No comprehensive data
available for 2021 and 2022.
Source: Guttmacher Montly Abortion Provision Study.
212 • Abortion Pills

In March 2024, the Guttmacher Institute also released research showing that 63 per-
cent of all abortions were done with medications—​a fact that raised the stakes in the
Supreme Court case.140 Medication abortion increased from 31 percent of all abortions
in 2014 to 63 percent of all abortions in 2023—​more than doubling in just ten years
(see Figure 6.2).
Another development heralded a continuing increase in use of abortion pills. In
March of 2024, CVS and Walgreens announced they would begin dispensing abortion
pills at brick-​and-​mortar pharmacies in some states, with a promise to expand soon to
more states.141
Telehealth abortion was also increasing. In May of 2024, the Society for Family
Planning reported that telehealth abortion accounted for 19 percent of all abortions in
the formal healthcare system in December 2023 (see Figure 6.3).142
By the spring of 2024, telemedicine abortion providers Aid Access, Abuzz, and
Cambridge Reproductive Health Consultants operating in shield states were serving over
ten thousand people in states banning abortion each month.143 Advocates created two new
abortion funds to enable these providers to continue to offer a sliding scale fee structure
to patients. These funds—​Healthcare Across Borders’ Abortion Sustainability Fund and
Abortion Coalition for Telemedicine’s Banned State Abortion Fund—​focused only on
funding telemedicine abortion serving people in states banning abortion. Most traditional

Figure 6.2: Use of medication abortion increased steadily over time, but accelerated after the FDA lifted
medically unnecessary restrictions in 2016 and 2021 (courtesy of Guttmacher).

Source: Guttmacher Abortion Provider Census and Monthly Abortion Provision Study.
 Chapter 6: Post-Dobbs Attempts to Block Mifepristone • 213

Figure 6.3: The dramatic rise in July 2023 is due to the fact that Aid Access shifted from serving patients
from outside the country to serving patients from telehealth provider shield states within the United
States, so the Society of Family Planning began including their counts (courtesy of Society of
Family Planning).

abortion funds were wary of supporting telemedicine abortion in states with bans for fear
that anti-​abortion politicians might prosecute them under aiding and abetting laws.144
In April of 2024, Maine passed legislation that included a shield provision for telehealth
abortion providers, becoming the seventh state to do so.145 The next month, Rhode Island
adopted a similar law, becoming the eighth state to have a telemedicine abortion provider
shield law. A fourth shield law provider opened in June of 2024, Armadillo Clinic, serving
six states banning abortion, with providers operating under the California shield law. A
fifth shield state provider, We Take Care of Us, began serving all 50 states in late summer
2024, operating as a provider cooperative with a social justice pricing structure.
Meanwhile, self-​managed abortion outside of the formal medical system increased
significantly. Researchers estimated that the total number of self-​managed abortions that
took place in the six months after Dobbs, from July 1 to December 31, 2022, increased by
26,055 abortions.146 Most of those pills came from community networks (see Figure 6.4).
On May 1, 2024, Red State Access affiliates reported they had served forty thousand cli-
ents in twenty-​one states and four territories.147 Plan C played a major part in increasing
access to abortion pills. In 2023 alone, the Plan C website received 1.8 million visitors
and 20 billion impressions from press and media articles and interviews.148 Plan C put
up billboards in April of 2024 in four states that banned abortion—​Texas, Tennessee,
Mississippi, and Oklahoma—​ saying, “Need to be un-​ pregnant? plancpills.org.”149
New services also developed to support people self-​managing abortion, such as Aya
214 • Abortion Pills

Figure 6.4: The first study to comprehensively track self-​managed abortion outside of the formal
healthcare system showed significant increases in the fall of 2022, especially from community networks
in October 2022 when Red State Access began mailing pills (courtesy of Kristin Hopkins).

This figure shows the monthly number of abortion pill packs supplied before and in the 6 months
immediately after the June 2022 Dobbs v. Jackson Women’s Organization decision. Community networks,
which are run by volunteers who also provide peer-​to-​peer support and information, accounted for over
half of the total supply of abotion pill packs post-​Dobbs.

Source: Abortions outside medical system increased sharply after Roe fell, study finds, Washington Post,
March 25, 2024.

Contigo, which provided Spanish-​speaking doulas to support Latinas in the United

States.150
In June of 2024, the Supreme Court ruled in FDA v. Alliance for Hippocratic Medicine,
dismissing the lawsuit for lack of standing. In response, anti-​abortion advocates and
politicians pledged to continue their efforts to remove abortion pills from the market.
The Heritage Foundation, a right-wing think tank, released a detailed policy agenda
calling for the next conservative president to order the FDA to remove mifepristone
from the market and direct the Department of Justice to use the Comstock Act to crimi-
nalize mailing abortion medications. Despite anti-​abortion efforts to suppress mifepris-
tone, public support for medication abortion remained high. In a survey by Navigator
Research, over two-​thirds of Americans support “allowing women to legally use pre-
scriptions abortion medication to end an early pregnancy at home.”151 Abortion pills
dispensed from both inside and outside the formal medical system continued to play a
critical role in maintaining access to safe abortion in the United States post-​Dobbs.
 Conclusion: “Putting Pills
Directly in the Hands of
Those Who Need Them”

Pills have legs. Pills go places. This pill can go places outside of the prescription
setting.
Cynthia Pearson, recalling a comment made at a
meeting on self-​managed abortion.1

“Almost no pharmaceutical product has captured the public imagination with the
force of mifepristone,” said Beverly Winikoff and Carolyn Westhoff in 2015, on the
fifteenth anniversary of the FDA’s approval of mifepristone. They explained:

Initially, predictions were both dire and ecstatic: women would run rampant, having more
abortions than ever, boyfriends would slip mifepristone into their girlfriends’ tea, abortion
would become simple and easy, women would have access to abortion without any medi-
cal interface, and the politics of abortion would soften. Little of this set of predictions has
become reality. On the other hand, medical abortion has now made a profound change in
both the experience of abortion and the landscape of abortion provision.2

Winikoff and Westhoff predicted that medication abortion “seems poised to become
even more important in the next decades.”3 They were right. In the following years,
abortion pills became a critical political battleground, especially as the Supreme Court
overturned constitutional abortion rights and many states banned healthcare profes-
sionals from providing abortion services.
In the face of strident opposition, reproductive rights advocates fought an intense,
decades-​long battle to establish and expand access to abortion pills in the United States.
This movement included a diverse range of people—​from medicine, public health, pol-
itics, business, and philanthropy. They used innovative strategies to make an important
medication available in the United States. Abortion pill access has resulted from the
216 • Abortion Pills

efforts of medical researchers, healthcare providers, and reproductive rights advocates

here in the United States and abroad. From the feminist campaign to bring mifepris-
tone to the United States and win FDA approval for the medication in 2000, to the
ongoing campaigns to remove medically unnecessary FDA restrictions on abortion
pills and to make abortion pills available outside of the formal medical system, many
people have fought long and hard to establish and increase access to medication abor-
tion in the United States. Abortion rights supporters drew upon global resources and
networks, including international research to support FDA approval of mifepristone in
the United States and knowledge from women in Brazil who were using misoprostol to
end an unwanted pregnancy. US advocates were inspired by seeing abortion pills avail-
able over the counter in Ethiopia, and they turned to organizations based abroad like
Aid Access in Austria and Las Libres in Mexico to access pills when restrictive laws in
the United States made abortion inaccessible.
Abortion pill policy was advanced by medical research conducted by nonprofits,
private companies, and universities—​often with private funding from foundations and
anonymous donors. This research included the original clinical trials by the Population
Council, the groundbreaking TelAbortion study by Gynuity, and studies conducted at
ANSIRH, University of Washington Medicine, University of Texas at Austin, and other
locations. These studies supported the original approval of mifepristone as well as treat-
ment protocols, the loosening of the FDA REMS, and the rise of self-​managed abortion.
While the anti-​abortion movement produced its own “research” claiming to show the
dangers of mifepristone, the sheer volume of research showing the safety and effective-
ness of the medication drove the policy agenda forward, kept the medical community
informed, and reassured grassroots activists that they could safely share abortion pills
with people needing them. Republicans blocked the US government from support-
ing RU 486 research, which was a serious barrier to developing the medication.4 As a
result, advocates had to seek support for research on mifepristone from private sources.
Leading foundations supporting RU 486/​mifepristone research and advocacy included
the Susan Thompson Buffett Foundation, the David and Lucile Packard Foundation,
and the William and Flora Hewlett Foundation, as well as Open Society Institute, the
Prentice Foundation, and many anonymous contributors. These donors supported
Danco, GenBioPro, the ACLU’s Reproductive Freedom Project, Gynuity, and many
groups advocating for medication abortion.5
On the other hand, the anti-​abortion movement fought RU 486 every step of the
way with threats of boycotts, lawsuits, and lobbying for legislation restricting abor-
tion pills, as well as misinformation about abortion pills and even terrorist threats
and violence. “The anti-​abortion movement understood how critical it was to restrict
access to this technology,” said Coeytaux, “because it would be game over for them if
it was in the hands of people without the gatekeepers of the doctors. They were able
to scare the FDA.”6 The climate of fear and intimidation abortion opponents created
 Conclusion: Putting Pills in the Hands of Those Who Need Them • 217

likely influenced the cautious approach the FDA took in their approval of mifepristone
in 2000, and ironically contributed to later claims that the FDA acted in violation of
the law in Alliance for Hippocratic Medicine v. FDA. The anti-​abortion movement pro-
duced and promoted flawed studies to support inaccurate medical claims that medica-
tion abortion was dangerous, so they could frame themselves as protectors of women
as they were advocating for laws and policies that endangered women’s health and lives.
Abortion medications in early pregnancy weakened the anti-​abortion movement’s
strategy of portraying abortion as “baby killing” as both NRLC’s president John Willke
and their education director Richard Glasow admitted in the 1980s.7 So the movement
pivoted to arguments that “chemical abortion” harmed women’s health.
NARAL founder Lawrence Lader explained the intense opposition to abortion med-
ications as motivated by fears about the loss of male power and control over women.
Lader argued, “The loss of this power has stirred much of the anger now focused on
abortion, but at a deeper level, that anger is aimed at the women’s movement and the
sexual revolution, which have tested and eroded male dominance.”8 In his 1991 book
on RU 486, Lader said “the real agenda of the chastity bloc is not just an attack on abor-
tion but a ban on birth control,” noting how the head of the Pro-​Life Action League,
Joseph Scheidler, described contraception as “disgusting, people using each other for
pleasure.” In a July 2022 article in the New Yorker, Étienne-​Émile Baulieu gave his view
on why there has been such tremendous opposition to abortion pills from the anti-​
abortion movement: “A method that makes the termination of pregnancy less physi-
cally traumatic for women and less risky to their health has always been rejected by
pro-​lifers: what they really seek is to harm and punish women.”9
As abortion opponents have gained political power in recent years, overturned Roe,
and banned abortion in many states, access to abortion pills has nonetheless expanded
in many places by the increasing proliferation of telehealth during the COVID pan-
demic and the growth of organizations facilitating access to abortion pills outside of the
medical system. These contradictory trends have made abortion access geographically
uneven across the nation. Many states are banning abortion, but in states maintain-
ing legal abortion access, abortion pills and telemedicine abortion promise to increase
access and affordability of abortion health care as well as convenience and privacy.
The role that medication abortion plays in states with abortion bans is increasingly
clear: it is providing a safe alternative outside of the formal medical system. Before
Roe, abortion pills did not exist, nor did the internet and social media, where people
can now learn about abortion pills and order them online from companies inside or
outside the country. A robust network of organizations, healthcare providers, medical
researchers, and abortion rights advocates now exists to ensure that people know where
to find abortion pills, how to use them safely, and how to find legal help if they are
targeted by anti-​abortion prosecutors. However, unlike before Roe, the United States
today has an extensive criminal justice system and increasingly sophisticated digital
218 • Abortion Pills

surveillance systems that may increase the likelihood of criminal prosecutions of those
self-​managing abortion.
The abortion pill battles in 2023 echoed battles going back over three decades,
with advocates using similar legal and political strategies as well as social pressure
to achieve their ends. Advocates for and against abortion framed these medications
in diametrically opposed ways: as liberating or deadly. They tapped into political
opportunities available to them, and they mobilized the resources they had to achieve
their political goals. Abortion rights supporters sought to reframe abortion pills as
safe and effective, and make them accessible, with support, both inside the medical
system and outside of it. They produced research documenting the safety of abor-
tion pills, and communicated their findings to journalists, policymakers, and courts.
Abortion opponents, on the other hand, portrayed abortion pills as dangerous and
traumatizing. They spread these messages through crisis pregnancy centers and in
headlines on lawsuits they filed challenging FDA approval of abortion pills. Abortion
opponents resurrected a nineteenth-century law in the twenty-​first century. Early
abortion restrictions in a time before penicillin were motivated in part by concern for
women’s health. They were poison control measures designed to restrict the prolif-
erating market of questionable remedies in the 1850s to “restore menstruation.”10 By
the mid-​twentieth century, anti-​abortion advocates focused on fetuses, using Lennart
Nilsson’s intrauterine hi-​res photography released in the mid-​1960s to detach the
fetus from its environment and declare its full personhood.11 Medication abortion in
early pregnancy threatened this framing of abortion as involving “unborn babies” as
people used abortion pills and saw the results. This perhaps motivated the abortion
opponents’ shift back toward arguments about “chemical abortion” as dangerous to
women’s health.
These movements took advantage of the political opportunities available to them
at different periods of time. Republican presidential administrations clamped down
on abortion pills, from George Bush’s import alert in 1988, to the Trump adminis-
tration’s refusal to lift in-​person distribution requirements on mifepristone during the
COVID-​19 pandemic and his repeated appeals of the Maryland court decision allow-
ing telemedicine abortion during that time. Democratic administrations, on the other
hand, increased access to abortion pills, from the initial approval of mifepristone under
the administration of President Bill Clinton, to the FDA’s 2016 expansion of access to
mifepristone in 2016 under President Barack Obama, to the removal of the in-​person
distribution requirement in 2021 under President Joseph Biden.
Mifepristone and misoprostol have had a transformative impact on women’s
access to abortion, offering them the option of ending a pregnancy without the need
for an invasive procedure and within the privacy of their own homes. Telemedicine
abortion meant women did not have to walk through anti-​abortion protesters to
get abortion health care and they could more conveniently access this care without
 Conclusion: Putting Pills in the Hands of Those Who Need Them • 219

driving hundreds of miles. Abortion pills also offered women a safe and effective
way to end an unwanted pregnancy outside of the formal medical system—​especially
important as states began to prohibit clinic-​based abortion post-​Dobbs. While some
women might prefer procedural abortion or in-​clinic medication abortion, telemed-
icine abortion and abortion pills outside of the medical system provided options for
many women who would not otherwise be able to access abortion at all, especially
in the restrictive post-​Dobbs world.
FDA’s reduced restrictions on mifepristone—​including allowing pharmacies to
dispense the medication—​encouraged a wider range of providers to offer medica-
tion abortion, increasing access to abortion health care. Dr. Michele Gomez, a family
care provider practicing in Burlingame, California, explained why she thought it was
important for primary care providers to offer abortion services: “Abortion clinics have
done heroic work, but there’s no medical reason that abortion needs to be provided in
a specialty practice. Early abortion services, both medication abortion and aspiration
procedures, can be provided very safely in the privacy of patients’ own doctors’ offices.”
Dr. Gomez explained how primary care providers offering this care increases access
and enhances patient privacy and safety:

If more primary care providers offered early abortion services, there would also be increased
access—​no one should have to drive hours or days to get an abortion. It would also make it
harder for abortion services to be targeted by those who want to control pregnant people—​
what are they going to do, stand outside of every single regular old doctor’s office and assume
someone might be going in for an abortion? They might just be going in for a check-​up, or
to follow up on their blood pressure, or for a twisted ankle—​it would be impossible to know.
It’s easy to target Planned Parenthood, but much harder to target every primary care office
in the country.12

Primary care physician Dr. Emily Godfrey agreed: “The more we isolate abortion as a
standalone online service or in a standalone clinic, the more it can get attacked with
all this legislation. The more we think about integrating abortion into primary care the
same way we’ve integrated mental health into primary care, we can reduce stigma.”13
The Reproductive Health Access Project and the MYA Network worked to encour-
age more primary healthcare providers to offer abortion services, including medi-
cation abortion, and to raise public awareness about this option. At the University
of Chicago, the Department of Family Medicine formed the Excellence in Providing
Access to New Directions in Mifepristone Use (ExPAND Mifepristone) as a learning
collaborative to support evidence-​based use of mifepristone for early pregnancy loss
and/​or abortion in primary care settings. Co-​directed by Dr. Debra Stulberg, a family
physician, and Elizabeth Janiak, ScD, a public health researcher, the learning collab-
orative provided expert guidance and technical assistance in the form of specialized
220 • Abortion Pills

resources and tools, hands-​on training, in-​clinic trainings, and individualized admin-
istrative coaching. Their goal was to create a network of primary care providers and
clinical sites equipped with the resources and training needed to expand and protect
access to mifepristone.14
In addition to primary care providers offering medication abortion, many medical
providers began offering telemedicine abortion because it was more convenient, pri-
vate, and affordable for their patients. Dr. Deborah Oyer, the medical director of Cedar
River Clinics—​a brick-​and-​mortar clinic in the greater Seattle area, explained: “For
centuries, we have honored the provider’s time, and we have not honored the patient’s
time. Telemedicine abortion allows patients to be more in control in every way. They’re
in control of their time. They’re in control of how they get their medications.” In con-
trast to the burdens of in-​clinic abortion care, telemedicine abortion can happen quickly
without the need for taking time off work, finding childcare, and driving long distances.
Dr. Oyer also explained how telemedicine abortion enhances privacy: “Telemedicine is
even more important with abortion than with other care. Abortion is still a shameful
thing in our country, so the fewer people that have to be involved, the better.”15
Most revolutionary was the proliferation of virtual abortion clinics—​where health-
care providers offered fully remote care to patients, quickly and affordably. With low
overhead and sophisticated digital platforms, these telehealth providers were able to see
patients within a day or two, as opposed to the weeks it often took to get an appoint-
ment at a brick-​and-​mortar clinic. Some required videoconferencing, but many treated
patients by phone, text, or online form. All of them offered medication abortion at a
significantly reduced cost, sometimes at just a fraction of what the in-​clinic care would
cost. Telemedicine abortion providers were motivated by wanting to give their patients
more options, easier access, and greater control over their experience. Dr. Julie Amaon
of Just the Pill explained why she began offering telemedicine abortion:

While I appreciate our brick-​and-​mortars and know they need to be there for people, I just
felt like abortion care needed to be done a little bit different. We were always getting calls
from patients at the clinic asking, “Do I really have to come in for this?” Or comments like,
“I don’t need counseling. Can I just pick up my pills?” These experiences stuck with us when
we started Just the Pill. We asked ourselves, what would it mean to really center the patient
and give them what they have been needing in the way that feels most comfortable for them?
In the pandemic, it was very obvious that people wanted the security and privacy of doing
this in their home. At brick-​and-​mortar clinics, even for medication abortions, you still have
to be in the clinic for several hours because they have to do your counseling, and then they
do your ultrasound and lab work, and then you have to wait in between procedures to see
the physician. It doesn’t have to be that way. We were just trying to think outside the box to
make abortion more accessible.16
 Conclusion: Putting Pills in the Hands of Those Who Need Them • 221

Similarly, Lauren Dubey, a nurse and co-​founder of Choix, explained how the model
of traditional health care prevented access and often didn’t meet the needs of patients:

Access to abortion health care in California is extremely high compared to other places in
the country. And still, it doesn’t seem like enough. There are rules and protocols that are
rooted more in provider comfort or fear of liability than evidence-​based medicine. One of
my most heartbreaking things I ever had to do when I was working at Planned Parenthood
was someone would come in and they’d be ten weeks and two days in their ultrasound and
I would have to turn them away for medication abortion. And they would say, “Well, if
I could have just gotten in here two weeks ago when I made the appointment, when I took
the pregnancy test…” But my hands were tied. When you do this via telehealth, there’s no
waiting for an appointment for two weeks.17

As some of the first virtual abortion clinics in the country, Just the Pill and Choix cou-
rageously pioneered a new, patient-​centered model of care that became critical post-​
Dobbs. Between April 2022 and March 2023, virtual-​only abortion services increased
by 85 percent compared to the pre-​Dobbs period, from 5 percent of all abortions to
9 percent of all abortions.18
Ironically, the overturning of constitutional abortion rights in Dobbs and the subse-
quent state abortion bans played a significant role in expanding access to abortion pills
by jumpstarting the movement for self-​managed abortion. Abortion bans necessitated
bypassing the healthcare system and its tight control over abortion pills, placing them
directly into the hands of women needing them. Conflict existed not only between
abortion pill supporters and opponents, but also among reproductive health advocates,
who had starkly different visions and goals. They divided on how best to help main-
tain access to abortion after Dobbs. Mainstream reproductive healthcare providers and
abortion funds, such as Planned Parenthood, National Abortion Federation, Whole
Woman’s Health, and the National Network of Abortion Funds, took the more conser-
vative approach of strictly obeying abortion restrictions and working to transport peo-
ple from states with bans to medical providers in states where abortion was still legal.
As prime targets for lawsuits and other legal attacks, these large abortion-​providing
organizations pursued a legally cautious approach and fully complied with a restrictive
interpretation of new state abortion bans, making it harder to get abortion medica-
tions. One Planned Parenthood affiliate in the Midwest, for example, required patients
to take both pills over two days in a state that allows abortions, meaning patients from
out of state had to extend their trip. “We needed to protect our staff and protect our
organization,” said Veronica Jones, the chief operation officer of NAF.19 Abortion oppo-
nents banked on compliance with anti-​abortion laws. “Licensed professionals are not
in the business of violating the law. You have too much to lose,” said Peter Breen, vice
222 • Abortion Pills

president and senior counsel for the Thomas More Society, which represented anti-​
abortion clients and advised legislators.20
Meanwhile, Plan C, Aid Access, many of the new telehealth abortion providers, and
abortion pill networks like Las Libres, AccessMA, and WeSaveUs worked to get abor-
tion pills to people where they lived, no matter the law. “There are benefits to taking
calculated risks that break new ground, even if otherwise allied people disagree,” said
Linda Prine.21 Some reproductive health advocates attacked Plan C, accusing them of
placing providers and patients at legal risk. Advocates at Plan C responded that women
should be able to make the choice between the legal risks of self-​managing an abor-
tion and the risks of being forced to carry an unwanted pregnancy to term. The reality
was that half of women needing abortions lived in poverty, and 75 percent were low-​
income.22 They often lived in rural areas, already had children, and worked low-​wage
jobs that didn’t give them time off to travel many hours or days to find abortion health
care in states where it was legal. Like Kelly from Texas, whose story was described in
the introduction, many did not have that option. Because of their radical tactics, Plan
C lost their original fiscal sponsor and the organization was eventually ejected from the
GLC. Despite opposition from both sides of the political spectrum, Plan C continued
to do the critical work of making abortion pills accessible outside of the formal medi-
cal system, including working to pass telemedicine provider shield laws that enabled
providers in blue states to serve people in states banning abortion.
Mifepristone has remained highly restricted for decades because of a confluence of
factors, including the anti-​abortion movement, FDA action and inaction, the decisions
of the medical and pharmaceutical industries, and entrenched ideas about who should
control abortion. The anti-​abortion movement created a political climate of misinfor-
mation and fear that made the FDA unnecessarily cautious in approving mifepristone,
which the agency placed under unusual and discriminatory restrictions. The FDA then
repeatedly refused to lift those restrictions, even as medical science conclusively proved
the safety of mifepristone. Cynthia Pearson, who knew the head of the FDA committee
that approved obstetric and gynecological drugs, Dr. Phillip Corfman,23 explained what
she thinks happened:

I remember conversations with Dr. Corfman, where he said, we just need to make sure that
the first couple of years run really smoothly. No deaths, no bad complications. If we keep it
to the most experienced doctors for the first couple of years, and we get a good track record,
then it’ll go smoothly. That was such a narrow and wrong view because antis were never going
to accept that mifepristone was okay because they are opposed to all kinds of abortion. They
were always going to foment opposition and try to keep it narrowly contained. And it was
really wrong as a bureaucratic tactic, because the FDA didn’t loosen those restrictions. They
were subpart H restrictions for the first few years but then the FDA invented the REMS pro-
gram and they just got migrated into REMS and it’s very difficult to undo REMS restrictions.24
 Conclusion: Putting Pills in the Hands of Those Who Need Them • 223

According to Pearson, the FDA justified the restrictions not because the drug was
dangerous but because pregnancy was dangerous. As a result, the FDA restrictions,
along with the anti-​abortion movement’s misinformation and threats, created “cogni-
tive dissonance” contributing to the impression that mifepristone itself was dangerous
when it was not, and that the FDA had originally restricted the medication because
of dangers rather than politics. Sarah Christopherson said these misunderstandings
influenced everyone working on the issue. “Not only were the young repro activists
working on mife not familiar with the history of the restrictions, the FDA career staff
still in place in 2020 weren’t either! Even if they supported removing the restrictions,
they likely truly believed that the restrictions were originally imposed because they
were medically necessary, and didn’t know the sociopolitical context or the very real
fear of violence that guided the FDA in 2000,” said Christopherson.25 Paired with
ongoing misinformation and threats, policymakers, medical professionals, and even
advocates for loosening restrictions on mifepristone were treating the REMS as if they
were based on science when in fact they had always been political.
Christopherson also noted the FDA restrictions coincided with the George W. Bush
administration taking office, so the restrictions remained in place. Turnover in the
reproductive rights field then led to a loss of institutional knowledge and history, and
people came to accept the restrictions. Some even supported them, said Christopherson:

The restrictions were inconvenient, but we’ve now built up an infrastructure around manag-
ing them. By 2009, when the Obama administration takes over, there is a whole system set
up and doctors like having that control of people coming in. And there is a slice of providers
that are actually fairly conservative. They don’t really trust women. There is an element of
paternalism. There were some providers who liked the fact that women had to physically
come in to see them and get permission. Some of the lead policy influencers for the move-
ment had a fundamental conservatism about how much to push the envelope, because if you
don’t trust women, then you don’t push for a system that gives them more power.26

On removing the in-​person dispensing requirement, Christopherson said that some

people in the movement feared how telemedicine abortion would impact brick-​and-​
mortar clinics. She said in her advocacy, she had to be clear that the National Women’s
Health Network did not think mifepristone was a substitute for in-​clinic care, but that
it was a complement that would take pressure off of clinics in sanctuary states experi-
encing a mass influx of patients once Roe was overturned. “It was something that I felt
like I needed to approach with a lot of sensitivity and diplomacy, because there was
this sense of defensiveness, like ‘It’s not the solution. It’s not the solution.’ And I was
always like, ‘well, it’s part of the broader solution.’ ”27
Barriers to abortion pills were also created by the medical profession, which estab-
lished a protocol requiring unnecessary ultrasounds and blood tests that drove up the
224 • Abortion Pills

price of medication abortion. These tests discouraged most primary care doctors from
offering medication abortion because they did not have access to expensive ultrasound
equipment. The high cost was also justified by arguments that medication abortion
should be priced the same as procedural abortion so as not to influence lower-​income
people’s choice of service. But the result was that abortion pills were made unafford-
able for many low-​income and poor women. Some believed that Danco, Planned
Parenthood, and NAF, representing independent clinics, did not push for full removal
of the FDA restrictions on mifepristone because the REMS allowed them to maintain
control over the medication. Others believed that only incremental change was pos-
sible. Some abortion providers even resisted alternative modes of care such as telemedi-
cine abortion that are more accessible and convenient for patients, but threatened their
business model. Finally, large pharmaceutical companies with the resources for clinical
trials, the FDA approval process, and marketing refused to take on mifepristone, forc-
ing it into the hands of a small, inadequately resourced company, which caused delays
and may have contributed to the restrictions placed on the medication by the FDA. As a
result, the medication ended up entirely in the hands of a small private company, Danco
Laboratories, which was able to charge a high price for the medication and maintain a
monopoly on mifepristone for fifteen years after its patent expired. Anti-​abortion pres-
sure and threats, a risk-​averse FDA, and rigid medical and pharmaceutical systems kept
mifepristone highly restricted and highly priced for decades after the FDA approved
the medication. Paradoxically, Dobbs together with the COVID-​19 pandemic finally
freed mifepristone from the vise grip of the US medical and pharmaceutical industries,
making the medication affordably available for the first time through telemedicine pro-
viders and community networks.
Even before Dobbs, the medical system excessively restricted abortion pills, spurring
the creation of organizations to support people needing to access abortion pills outside
of the formal medical system. These organizations exposed the medical gatekeeping
as unnecessary and harmful. Women realized that abortion pills were safe and easy to
use. They realized they could have private and convenient abortions, without having
to travel hundreds of miles, cross lines of protestors, pay large sums of money, and put
their feet up in stirrups. COVID and Dobbs pushed mifepristone out of the medical
system in many states and put abortion pills in women’s hands much more quickly
than ever would have happened through the normal processes of change in FDA policy
and medical protocols. People realized they could access abortion pills conveniently
and affordably, and use them in the privacy of their own homes. For many people,
this was liberating. But even for those who wanted to use pills with a medical profes-
sional’s involvement, these changes opened up access as primary care providers realized
they didn’t need ultrasound machines to offer this care, and pharmacies like Honeybee
and American Mail Order Pharmacy could send pills quickly and directly to patients.
Abortion restrictions motivated people to develop organizations and networks like
 Conclusion: Putting Pills in the Hands of Those Who Need Them • 225

SASS, Plan C, MYA Network, and Red State Access, which created pathways around
legal bans and medical gatekeepers to re-​envision how abortion pills could be accessed
and used.
Other organizations like the M+​A Hotline, Repro Legal Helpline, Aya Contigo, and
the abortion subreddit OARS helped support people self-​managing abortion. By July
2023, OARS was receiving four to five thousand views a day.28 An attorney and OARS
volunteer, Nina Henry, said the subreddit provided reassurance and support to people
having abortions. “We get a lot of people who are worried that they’re too upset, or
that they’re not upset enough, or that the way they’re feeling is totally abnormal,” said
Henry. “One of the things that I often type is, ‘This is normal.’ The other thing I type
the most is, ‘There’s no right way to feel about your abortion.’ ”29 Henry said her experi-
ence working as a volunteer moderator for the abortion subreddit made her feel more
hopeful about the future of abortion access: “The closer to working in abortion support
that I get, the more optimistic that I feel about people taking care of each other, people
sharing their experiences.”30
While Plan C advocates achieved many of their goals, they had not as of 2024
achieved the kind of access they found at that pharmacy in Ethiopia. There was not an
FDA-​approved dedicated product: clinicians had to send two prescriptions to patients—​
one for mifepristone and one for misoprostol (see Figure C.1). The price was still much
higher than the $6 or $7 they paid for the MTP (medical termination of pregnancy) kit
in Ethiopia. However, Plan C’s work was making abortion pills more affordable than
ever in the United States. Websites selling pills lowered their prices, provided extra
misoprostol, and offered faster shipping in order to be included at the top of the Plan C
list of online websites offering abortion pills. “Initially, we said we would test companies
that come in with pricing under $200 that have the ability to offer extra misoprostol and
fast shipping. We still had so many requests that we said if you’re under $140, we’ll test
you. So, sure enough, we’re getting these requests from companies saying they can sell it
for less. I’m in conversation right now with three different websites that are gonna come
in probably around a hundred dollars and offer extra misoprostol and shipping time of
a week or less.”31 By late May of 2023, Plan C had a company offering an MTP kit32 plus
ten extra misoprostol pills with three-​day delivery for $100. By mid-​July 2023, com-
panies were offering abortion pills for as low as $37 with three-​day delivery.33 “These
aren’t just regular mail order businesses,” said Wells. “These are businesses that are set-
ting up to try and help get abortion pills out there. Some of them are profit driven. But
a lot of them are also mission driven. They’re taking risks when they’re doing this.”34
The legal future of abortion pills remains uncertain. Most progress on abortion
pills has occurred during moments of transition, when Democrats were either gain-
ing control or losing it—​in 2000, when the FDA originally approved mifepristone as
Clinton was leaving office; in 2016 when the FDA expanded access to mifepristone
when Obama was leaving office; and in 2021 when the FDA allowed telemedicine
226 • Abortion Pills

Figure C.1: In Europe, mifepristone and misoprostol are combined in one blister pack under the name
Mifegest (below). In the United States, mifepristone and misoprostol are packaged separately (above)
(photo credit: Carrie N. Baker).

abortion right after Biden became president. The next obvious step forward is removal
of the FDA REMS. Danco and GenBioPro have not applied to the FDA for removal
of the REMS. The FDA has already rejected advocates’ citizen petition to remove the
REMS. The lawsuit brought by state attorneys general of seventeen states and DC in a
federal court in Washington state is a possible avenue forward, or a presidential execu-
tive order requesting the FDA to review the REMS, similar to Biden’s executive order
issued in May of 2021 for removal of the in-​person distribution requirement. Another
possibility is a federal lawsuit filed by abortion providers in Virginia, Montana, and
Kansas on May 8, 2023, against the FDA, seeking an order to maintain and expand
access to mifepristone. Represented by the Center for Reproductive Rights, the plain-
tiffs spoke from their experiences as abortion providers: “plaintiffs are continuously
facing the weaponization of the REMS by anti-​abortion activists around the country,”
they argued. “By making mifepristone seem uniquely dangerous, FDA’s continuing
 Conclusion: Putting Pills in the Hands of Those Who Need Them • 227

restriction of mifepristone stigmatizes medication abortion and contributes to the

chaos anti-​abortion activists now sow.”35 The plaintiffs, who are independent abortion
providers with limited resources in hostile states, argued the REMS restrictions endan-
gered their practices and patients. “These restrictions perpetuate harm, stigma, and
create unnecessary barriers to a medication that is safer than penicillin or Tylenol,” said
Nicole Smith, Executive Director of Blue Mountain Clinic. “It is time to end this ideo-
logically driven government interference in the practice of medicine.”36
The complaint explained in frank and striking detail why medication abortion
access was so important. “Medication abortion allows people to forgo the physical con-
tact and vaginal insertions of a procedural abortion, which may be particularly impor-
tant for survivors of sexual violence and people experiencing gender dysphoria.”37
Telemedicine abortion could “eliminate the exposure risks inherent in in-​person clinic
visits, particularly in light of the persistent and escalating violence and harassment at
clinics known to provide abortion.”38 The complaint described the harms caused by
delayed access to abortion health care: “Each day a person remains pregnant means
they continue to experience the symptoms, risks, and potential complications of preg-
nancy. Pregnancy—​even when uncomplicated—​stresses the body, causes physiological
and anatomical changes, and affects every organ system. Pregnancy can also worsen
underlying health conditions, many of which are common, such as diabetes and hyper-
tension.”39 The complaint detailed the harms of forced childbirth, including significant
risks resulting from systemic discrimination and inequitable access to health care:

Every pregnancy-​related complication is more common among people having live births
than among those having abortions. Vaginal delivery can result in trauma to the pelvic floor
and other significant injury. And, for the approximately one-​third of pregnancies ending
in a caesarean section (C-​section), patients will undergo a major abdominal surgery that
carries risks of infection, hemorrhage, and damage to internal organs. Pregnancy also has
potentially long-​term physical, emotional, and mental effects on a person who goes through
childbirth, sometimes persisting well after birth.40

The complaint noted that the United States had one of the highest maternal mortal-
ity rates among wealthy democracies, especially for Black women, who are three to
four times more likely to die of a pregnancy-​related death in the United States than
white women, and Indigenous women, who are 2.3 times more likely to die than white
women. Forced pregnancy and childbearing also have long-​term impacts on a person’s
educational and economic futures, and their ability to shape their lives. “People who
are denied a wanted abortion are more likely to experience economic insecurity and
raise their existing children in poverty,” stated the complaint. “The financial impacts
of being denied an abortion are as large as or larger than being evicted, losing health
insurance, or being hospitalized.”41
228 • Abortion Pills

The plaintiffs argued that FDA restrictions on mifepristone also violated women’s
dignity and autonomy. “The ability to make decisions about whether to continue or
end a pregnancy, and by what method, is critical to a person’s dignity and autonomy.
Continued enforcement of the REMS perpetuates harmful and unnecessary barri-
ers that make it more difficult to access essential health care and interferes with this
decision-​making.”42 The complaint concluded, “From the very beginning, FDA has
overregulated mifepristone in ways that are unjustified and discriminatory. But even
as decades of data has accumulated showing mifepristone to be one of the safest medi-
cations available in the United States, FDA has continued to subject mifepristone to
uniquely burdensome restrictions with increasingly little reason for doing so. These
restrictions are already irrational, but in light of the recent chaos surrounding mifepris-
tone, they have also become intolerable and incompatible with Plaintiffs’ ability to meet
the needs of their patients.”43
The plaintiffs asked the court to order the FDA to remove the REMS restrictions
or, alternatively, to enjoin the FDA from altering the current availability of mifepris-
tone. “We are tired, and we are angry, and we will not compromise or sit idly by as
anti-​abortion opportunists continue to attempt to block the safest, most effective,
and preferred method of medication abortion in this country,” said Amy Hagstrom
Miller, president and CEO of Whole Woman’s Health and Whole Woman’s Health
Alliance. “Our patients deserve every single option that is available to them as they
are making these choices for themselves and their families.”44 On August 21, 2023,
a federal court in Virginia denied the Center for Reproductive Rights’ preliminary
injunction request.45
In addition to removal of the REMS, advocates are working toward approval of over-​
the-​counter access to mifepristone, which is justified by medical science but is politi-
cally unlikely to happen any time soon. But researchers at ANSIRH are nevertheless
pursuing studies to lay the groundwork for this eventual development.46 Some advo-
cates, like Kirsten Moore of the EMAA Project, continue to work within the system,
fighting to improve FDA regulation of mifepristone. Others have become frustrated,
and shifted toward working outside of the medical and legal systems. “The more we
work with the FDA, the more I feel like we just empower them, embolden them,” said
Francine Coeytaux “It’s just really, really difficult to watch and be a part of continuing
to put fingers in holes of a broken system. Our medical system is entirely broken. Our
health insurance system is entirely broken. Our human rights system is broken.”47
Progress on abortion pills has at times been stymied by movement stakeholders
with vested interests in the current system, who have resisted change that would have
expanded access to abortion pills but endangered the status quo. In the film Plan C, an
Alabama abortion provider was explicit about their concerns. “All of our first trimester
procedures before ten weeks are $700. It’s the same, surgical and medical,” said Robin
Marty, operations director of the West Alabama Women’s Center in Tuscaloosa at the
 Conclusion: Putting Pills in the Hands of Those Who Need Them • 229

time. “It’s expensive to run a clinic. Right now, most clinics are doing both procedures
and medication abortion. We can operate because we have so much medication abor-
tion and if you take that from us, if we were a state where you could just get medica-
tion through the mail and do it far more cheaply, then we would close.”48 Dr. Carolyn
Westhoff explained: “Most of those freestanding clinics where all of later abortions take
place have a business model where early abortions to some extent are subsidizing the
later abortion care. So in these freestanding clinics if people go elsewhere for medica-
tion abortion, such as competing clinics that do nothing but medication abortion, it
really ruins their business model.”49 In fact, high prices delay access, pushing people
into later abortion care.
Similarly, telehealth providers were threatened by the development of even more
affordable models of care. Coeytaux gave the example of how some telehealth providers
were threatened by the passage of shield laws protecting telehealth providers serving
people outside of their state. “They’re all worried about how they’re going to lose their
market share when you can do anything anywhere,” said Coeytaux.50 Marlene Gerber
Fried put it another way: “In these moments of horrible repression, the tendency is to
protect whatever ground you have right now, however small.”51 She explained: “If you
are pushing the radical edge, some advocates fear that you are endangering what exists;
that you’re endangering other more modest changes that are important, even though
they are not the best thing that you can have. And that’s what I think you’re seeing in
this moment. People feel like they have, even if only temporarily, a solution or a stop
gap. And at each level, the people who think theirs is the right way are like, ‘No, that’s
gonna shut it all down.’ ”52
Some abortion providers were not willing to take any risks to serve desperate
patients from states with bans. After the Supreme Court handed down Dobbs in June
2022, the CEO of Planned Parenthood in Montana, Martha Fuller, announced that in
order to avoid legal hazards, they would not provide medication abortions to out-​of-​
state patients at all. “As a healthcare provider, we must identify and mitigate risks con-
stantly,” she said. “The risks around cross-​state provision of services are currently less
than clear, with the potential for both civil and criminal action for providing abor-
tions in states with bans.”53 Despite these legal risks, two independent providers—​Blue
Mountain Clinic in Missoula and All Families Healthcare in Whitefish—​offered medi-
cation abortion to out-​of-​state patients. Planned Parenthood eventually agreed to serve
people from other states, but only if they were willing to travel all the way to their
offices, whereas the independent clinics mailed abortion pills to the state’s borders for
patients coming from Idaho, Wyoming, and the Dakotas to save them having to travel
hundreds of extra miles. Blue Mountain’s executive director, Nicole Smith, said their
independent clinic was willing to take on some risk to serve their patients who had few
alternatives: “I’m not going to be afraid of some hypothetical. For us, we have been try-
ing to find a balance—​how do we take on more of the risk as providers versus putting
230 • Abortion Pills

that risk on the patients? There is this level of risk that either gets placed on the patient
or on the provider. As much as possible, I think we’re trying to take on that risk.”54
Abortion pill access resulted from the brave, determined, and visionary action of
many people across decades, who faced down opposition from the anti-​abortion move-
ment, from the medical and legal systems, and sometimes even from allies in the repro-
ductive health movement. They faced an obstacle course of barriers navigating multiple
institutions, systems, and stakeholders, including the FDA, federal and state govern-
ment officials and courts, the medical, pharmaceutical, and insurance industries, some
medical providers with vested interests in the status quo, the anti-​abortion movement,
and other activists with different priorities. As a result medication with many life and
health saving potentials was held hostage for years.
The abortion pill movement had advocates who worked within the system taking
an incremental approach, such as Marie Bass, Beverly Winikoff, and Kirsten Moore,
and people with more radical, confrontational tactics, such as Eleanor Smeal, Lawrence
Lader, Francine Coeytaux, Elisa Wells, and Susan Yanow. Groups like RHTP, Population
Council, and EMAA Project were reformist, whereas FMF, ARM, and later Plan C used
more radical and confrontational tactics that pushed forward abortion pills access at
critical points. “People who are on the fringes move things along in their own way,” said
Winikoff. “I think Larry Lader was a gadfly and provocateur, but an interesting histori-
cal character that moved the process along.”55
Larry Lader and Eleanor Smeal used high-​profile publicity stunts. Lader staged
the confiscation of a woman’s mifepristone by customs agents at JFK airport, then
held a press conference and filed a lawsuit. Smeal orchestrated the collection of hun-
dreds of thousands of petitions and delivered them in boxes to the corporate head-
quarters of Roussel Uclaf in Paris and Hoechst AG in Frankfurt. Meanwhile, Marie
Bass and Beverly Winikoff were working behind the scenes to educate and mobi-
lize researchers, doctors, and policymakers about the science of mifepristone. Marie
Bass and Joanne Howes formed RHTP to play the important role of bringing people
together across multiple divides and creating an inclusive space for conversations
among diverse constituents, including physicians, scientists, and activists. Winikoff
brought a similarly diverse group of stakeholders to the table with the Coalition to
Improve Access to Mifepristone in the United States. Coeytaux explained Winikoff ’s
contribution:

Beverly [Winikoff] has been at the heart of this whole thing. Her leadership and her work
have been critical. Beverly is a visionary and understands better than anybody all the levers
and what’s needed for change. I believe that from the get-​go she was as upset as I was at how
the REMS was not evidence-​based and we shouldn’t put up with it, but she was trying to bring
along the people who needed to be brought along—​the NAFs, the Planned Parenthoods, and
Danco. They needed to trust her. She had to get everybody to the meetings. So she had to
 Conclusion: Putting Pills in the Hands of Those Who Need Them • 231

hold her cards close to her chest a lot more than I did. My role was to be open about the fact
that the REMS was a mistake. If she had said that, would she have been able to get them to
the meetings? She wouldn’t have been able to play the role she did if they had sensed that she
was judging this to be wrong in the first place.56

Bringing together a wide range of stakeholders was a critical step to getting the FDA
to loosen its restrictions on mifepristone.
Lawyers also played a critical role by filing lawsuits, including the ACLU’s lawsuit to
remove the FDA’s in-​person distribution requirement during the pandemic, the lawsuit
by state attorneys general demanding removal of the REMS altogether, and GenBioPro’s
lawsuit to preempt state restrictions on mifepristone. As self-​managed abortion became
a reality, groups such as Plan C, SASS, and Reproaction worked to educate people about
abortion pills online and in person. “We took small, consistent, bold, unapologetic,
direct action,” said Pamela Merritt of Reproaction, who described self-​managed abor-
tion as an “essential liberating tool.”57
Activists centering reproductive justice called attention to racial and economic con-
siderations of abortion medications. In the 1980s, they raised concerns about potential
dangers and coercive uses of new reproductive technologies. After FDA approval of
mifepristone in 2000, they noted the disparate impact of the REMS on women of color.
In 2020, the reproductive justice organization SisterSong became a plaintiff lawsuit
that removed the in-​person distribution requirement on mifepristone for the first time.
As access to clinic-​based abortion decreased and people increasingly accessed abor-
tion pills outside of the medication system, however, reproductive justice advocates
warned about the uneven legal risks of self-​managed abortion for women of color and
low-​income women. This perspective was especially important considering the dispro-
portionate rates of abortion among women of color and low-​income women. Several
organizations that advocated for abortion pills, including RHTP and the GLC, recog-
nized the importance of race and insisted on creating racially diverse boards. Despite
the potentially disproportionate legal risks, the development of alternative supply net-
works increased access to abortion pills for many low-​income women and women
of color, who had for years faced steep barriers to clinic-​based medication abortion
because of the Hyde Amendment. Indigenous women, for example, never had access to
abortion medications through the Indian Health Services, and often had to drive hun-
dreds of miles to the nearest abortion clinic offering this service. The overturn of Roe
spurred the expansion of telemedicine abortion and alternative supply networks that
increased access to abortion pills. In these and other ways, reproductive justice activists
played a critical role in abortion pill politics.
On the other side of the issue, abortion opponents echoed the politics of the nine-
teenth century. Hostility to changing sexual norms led to passage of the Comstock Act
in 1873, restricting the distribution of “obscene materials” in the US mail, including
232 • Abortion Pills

information about contraception and abortion. Today, anti-​abortion advocates’ hostil-

ity to contemporary sexual norms fuels attempts to revive the Comstock Act. In the
early nineteenth century, the first laws restricting abortion were poison control mea-
sures designed to protect women from a proliferating array of businesses openly sell-
ing abortifacients, some of which were dangerous.58 With the advent of fetal imaging
in the 1960s, abortion opponents came to focus their arguments on the right to life
of fetuses.59 Contemporary abortion opponents, however, have returned to a focus on
purported concerns about women’s health, but now base these claims about the dan-
gers of “chemical abortion” on pseudoscience. According to Loretta Ross, “the 1980s
was when the anti-​science wing of the anti-​abortion movement got a foothold. They
had not weighed in significantly on drug and device approval until RU 486.”60 These
anti-​science perspectives would later go mainstream on the right across a wide range
of issues, especially after the rise to power of Donald Trump. Historian Carol Mason,
who studies the influence of the anti-​abortion movement on contemporary politics,
asks, “Would people have snubbed their noses at Anthony Fauci if physicians hadn’t for
decades been depicted as quacks and bottom-​feeders by anti-​abortionists? Would we be
seeing reports of medical workers sabotaging COVID-​19 vaccinations if so-​called ‘con-
science clauses’ hadn’t already been written into law? Such clauses allowed and encour-
aged pharmacists to refuse to fill prescriptions, and employers to refuse to grant health
insurance for contraception.”61
Economics also underpinned abortion politics in both eras. Nineteenth-​century
restrictions on abortion were pushed by men forming the field of medicine, who sought
to “win professional power, control medical practice, and restrict their competitors, par-
ticularly homeopaths and midwives.”62 Today’s medical system has sought to keep tight
control over abortion medications, despite strong evidence that these medications are
safe enough to be available over the counter. Historic and contemporary anti-​abortion
campaigns were both motivated by gender, racial, and class anxieties. Historian Leslie
Reagan argues:

The visible use of abortion by middle-​class married women, in conjunction with other chal-
lenges to gender norms and changes in the social makeup of the nation, generated anxi-
eties among American men of the same class. Birth rates among the Yankee classes had
declined by midcentury while immigrants poured into the country. Anti-​abortion activists
pointed out that immigrant families, many of them Catholic, were larger and would soon
out-​populate native-​born white Yankees and threaten their political power.63

Dr. Horatio R. Storer, who led the campaign against abortion, asked whether the
country “shall be filled by our own children or by those of aliens? This is a question
our women must answer; upon their loins depends the future destiny of the nation.”64
Reagan argues, “hostility to immigrants, Catholics, and people of color fueled this
 Conclusion: Putting Pills in the Hands of Those Who Need Them • 233

campaign to criminalize abortion. White male patriotism demanded that maternity

be enforced among white Protestant women.”65 Similar hostilities have fueled the
contemporary anti-​abortion movement. With Catholics now firmly aligned with the
white majority, contemporary abortion opponents direct their ire toward current-​day
immigrants, Jews, and people of color, as documented in the scholarship of Carol
Mason, which reveals the deep ties between the anti-​abortion and white supremacy
movements.66 “If we continue to abort our babies and import a replacement for them
in the form of young violent men, we are supplanting our culture, our civilization,”
said Rep. Steve King (R-​IA) in 2018, an eerie echo of Horatio Storer.67
In her book on the history of abortion and the law, legal scholar Mary Ziegler argues
that advocates on both side of the abortion issue have increasingly disagreed about the
basic facts of abortion.68 This argument certainly applies to abortion pills. As abortion
access dwindled over the first two decades of the twenty-​first century, and abortion
pills became an increasingly important avenue for American women to end their preg-
nancies both inside and outside of the formal medical system, the anti-​abortion move-
ment increasingly claimed “chemical abortions” were dangerous to pregnant women
and advocated the made-​up “abortion pill reversal” claim. Meanwhile, abortion sup-
porters produced peer-​reviewed medical research supporting the safety and efficacy
of these medications, including by telemedicine and in self-​managed contexts. Battles
over science and facts fundamentally shaped public discussions of abortion pills in the
United States from the 1980s to today.
In her book Pregnancy and Power, reproductive politics scholar Rickie Solinger
explains how since 1970, “many public officials and others have used legislatures,
courts, and media to define, advocate, and legislate a complex array of public pow-
ers over women’s reproductive capacity.”69 She argues that rarely have debates about
reproductive politics focused on women but rather focus on how to solve social prob-
lems facing the country. For example, governments have proposed scheme after scheme
limiting Black women’s reproduction to solve poverty, excessive welfare expenditures,
teen pregnancy, unwed motherhood, and more. She notes women’s reproductive capac-
ity was often considered a national resource, such as providing soldiers or laborers,
and women were pressed to reproduce or not in ways that were consistent with a par-
ticular version of the country’s needs. But women have always resisted. She argues
that women engaged in “reproductive misbehavior”: “throughout history women have
resisted systems of reproductive constraint…through everyday practice.” High rates of
illegal abortion shaped reproductive politics in the United States leading up to Roe,
and made legalization an inevitability. She argues single motherhood, for example, has
been an “everyday practice” resistive to patriarchal ideology requiring childbirth only
in marriage and redefining legitimate motherhood. When women resist reproductive
constraints, they violate traditional gender roles. “Today, policies denying individu-
als reproductive autonomy and health services spring from religious fervor and from
234 • Abortion Pills

old nativist, often racist, and class-​based politics that roots its power in revitalizing
the vulnerability (or powerlessness) of traditional targets.”70 Solinger wrote these words
in 2005. Almost twenty years later, this statement is truer than ever. And women’s
resistance is as well. Self-​managed abortion with pills is today’s “everyday practice” of
“reproductive misbehavior.”
The anti-​abortion movement has been successful in making abortion pills seem
dangerous. Many people thought the FDA was protecting women by enforcing restric-
tions on access to mifepristone, but the agency in fact limited access to a safe medica-
tion that would have eliminated the need for women to have to travel long distances
for abortion care and cross judgmental and often dangerous protestors outside of clin-
ics. But the restrictions often served the interests of those to whom the FDA gave the
right to control the medication: abortion providers and the drug manufacturer Danco.
According to Coeytaux, Danco, Planned Parenthood, and NAF, providers were “happy
that they were the only ones who had access to mifepristone.”71
After the passage of S.B. 8, abortion providers in Texas refused to share information
about ways to obtain abortion pills by mail with their patients, instead insisting upon
physically transporting patients to their clinics out of state to obtain abortion pills.
They feared they might be sued for “aiding and abetting” abortion in violation of S.B. 8
and held liable for huge sums of money. Lawyers advised abortion providers not to talk
about Aid Access or other ways people might get abortion pills, said Coeytaux. “We’ve
got a triumvirate of lawyers, doctors, and organizations who are going to follow the law
no matter how unjust,” said Coeytaux. “If you make clear that that’s what you’re going
to do, they pass more and more egregious laws. That they probably wouldn’t stand
doesn’t matter.”72 Plan C members shared information about Aid Access with people in
Texas and urged others there to do so, but they received hostile reactions from abortion
providers in Texas. When the Atlantic magazine published an article, “The Abortion
Backup Plan No One is Talking About,” quoting Coeytaux, a Texas abortion provider
tweeted, “I don’t need a Plan C. I’d rather dismantle white supremacy,” instigating a
flood of vicious tweets directed at Coeytaux.73
After Dobbs, many abortion providers continued to insist on transporting people
hundreds of miles to far-​away states to get abortion pills, sometimes pushing patients
past twelve weeks so medication abortion was no longer an option, despite the easy
availability of abortion pills through the mail and supportive services like the M+​A
Hotline. “It’s been so difficult to get people to really embrace medication abortion,” said
Coeytaux. “There was never any evidence that mifepristone wasn’t safe and effective,
but it doesn’t matter. They were just really, really worried about medication abortion,
and not wanting to move it forward. There was a lot of fear, but the REMS are not
evidence-​based restrictions. It’s still so political.”74 Coeytaux concluded, “It wasn’t ever
really about giving women power. It was about which doctors were going to be allowed
to do what and defending the doctors.”75
 Conclusion: Putting Pills in the Hands of Those Who Need Them • 235

The anti-​abortion movement created a climate of danger that fundamentally shaped

the behavior of policymakers, medical providers, insurance companies, and even many
activists, making them overly cautious and resistant to expanded access. They stayed
within the bounds of the law, even if those laws were clearly unconstitutional like S.B.
8, and they conformed to the most conservative interpretation of laws out of fear they
might be charged with violating them. Yale historian Timothy Snyder, a scholar of
authoritarianism, explains, “most of the power of authoritarianism is freely given. In
times like these, individuals think ahead about what a more repressive government will
want, and then offer themselves without being asked. A citizen who adapts in this way
is teaching power what it can do.”76
The dream of early advocates has not been achieved. They envisioned a combined
product of mifepristone and misoprostol, easily and affordably accessible on pharmacy
shelves for a few dollars. Abortion pills are a long way from over the counter, or even
behind the counter. They’ve only just arrived at pharmacies—​or at least certified phar-
macies in states without abortion bans. We do not yet have a combined product, as
exists in many countries around the world. In the United States, clinicians still have to
give patients two prescriptions—​one for mifepristone and one for misoprostol. And
while telemedicine is making the medications available for around $150, most medical
providers still charge on average $550 for medication abortion services in clinic. We
still have a long way to go.
No matter what happens in the future, abortion pills are fundamentally changing
the abortion landscape in the United States post-​Roe. Abortion pills offer a safe, afford-
able way to end a pregnancy outside of the formal medical system and beyond the law.
COVID began the process of dislodging abortion pills from rigid medical systems that
kept them highly restricted. The overturn of Roe v. Wade removed abortion pills from
the medical system in many states and spurred the development of informal networks
of pill distribution and support for using them. Rather than moving patients to pro-
viders, advocates worked to move pills to people. As a result, more and more people
became aware of abortion pills and realized they were safe and easy to use. The future
of abortion pills in the medical system is uncertain, but one thing is sure: abortion pills
are not going away.
How is it that a medication that is so safe and effective for abortion and has many
other potential uses could be so heavily restricted for so long? Politics, bureaucracy,
vested interests, profits, white supremacy, and misogyny all played a role in keeping
this medication so inaccessible for so long. Betrayals abounded, including the FDA’s
vise grip on mifepristone years after it had been shown to be safer than many over-​the-​
counter medications, the profit motives behind the pharmaceutical industry’s refusal
to take on RU 486 in the 1980s, doctors’ cautious practices that required unnecessary
tests and burdensome procedures for patients to obtain the medication, and the fears of
people within the reproductive health movement who slow-​walked expanding access
236 • Abortion Pills

to mifepristone. After the FDA approved mifepristone, the failure to push for lifting all
the restrictions placed on the medication or to push for increased access from a wider
range of providers despite the restrictions was a betrayal of the women needing this
medication for abortion and other medical conditions.
But the movement also had many successes, including the relentless work by
FMF, RHTP, ARM, and the Population Council to get mifepristone to market in the
United States, the determined campaign to lessen the FDA restrictions on mifepris-
tone led by Gynuity Health Projects, ANSIRH, and the EMAA Project, the small
number of bold, creative healthcare providers who pioneered telemedicine abortion,
the organizations and community support networks that supported self-​managed
abortion, especially after Dobbs, and the smart, determined women, such as Kelly,
who spoke out about the need for increased access to medication abortion. These
people were able to de-​medicalize abortion and put abortion pills directly in wom-
en’s hands.77
Diana Lugo-​Martinez, co-​director of the reproductive justice organization Forward
Together, argues that community care is part of a long and important tradition in the
United States:

People in the United States have lost connection to the traditional elements of community
care. Folks had these traditions in their communities for a long time, in the Puritan commu-
nities to the enslaved communities. But with the privatization and professionalization of the
health care, we’ve lost access to the possibilities of community care and community wellness
and that’s led us to a very dangerous place where our survival, our well-​being, is tied to the
State and the government in a way that is often fatal to so many of our community members.
We are so dependent on the State and the government for everything, including access to
health care. That makes it easier to tear away access from those who need it most. We have
to have other systems of care, not just for abortion access, but also just in general. It’s in the
tradition of the Black Panthers and The Young Lords and the work that they did to establish
community clinics.78

After Dobbs, as many states banned abortion and medical systems were no longer
willing or able to help people access abortion health care, advocates created their own
systems of community care. Despite anti-​abortion threats, women’s resilient spirit
remained undaunted. “They thought they were going to break us, but they’ve done
nothing but make us stronger,” said Michelle Cohen of SHERo. “They made us develop
new relationships, mentor and train the next generation of the movement. History has
shown that women have helped women for eons with childbirth, with abortion, with
family care. That’s not going to stop now.”79
At a time when many nations have decriminalized abortion, including Mexico,
Argentina, Thailand, and Ireland, the United States is going in the opposite direction, but
 Conclusion: Putting Pills in the Hands of Those Who Need Them • 237

advocates are learning from women in those countries. In Ireland, the unenforceability
of a longstanding abortion ban—​the Eighth Amendment of the Irish Constitution—​
was a factor that contributed to the legalization of abortion in that country in 2018.
“Pills had made restrictions obsolete and unenforceable, undermining the totality of
the 8th Amendment legal regime,” argued British scholar of abortion politics Sydney
Calkin.80 In the United States, abortion pills may in the future play a role in once again
decriminalizing abortion. But in the meantime, they provide a critical avenue to abor-
tion for tens of thousands of people, while simultaneously revolutionizing abortion in
the United States by making it more accessible, affordable, and private than ever before.
The new pathways to abortion pills spurred by COVID-​19 and Dobbs finally freed
mifepristone from the vise grip of medically unnecessary FDA restrictions on mife-
pristone as well as the overmedicalization of medication abortion that together have for
decades made abortion medications hard to access and expensive. COVID-​19, Dobbs,
a bit of ingenuity and a lot of determination by reproductive health advocates ripped
away decades of political red tape and finally placed abortion pills directly in the hands
of the people who need them.
By August 2024, interstate telemedicine abortion and robust alternative supply net-
works for abortion pills meant that people living in states banning abortion had many
more options than Kelly did in spring of 2022. Rather than having to use mail for-
warding, they could order pills directly from five different telemedicine abortion clinics
located in states where abortion was legal, and get abortion pills in just a few days. They
could also get free pills from community networks or order them online for under $50.
If they weren’t sure what to do, Charley the Chatbot could walk them through their
options. After they obtained their medications, they could call on the M+​A Hotline or
Aya Contigo for confidential advice from medical professionals or obtain emotional
support from the Reprocare Healthline. If they had any legal questions, they could call
the Repro Legal Helpline for free legal advice. Surprisingly, states did not criminalize
self-​managed abortion in the first two years after Dobbs, and no one using pills in early
pregnancy had been arrested or prosecuted as of August of 2024. The future was uncer-
tain, but advocates had made safe abortion much more widely available than before
Roe—​and in some respects even during Roe.
 Appendix A: Abortion Pill Timeline

1980 Roussel Uclaf patents mifepristone.

1988 The French government approves use of mifepristone for abortion.
1994 Roussel Uclaf donates its US patent rights for mifepristone to the Population Council, which
begins clinical trials.
1996 On July 19, 1996, the FDA Advisory Committee on Reproductive Health Drugs recom-
mends the FDA approve mifepristone and misoprostol for abortions up to seven weeks
gestation, but recommends close medical supervision of mifepristone administration.
On September 18, 1996, the FDA issues an “approvable letter” for mifepristone for early
abortion, but notes that additional information is needed on the manufacturing process and
labeling before a final decision will be made.
1999 The FDA authorizes the Feminist Majority Foundation to administer the “compassionate
use program” for use of mifepristone to treat meningioma and other cancers.
2000 The FDA approves mifepristone for abortion under the brand name Mifeprex made by
Danco Laboratories. The FDA recommends a dosage of 600 milligrams of mifepristone and
400 micrograms of misoprostol for use during the first forty-​nine days of pregnancy, but
allows only certified physicians to dispense the medications directly to patients. The FDA
does not allow pharmacies to dispense mifepristone.
2004 South Carolina authorities arrest a twenty-​two-​year-​old undocumented migrant farm
worker, Gabriella Flores, for taking misoprostol to end a sixteen-​week pregnancy. Her sister
in Mexico sent her the pills.
2005 The FDA issues a public health warning about mifepristone/​misoprostol-​induced abortion
and its association with clostridium sordellii-​related deaths.
2007 Authorities in Massachusetts arrest a teenaged immigrant woman, Amber Abreu, for using
misoprostol she had obtained from her sister in the Dominican Republic. Abreu is indicted
for procuring a miscarriage.
2010 Ohio passes a law requiring medical providers to follow the FDA dosing recommendations,
despite research showing a lower dosage of mifepristone is safer and has fewer side effects.
2011 FDA places mifepristone in the Risk Evaluation and Mitigation Strategy (REMS) drug safety
program, continuing the previous restrictions.
2012 FDA approves mifepristone for treatment of Cushing syndrome under the brand name
Korlym made by Corcept Therapeutics. Korlym is not placed within a REMS, even though
the dosage is much higher than the dosage approved to end a pregnancy.
240 • Appendix A: Abortion Pill Timeline

2016 The FDA modifies the Mifeprex label, recommending 200 milligrams of mifepristone and
800 micrograms of misoprostol for use through ten weeks of gestation. The FDA modifies
the REMS to allow any certified medical provider to prescribe mifepristone and approves
the TelAbortion research project.
2019 The FDA approves a generic form of mifepristone, produced by GenBioPro.
2020 Because of COVID-​19 concerns, a Maryland federal court partially enjoins the REMS,
allowing providers to mail abortion pills to patients. The online pharmacy Honeybee Health
begins dispensing mifepristone and is later joined by the American Mail Order Pharmacy.
2021 In January the Supreme Court reverses the Maryland injunction and reinstates the REMS.
In April, the FDA removes the in-​person dispensing requirement for the duration of the
COVID-​19 pandemic. In May, President Joseph Biden orders the FDA to review the REMS.
In December the FDA modifies the REMS, permanently removing the in-​person distribu-
tion requirement and allowing healthcare providers to mail abortion pills. The FDA also
announces they will allow certified pharmacies to dispense mifepristone.
2022 On June 24, 2022, the Supreme Court rules in Dobbs v. Jackson Women’s Health Organization
that there is no constitutional right to abortion, overturning the forty-​nine-​year-​old
precedent of Roe v. Wade. In July, Massachusetts passes a provider shield law protecting
telemedicine abortion providers serving patients located in any state.
In November 2022, a community support network Red State Access forms with the mission of
facilitating the provision of free abortion pills to people in states banning abortion. In the first
nine months, Red State Access affiliates mail abortion pills to over fifteen thousand people.
2023 In January, the FDA announces the certification process for pharmacies.
On April 7, a federal district court judge in Texas issues a nationwide stay on the FDA
approval of mifepristone, ruling the agency improperly approved mifepristone in 2000.
On April 13, the Fifth Circuit reverses in part, but orders the pre-​2016 restrictions back in
place.
On April 21, the Supreme Court issues a stay until final resolution of the case.
In 2023, five more states pass telemedicine abortion provider shield laws: Washington,
Colorado, Vermont, New York, and California. In June, Aid Access begins providing
telemedicine abortion services from shield states to patients in all fifty states. Abuzz Health
forms with plans to eventually offer similar services in all fifty states, operating from
shield states. In October 2023, Cambridge Reproductive Health Consultants forms The
Massachusetts Medication Abortion Access Project (The MAP), offering telemedicine abor-
tion to patients in all fifty states.
2024 In June 2024, the Supreme Court dismissed in FDA v. Alliance for Hippocratic Medicine. Two
more states pass telemedicine abortion provider shield laws: Maine and Rhode Island. In
June, Armadillo Clinic forms and begins offering telemedicine abortion to people living in
six states with abortion bans, operating from shield states.
In August, a fifth shield state provider, We Take Care of Us, begins serving people in all 50
states.
 Appendix B: Glossary

Abortion pills: Medications that cause abortion, including mifepristone, misoprostol, and methotrexate.
Antiprogesterone (antiprogestin): A class of drug that prevents absorption of the hormone progesterone,
blocking its biological effects. Also known as progesterone antagonists or progesterone blockers.
Emergency contraception: Methods of contraception that can prevent pregnancy after sexual intercourse.
Brand names emergency contraceptives include Plan B (over the counter) and Ella (by prescription),
which function by preventing fertilization of an ovum. Also known as “morning after pills,” emergency
contraception can be effective up to 120 hours (five days) after having unprotected sex. Emergency
contraceptives do not affect established pregnancies.
Geofencing: A virtual boundary that triggers an ad on a mobile device when a user enters or exits that
boundary.
Harm reduction: Strategies to lessen the negative consequences associated with criminalized behaviors,
such as needle and syringe programs for drug users or condoms for sex workers.
Korlym: A form of mifepristone approved by the FDA for treatment of Cushing disease. Corcept
Therapeutics distributes the medication in 300-​milligram tablets.
Medication abortion or medical abortion: An abortion caused by medications. The “gold standard” for
medication abortion in the United States is use of a combination of mifepristone and misoprostol, but
misoprostol alone is also very effective.
Methotrexate: An FDA-​approved cancer medication that is used off label in conjunction with misoprostol
for treatment of ectopic pregnancies (a dangerous condition of a fertilized egg growing outside the
uterus). Methotrexate stops fetal cells from growing by blocking the folic acid needed to maintain an
early pregnancy.
Mifeprex: The brand-​name mifepristone manufactured by Danco Laboratories.
Mifepristone: An antiprogesterone that blocks the hormone progesterone that sustains a pregnancy. The
FDA has approved mifepristone for use in early abortion as well as for treatment of Cushing syndrome.
The FDA also allows use of mifepristone for meningioma (non-​cancerous tumors near the brain) in
limited circumstances (under their “compassionate use” program). Research has shown mifepristone
is effective for treating fibroids, endometriosis, breast cancer, and depression, and can be used as an
emergency or monthly contraceptive.
Misoprostol: A synthetic prostaglandin approved by the FDA and developed by Searle for the treatment
of ulcers in 1988. Used in conjunction with mifepristone, misoprostol causes uterine contractions to
expel pregnancy tissue. Misoprostol is also used off label for miscarriage management and to assist
labor during childbirth. Misoprostol alone is safe and effective to cause an abortion and is used widely
around the world for that purpose.
Plan B: A brand-​name emergency contraceptive.
Procedural abortion (surgical abortion): An abortion done by suction or manual removal of pregnancy
tissue from the uterus.
Progesterone: A hormone that prepares the lining of the uterus (called the endometrium) for a fertilized
egg to implant and grow. If an egg is fertilized, progesterone increases to support a pregnancy. If there
is no fertilized egg present, the endometrium lining sheds as a menstrual period.
242 • Appendix B: Glossary

Prostaglandins: A hormone-​like substance that affects several bodily functions, including inflammation,
pain, and uterine contractions. Healthcare providers use synthetic forms of prostaglandins to treat
several conditions. They also use medications to block the effects of prostaglandins. Prostaglandins
used with mifepristone for abortion have included injections of sulprostone and a vaginal suppository
of gemeprost in the 1980s, and now misoprostol, which can be taken orally, buccally (in the cheek
pouch), or vaginally.
REMS: The Risk Evaluation and Management Strategy program that allows the FDA to restrict and closely
monitor medications considered to have serious safety concerns in order to help ensure the benefits of
the medication outweigh its risks.
Self-​managed abortion: When a person obtains and uses abortion pills outside of the formal medical sys-
tem. Researchers have identified a spectrum of self-​managed abortion, from a person obtaining and
using abortion pills wholly independently of the formal medical system, to partial self-​management,
such as taking medications at home instead of inside of a clinic, but still under the supervision of a
medical professional.1
Telemedicine abortion: When a clinician screens a patient by videoconferences, telephone, or online form,
then prescribes abortion pills to be mailed to the patient.
 Appendix C: Interviews

The people interviewed for this book are listed below, identified by their affiliation at the time of their
work on abortion pills.

Anonymous, GenBioPro
Anonymous, Red State Access
Phoebe Abramowitz, Reprocare
Billy Adam (Alias), Private Emma
Cindy Adam, Choix
Julie Amaon, Just the Pill
Abigail R.A. Aiken, University of Texas at Austin
Amy Allina, National Women’s Health Project and Generative Learning Community
Sarah Baruch, Reproductive Health Technologies Project
Marie Bass, Reproductive Health Technologies Project
Antonia Biggs, ANSIRH
Maggie Carpenter, Aid Access, Abortion Coalition for Telemedicine Access
Alison Case, Whole Woman’s Health
Sarah Christopherson, National Women’s Health Network
Francine Coeytaux, Plan C
David Cohen, Drexel Kline School of Law
Michelle Colon, SHERo (Sisters Helping Every Woman Rise and Organize) Mississippi
Peggy Cooke, Reproaction
Leah Coplon, Maine Family Planning
Mitchell D. Creinin, University of California Davis Medical Center
Teresa DePiñeres, Period Pills
Farah Diaz-​Tello, If/​When/​How: Lawyering for Reproductive Justice
Greer Donley, University of Pittsburgh School of Law
Lauren Dubey, Choix
Emme Edmunds, Researcher
Steven Eisinger, University of Rochester Medical Center
Catherine Euvrard, Roussel Uclaf
Kevin Fiscella, University of Rochester
Jessica Sarah Flaum, Filmmaker
Marlene Gerber Fried, Hampshire College
244 • Appendix C: Interviews

duVergne Gaines, Feminist Majority Foundation

Sylvia Ghazarian, Women’s Reproductive Rights Assistance Fund
Roopan Gill, Vitala Global Foundation
Emily Godfrey, University of Washington Medical School
Michele Gomez, Family Care Associates and MYA Network
Rebecca Gomperts, Aid Access
Melissa Grant, carafem
Daniel Grossman, ANSIRH, University of California, San Francisco
Nina Henry, Online Abortion Resource Squad (OARS)
Lara Islinger, Visiting Student Researcher, University of California, Berkeley
Jennifer Jackman, Feminist Majority Foundation
Jodi Jacobson, Healthcare Across Borders
Dana Johnson, Ibis Reproductive Health
Dr. Beth Jordan, Medical Director, Compassionate Use Program, Feminist Majority Foundation
Julia Kaye, ACLU Reproductive Freedom Project
Julie F. Kay, Abortion Coalition for Telemedicine
Hanna Kim, Hey Jane
Diana Lugo-​Martinez, National Latina Institute for Reproductive Justice and Forward Together
April Lockley, M+​A Hotline
Abby Long, Director of Public Affairs and Marketing, Danco Laboratories
Morgan Love, Reprocare
Kara Mailman, Reproaction
Luz Alvarez Martinez, National Latina Health Organization
Erin Matson, Reproaction; Abortion On Our Own Terms
Jenifer McKenna, The Alliance: State Advocates for Women’s Rights and Gender Equality
Amy Merrill, Plan C
Pamela Merritt, Reproaction; Medical Students for Choice
Ariella Messing, Online Abortion Resource Squad (OARS)
Kirsten Moore, EMAA (Expanding Medication Abortion Access) Project
Judith Norsigian, Our Bodies, Ourselves
Deborah Oyer, Cedar River Clinics
Lynn Paltrow, National Advocates for Pregnant Women
Cynthia Pearson, National Women’s Health Network
Jamila Perritt, Physicians for Reproductive Health
Skye Perryman, Democracy Forward
Jamie Phifer, Abortion on Demand
Christie Pitney, Forward Midwifery
Linda Prine, Reproductive Health Access Project, Aid Access, Abortion Coalition for Telemedicine Access
Razel Ramen, Pills by Post
Rachel Rebouché, Temple University School of Law
Paula Rita Rivera, Telefem
Loretta Ross, SisterSong: Women of Color Reproductive Justice Collective
Tara Shochet, TelAbortion Project, Gynuity Health
 Appendix C: Interviews • 245

Eleanor Smeal, Feminist Majority Foundation

Tracy Droz Tragos, Filmmaker
Robin Tucker, Metro Advanced Practice Healthcare
Ushma Upadhyay, ANSIRH
Steven Vladeck, University of Texas School of Law
Aisha Wagner, Choix
Rebecca Wang, If/​When/​How: Lawyering for Reproductive Justice
Tracy Weitz, Director for the Susan Thompson Buffett Foundation and co-​founder and Director of the
Advancing New Standards in Reproductive Health
Elisa Wells, Plan C
Carolyn Westhoff, Columbia University Irving Medical Center
Beverly Winikoff, Population Council and Gynuity Health Projects
Susan Yanow, SASS (Self-​Managed Abortion, Safe and Supported)
Miriam Yeung, National Asian Pacific American Women’s Forum
 Acknowledgments

This book grew out of my public writing on abortion pills over the last six years, primarily for Ms. maga-
zine. In that reporting, I came to know many of the people featured in this book—​activists, researchers,
medical providers, people seeking abortion pills, and more. I am grateful to all the people who shared
their memories, their perspectives, and their personal records, especially Francine Coeytaux and Elisa
Wells of Plan C. I am also grateful to Kathy Spillar, Roxy Szal, and Carmen Rios at Ms. magazine, who
encouraged me to do this work.
Thanks to the many people who read drafts of the manuscript and provided me with feedback, includ-
ing Marilyn Schuster, Elisa Wells, Francine Coeytaux, Laura Briggs, Lara Islinger, Susan Faludi, Andrea
Zarafshon Moore, Emily Wojcik, Sarah Evans, Emmaline Kenney, Tallulah Costa, Lauren Thompsen,
Anya Rozario, and two anonymous readers.
I’d especially like to thank Beth Bouloukos at Amherst College Press, who inspired me to write this
book and encouraged me along the way. I am also grateful to Hannah Brooks-​Motl at Amherst College
Press for her helpful guidance.
My thanks and love to my family and friends who have supported me throughout the process of
researching and writing this book.
The book is dedicated to the many abortion pill advocates who fought tirelessly for decades to increase
access to these important medications.
 Endnotes

Introduction
1 Kelly, interview by Carrie N. Baker, March 26, 2022 (full name and identifying details are with-
held for safety reasons). An edited version of the interview is published at Carrie N. Baker, “Kelly’s
Story: Overcoming S.B. 8 and a ‘Crisis Pregnancy Center’ to Have an Abortion in Texas,” Ms. Magazine,
April 4, 2022, https://​msm​agaz​ine.com/​2022/​04/​04/​texas-​s-​b-​8-​cri​sis-​pregna​ncy-​cen​ter-​med​icat​ion-​
abort​ion-​pills/​.
2 Plan C (@plancpills), “Mifepristone Is Still Available,” Instagram, April 20, 2023, https://​www.instag​
ram.com/​p/​CrO4​8_​OI​q70/​.
3 Angela Hume, Deep Care: The Radical Activists Who Provided Abortions, Defied the Law, and Fought
to Keep Clinics Open (Chico, CA: AK Press, 2023); Mary Ziegler, Abortion in America: A Legal History
from Roe to the Present (New York: Cambridge University Press, 2020); Rickie Solinger, Pregnancy and
Power: A History of Reproductive Politics in the United States, rev. ed. (New York: New York University
Press, 2019); Leslie J. Reagan, When Abortion Was a Crime: Women, Medicine, and Law in the United States,
1867–​1973 (Berkeley: University of California Press, 1997); Laura Kaplan, The Story of Jane: The Legendary
Underground Feminist Abortion Service, 1st ed. (New York: Pantheon Books, 1995).
4 Naomi Braine, Abortion beyond the Law: Building a Global Feminist Movement for Self-​Managed
Abortion (New York: Verso Books, 2023); Sydney Calkin, Abortion Pills Go Global: Reproductive Freedom
across Borders (Oakland: University of California Press, 2023).
5 Appendix B is a glossary of terms.
6 “Food and Drug Administration: Information on Mifeprex Labeling Changes and Ongoing
Monitoring Efforts” (Washington, DC: US Government Accountability Office, March 2018), https://​www.
gao.gov/​ass​ets/​gao-​18-​292.pdf.
7 World Health Organization, “Abortion Care Guidance” (Geneva, Switzerland: World Health
Organization, 2022), https://​www.who.int/​publi​cati​ons/​i/​item/​978924​0039​483.
8 Jessica L. Morris et al., “FIGO’s Updated Recommendations for Misoprostol Used Alone in
Gynecology and Obstetrics,” International Journal of Gynecology & Obstetrics 138, no. 3 (2017): 363–​66,
https://​doi.org/​10.1002/​ijgo.12181.
9 World Health Organization, “Abortion Care Guidance.”
10 Abigail R.A. Aiken et al., “Effectiveness, Safety and Acceptability of No‐Test Medical Abortion
(Termination of Pregnancy) Provided via Telemedicine: A National Cohort Study,” BJOG: An International
Journal of Obstetrics & Gynaecology 128, no. 9 (August 2021): 1464–​ 74, https://​
doi.org/​10.1111/​
1471-​0528.16668.
11 Ushma D. Upadhyay et al., “Incidence of Emergency Department Visits and Complications after
Abortion,” Obstetrics & Gynecology 125, no. 1 (January 2015): 175–​83, https://​doi.org/​10.1097/​AOG.00000​
0000​0000​603.
12 Dana M. Johnson et al., “Safety and Effectiveness of Self‐Managed Abortion Using Misoprostol
Alone Acquired from an Online Telemedicine Service in the United States,” Perspectives on Sexual and
Reproductive Health 55, no. 1 (March 2023): 4–​11, https://​doi.org/​10.1363/​psrh.12219.
250 • Endnotes

13 Rebecca Chalker and Carol Downer, A Woman’s Book of Choices: Abortion, Menstrual Extraction,
RU-​486, 1st ed. (New York: Four Walls Eight Windows, 1992).
14 Carrie N. Baker, “Abortion Pill Effective for Treating Fibroids, but Anti-​abortion Politics Stymie
Access,” Ms. Magazine, July 26, 2021, https://​msm​agaz​ine.com/​2021/​07/​26/​mifep​rist​one-​abort​ion-​pill-​
fibro​ids-​endome​trio​sis-​dep​ress​ion-​fda-​rems-​biden/​.
15 Carrie N. Baker and Carly Thomsen, “The Importance of Talking about Women in the Fight
against Abortion Bans,” Ms. Magazine, June 23, 2022, https://​msm​agaz​ine.com/​2022/​06/​23/​women-​abort​
ion-​bans-​inclus​ive-​langu​age-​pregn​ant-​peo​ple/​.
16 Linda Gordon, The Moral Property of Women: A History of Birth Control Politics in America, First
Illinois paperback edition (Urbana and Chicago: University of Illinois Press, 2007).
17 Ibis Reproductive Health, “Feminist Medication Abortion Accompaniment 101” (Cambridge,
MA, November 2021), https://​www.ibi​srep​rodu​ctiv​ehea​lth.org/​sites/​defa​ult/​files/​files/​publi​cati​ons/​Abort​
ion%20ac​comp​anim​ent%20101.pdf; Naomi Braine, Abortion beyond the Law: Building a Global Feminist
Movement for Self-​Managed Abortion (New York: Verso Books, 2023); Sydney Calkin, Abortion Pills Go
Global: Reproductive Freedom across Borders (Oakland: University of California Press, 2023).
18 Leslie J. Reagan, When Abortion Was a Crime: Women, Medicine, and Law in the United States,
1867–​1973 (Berkeley: University of California Press, 1997).
19 Susan Rinkunas, “Nebraska Mom Pleads Guilty to Giving Abortion Pills to Her Teen Daughter,”
Jezebel, July 10, 2023, https://​jeze​bel.com/​nebra​ska-​mom-​ple​ads-​gui​lty-​to-​giv​ing-​abort​ion-​pills-​to-​185​
0621​217.
20 “#WeCount Report April 2022 to June 2023” (The Society of Family Planning, October 24, 2023),
https://​doi.org/​10.46621/​21856​9qkg​mbl.
21 Loretta J. Ross and Rickie Solinger, Reproductive Justice: An Introduction (Oakland: University of
California Press, 2017).
22 See Appendix A for a timeline of major events.
23 Carrie N. Baker, “No-​Test Medication Abortion Increases Safety and Access during COVID-​19,”
Ms. Magazine, May 13, 2020, https://​msm​agaz​ine.com/​2020/​05/​13/​no-​test-​med​icat​ion-​abort​ion-​increa​
ses-​saf​ety-​and-​acc​ess-​dur​ing-​covid-​19/​.
24 International family planning programs had for years promoted medication abortion in global
South countries with high maternal mortality rates due to unsafe, often illegal abortion. Rebecca
F. Baggaley, Joanna Burgin, and Oona M.R. Campbell, “The Potential of Medical Abortion to Reduce
Maternal Mortality in Africa: What Benefits for Tanzania and Ethiopia?,” PLOS ONE 5, no. 10 (October 11,
2010): e13260, https://​doi.org/​10.1371/​jour​nal.pone.0013​260.
25 Carrie N. Baker, “ ‘Plan C’ Film Documents Campaign for Universal Abortion Pill Access in the
U.S.,” Ms. Magazine, February 1, 2023, https://​msm​agaz​ine.com/​2023/​02/​01/​plan-​c-​abort​ion-​pills-​movie-​
film-​sunda​nce/​.

Chapter 1
1 Étienne-​Émile Baulieu and Mort Rosenblum, The “Abortion Pill”: RU-​486, a Woman’s Choice
(New York: Simon & Schuster, 1991), 129.
2 Steven Greenhouse, “A New Pill, a Fierce Battle,” New York Times Magazine, February 12, 1989, 23.
3 Baulieu and Rosenblum, The “Abortion Pill,” 17.
4 Lauren Collins, “The Complicated Life of the Abortion Pill,” New Yorker, July 5, 2022, https://​www.
newyor​ker.com/​scie​nce/​ann​als-​of-​medic​ine/​emile-​baul​ieu-​the-​comp​lica​ted-​life-​of-​the-​abort​ion-​pill.
5 Baulieu and Rosenblum, The “Abortion Pill,” 18.
6 Étienne-​Émile Baulieu, “Steroid Receptors and Hormone Receptivity,” Journal of the American
Medical Association 125, no. 2 (August 15, 1976): 1049. Other researchers at Roussel Uclaf included Alain
Belanger, Beatrice Couzinet, and Gilber Schaison.
 Endnotes • 251

7 Lawrence Lader, A Private Matter: RU 486 and the Abortion Crisis (New York: Prometheus Books,
1995), 121.
8 Lader, 120.
9 Clinicians at first used the synthetic prostaglandin sulprostone administered intramuscularly by
injection, but after several serious reactions they switched to the vaginal suppository gemeprost, which
worked but was relatively expensive and required refrigeration. Misoprostol eventually became the pre-
ferred prostaglandin because it was stable at room temperature, active orally, buccally (in the cheek pouch),
and vaginally, and is available in an inexpensive generic. Eric A. Schaff, “Mifepristone: Ten Years Later,”
Contraception 81, no. 1 (January 2010): 1–​7, https://​doi.org/​10.1016/​j.contra​cept​ion.2009.08.004.
10 Marc Bygdeman, “Progesterone Receptor Blockage,” Contraception 32, no. 1 (July 1985): 45.
11 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project”
(Washington, DC: Reproductive Health Technologies Project, 1992), 23.
12 Department of Health and Human Services, Public Health Service, Food and Drug Administration,
Center for Drug Evaluation and Research, “Application Number 20–​687: Statistical Reviews,” February
14, 2000.
13 R. Alta Charo, “A Political History of RU486,” in Biomedical Politics (Washington, DC: National
Academy Press, 1991), 43–​93.
14 Charo, 43–​93.
15 Charo, 43–​93.
16 Greenhouse, “A New Pill, A Fierce Battle.”
17 Charo, “A Political History of RU486,” 57.
18 Greenhouse, “A New Pill, a Fierce Battle.”
19 Greenhouse.
20 Schaff, “Mifepristone,” 2. In 1998, the ministry of health allowed gynecologists and general practi-
tioners to administer medication abortion in private medical offices.
21 “The Case for Antiprogestins,” 23.
22 W. Brennan, “Chemical Warfare on the Unwanted: The I.G. Farben-​Hoechst Connection,” National
Right to Life News, January 8, 1991.
23 “Upjohn Drops Research on Drug Criticized by Anti-​abortion Groups,” AP News, October 29,
1986, sec. Archive, https://​apn​ews.com/​arti​cle/​72cba​fa2c​dbdd​abda​2a4a​3163​607b​548; Michael Klitsch, RU
486: The Science and the Politics (New York: The Alan Guttmacher Institute, 1989), 16.
24 Rebecca Chalker and Carol Downer, A Woman’s Book of Choices: Abortion, Menstrual Extraction,
RU-​486, 1st ed. (New York: Four Walls Eight Windows, 1992), 216.
25 Charo, “A Political History of RU486,” 61–​62.
26 Greenhouse, “A New Pill, a Fierce Battle.”
27 Charo, “A Political History of RU486,” 60–​61.
28 Pamela Belluck, “The Father of the Abortion Pill,” New York Times Magazine, January 17, 2023,
https://​www.nyti​mes.com/​2023/​01/​17/​hea​lth/​abort​ion-​pill-​inven​tor.html.
29 Charo, “A Political History of RU486,” 61.
30 Greenhouse, “A New Pill, a Fierce Battle.”
31 This conference was sponsored by the World Health Organization and the International Federation
of Gynecology and Obstetrics.
32 “Abortion Pill Creator Calls for Action to Get It on the Market,” Reuters Library Report, October
27, 1988.
33 Greenhouse, “A New Pill, a Fierce Battle.”
34 Marie Bass, “Toward Coalition: The Reproductive Health Technologies Project,” in Abortion
Wars: A Half Century of Struggle, 1950–​2000, ed. Rickie Solinger (Los Angeles: University of California
Press, 1998), 258.
35 Charo, “A Political History of RU486,” 63–​64.
252 • Endnotes

36 Charo, 64.
37 Greenhouse, “A New Pill, a Fierce Battle.”
38 Greenhouse.
39 Rone Tempest, “France Orders Company to Distribute Abortion Pill,” Los Angeles Times, October
29, 1988. Some at the time suggested that the French government and Roussel Uclaf may have collaborated
in order to take pressure off of the company. Charo, “A Political History of RU 486,” 67. A French court later
ruled that Evin did not have the statutory authority to force Roussel Uclaf to keep RU 486 on the market.
40 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 7.
41 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 25.
42 Chalker and Downer, A Woman’s Book of Choices, 219.
43 Bass, “Toward Coalition: The Reproductive Health Technologies Project,” 261.
44 Webster v. Reproductive Health Services, 492 U.S. 490 (1989).
45 Hoechst AG, “Drug Induced Termination of Pregnancy with Mifepristone (RU 486)” (Memo pre-
pared by the Health Policy Department of the Pharmaceuticals Division, October 1991).
46 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 24.
47 Baulieu and Rosenblum, The “Abortion Pill,” 129.
48 Baulieu and Rosenblum.
49 This section draws on several primary and secondary sources, including the papers of Planned
Parenthood and Lawrence Lader at the Sophia Smith Collection, Smith College, Northampton,
Massachusetts; Jennifer Jackman, “Anatomy of a Feminist Victory: Winning the Transfer of RU 486 Patent
Rights to the United States, 1988–​1994,” Women & Politics 24, no. 3 (June 2002): 81–​99, https://​doi.org/​
10.1300/​J014v2​4n03​_​05; Charo, “A Political History of RU486”; Julie A. Hogan, “The Life of the Abortion
Pill in the United States” (Cambridge, MA: Harvard University, 2012), https://​core.ac.uk/​disp​lay/​28938​892.
50 Melissa Haussman, Reproductive Rights and the State: Getting the Birth Control, RU-​486, Morning-​
After Pills and the Gardasil Vaccine to the U.S. Market, Reproductive Rights and Policy (Santa Barbara,
CA: Praeger, 2013), 98.
51 In the 1970s, researchers tested synthetic prostaglandins as an abortifacient. While they found
them to be effective, about half the women studied experienced nausea, severe cramps, or diarrhea, so the
research ended. Klitsch, RU 486: The Science and the Politics.
52 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 13.
53 David A. Grimes et al., “Predictors of Failed Attempted Abortion with the Antiprogestin
Mifepristone (RU 486),” American Journal of Obstetrics and Gynecology 162, no. 4 (April 1990): 910–​17,
https://​doi.org/​10.1016/​0002-​9378(90)91291-​J.
54 Lawrence Lader, RU 486: The Pill That Could End the Abortion Wars and Why American Women
Don’t Have It (Reading, MA: Addison-​Wesley Pub. Co, 1991).
55 Jennifer Jackman, “Blue Smoke, Mirrors, and Mediators: The Symbolic Contest over RU 486,” in
Cultural Strategies of Agenda Denial: Avoidance, Attack, and Redefinition (Lawrence: University Press of
Kansas, 1997), 112–​38.
56 Mindy J. Lees, “I Want a New Drug: RU 486 and the Right to Choose,” Southern California Law
Review 63 (1990): 113.
57 Megan Rosenfeld, “Conception of a Controversy: The French Doctor and His Pill to Prevent
Pregnancy,” Washington Post, December 18, 1986.
58 Laura Fraser, “Pill Politics,” Mother Jones, June 1988, 33.
59 Margaret Talbot, “The Little White Bombshell,” New York Times Magazine, July 11, 1999, sec. 6.
60 Richard Glasow and John Wilkie, “Omen of the Future? The Abortion Pill RU 486” (Washington,
DC: National Right to Life Committee, 1990).
61 Jackman, “Blue Smoke, Mirrors, and Mediators: The Symbolic Contest over RU 486.”
62 Feminist Majority Foundation, “Feminist Majority Foundation Demonstrates against Operation
Rescue,” June 18, 1992.
 Endnotes • 253

63 David A. Grimes et al., “An Epidemic of Antiabortion Violence in the United States,” American
Journal of Obstetrics and Gynecology 165, no. 5 (November 1991): 1263–​68, https://​doi.org/​10.1016/​
0002-​9378(91)90346-​S.
64 “Violence to Abortion Providers,” Feminist Majority Foundation (blog), accessed August 21, 2023,
https://​femin​ist.org/​our-​work/​natio​nal-​cli​nic-​acc​ess-​proj​ect/​viol​ent-​atta​cks-​on-​abort​ion-​provid​ers-​
murd​ers-​attemp​ted-​murd​ers-​kid​napp​ing/​.
65 “Freedom of Access to Clinic Entrances Act,” 18 U.S. § 248 (1994), https://​www.law.corn​ell.edu/​
usc​ode/​text/​18/​248.
66 Carol Mason, Killing for Life: The Apocalyptic Narrative of Pro-​Life Politics (Ithaca, NY: Cornell
University Press, 2002).
67 Collins, “The Complicated Life of the Abortion Pill.”
68 Marie Bass and Joanna Howes, “A Report on RU 486 and Its Prospects for Use in the United States”
(Washington, DC: Bass and Howes, 1987), 37–​39.
69 Jean Reith Schroedel and Tanya Buhler Corbin, “Gender Relations and Institutional Conflict over
Mifepristone,” Women & Politics 24, no. 3 (June 2002): 41, https://​doi.org/​10.1300/​J014v2​4n03​_​03; “The
Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 23.
70 Feminist Majority Foundation, “A Brief Chronology in the Fight to Make RU 486 Available in the
US,” n.d., https://​femin​ist.org/​our-​work/​mifep​rist​one/​timel​ine/​.
71 US Food and Drug Administration, “Regulatory Procedures Manual Chapter 9-​ 71-​
30(C),”
February 1, 1989.
72 Haussman, Reproductive Rights and the State, 104.
73 RU 486: The Import Ban and Its Effect on Medical Research: Hearing before the Subcomm. on
Regulation, Bus. Opportunities, and Energy of the H.R. Comm. on Small Bus., 101st Cong. 31 (1990), at 4–​6,
18 (testimony of William Regelson, MD, professor of medicine, Medical College of Virginia; testimony of
George P. Chrousos, MD, senior investigator and section chief, Pediatric Endocrinology, National Institute
of Child Health and Human Development, National Institutes of Health).
74 Schroedel and Corbin, “Gender Relations and Institutional Conflict over Mifepristone,” 35–​60, 40.
75 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 24.
76 Chalker and Downer, A Woman’s Book of Choices, 217.
77 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 25.
78 Lader, RU 486, 132.
79 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 14.
80 Tempest, “France Orders Company to Distribute Abortion Pill”; “The Case for Antiprogestins: A
Report of the Reproductive Health Technologies Project,” 13.
81 Charo, “A Political History of RU486,” 55–​56; “The Case for Antiprogestins: A Report of the
Reproductive Health Technologies Project,” 15.
82 Carol Pogash, “Does the Abortion Pill Have a Future in America?,” San Francisco Examiner, April
14, 1991, 14–​15.
83 Lou Finter, “French Abortion Drug RU 486: U.S. Research Battle Heats Up,” Journal of the National
Cancer Institute, March 6, 1991, 316.
84 Terri Kapsalis, “Mastering the Female Pelvis: Race and the Tools of Reproduction,” in In Skin Deep,
Spirit Strong: The Black Female Body in American Culture (Ann Arbor: University of Michigan Press, 2002),
263–​300.
85 Laura Briggs, Reproducing Empire: Race, Sex, Science, and U.S. Imperialism in Puerto Rico
(Berkeley: University of California Press, 2002), 11.
86 Dorothy E. Roberts, Killing the Black Body: Race, Reproduction, and the Meaning of Liberty, Vintage
Books 2nd ed. (New York: Vintage Books, 2017).
87 Janice G. Raymond, Renate Klein, and Lynette J. Dumble, RU 486: Misconceptions, Myths and
Morals (Cambridge, MA: Institute on Women and Technology, 1991), 112.
254 • Endnotes

88 Carrie N. Baker, “Abortion How-​To: The Ms. Q&A on Menstrual Extraction with Carol Downer,”
Ms. magazine, July 14, 2022, https://​msm​agaz​ine.com/​2022/​07/​14/​abort​ion-​how-​to-​carol-​dow​ner-​menstr​
ual-​ext​ract​ion/​.
89 Raymond, Klein, and Dumble, RU 486: Misconceptions, Myths and Morals, 117.
90 Raymond, Klein, and Dumble, 120.
91 Raymond, Klein, and Dumble, 122.
92 Alexandra Minna Stern, Eugenic Nation: Faults and Frontiers of Better Breeding in Modern America
(Berkeley: University of California Press, 2005); Betsy Hartmann, “Everyday Eugenics,” ZNetwork,
September 22, 2006, https://​znetw​ork.org/​znet​arti​cle/​every​day-​eugen​ics-​by-​betsy-​hartm​ann/​.
93 Charo, “A Political History of RU486,” 48, 56–​57.
94 Janice G. Raymond, Renate Klein, and Lynette J. Dumble, “RU 486: No,” Ms. magazine, January
10, 1993.
95 Janet Callum and Rebecca Chalker, “RU 486: Yes,” Ms. magazine, January 10, 1993.
96 Bass and Howes, “A Report on RU 486 and Its Prospects for Use in the United States,” 58.
97 Bass and Howes, 30.
98 Bass and Howes, 41.
99 Bass and Howes, 48–​49.
100 Bass and Howes, 61.
101 Bass and Howes.
102 Bass, “Toward Coalition: The Reproductive Health Technologies Project,” 260.
103 Bass, 260.
104 Judy Norsigian, interview by Carrie N. Baker, June 29, 2023.
105 Cynthia Pearson, interview by Carrie N. Baker, July 5, 2023.
106 Bass, “Toward Coalition: The Reproductive Health Technologies Project,” 261.
107 Bass, 262.
108 Amy Allina, interview by Carrie N. Baker, May 16, 2023.
109 Linda Gordon, The Moral Property of Women: A History of Birth Control Politics in America, First
Illinois paperback edition (Urbana and Chicago: University of Illinois Press, 2007).
110 Baker, “Abortion How-​To: The Ms. Q&A on Menstrual Extraction with Carol Downer.”
111 Carol Downer, interview by Carrie N. Baker, October 19, 2023.
112 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 24.
113 Bass, “Toward Coalition: The Reproductive Health Technologies Project,” 261.
114 “Review of Programs, 1995–​1996” (Washington, DC: Reproductive Health Technologies Project,
1996), 3.
115 Rickie Solinger, ed., Abortion Wars: A Half Century of Struggle, 1950–​2000 (Berkeley: University
of California Press, 1998), 252.
116 Luz Alvarez Martinez, interview by Carrie N. Baker, June 29, 2023.
117 Reproductive Health Technologies Project [oral history] interview 4A with Amy Allina, Susan
Wood, Jessica Arons, Kimberly Inez Maguire, and Susannah Baruch. 2017. Records of Reproductive
Health Technologies Project, 1992–​2017, MC 934: T-​542: CD-​115: Vt-​288: DVD-​138, E.9. Schlesinger
Library, Radcliffe Institute.
118 After working in international reproductive health and family planning for many years, in 1993
Coeytaux founded the Pacific Institute for Women’s Health, a data-​driven advocacy organization focused
on women’s sexual and reproductive health in the United States and abroad, with a focus on applied
research, advocacy, community involvement, consultation, and training.
119 Francine Coeytaux, interview by Carrie N. Baker, April 3, 2023.
120 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project.”
121 Marie Bass, interview by Carrie N. Baker, April 3, 2023.
122 Reproductive Health Technologies Project [oral history] interview 1A, 1B, 1C, and 2A with Marie
Bass, Sharon Camp, and Joanna Howes. 2017. Records of Reproductive Health Technologies Project,
 Endnotes • 255

1992–​2017, MC 934: T-​542: CD-​115: Vt-​288: DVD-​138, E.9. Schlesinger Library, Radcliffe Institute, https://​
id.lib.harv​ard.edu/​ead/​c/​sch​0159​0c00​401/​cata​log. Accessed March 21, 2023; Marie Bass, interview by Carrie
N. Baker, April 3, 2023.
123 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 4.
124 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 6.
125 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 25.
126 Eleanor Smeal, interview with Carrie N. Baker, June 16, 2023. Smeal said Yorkin was a major
funder of the campaign and that she “always thought big” and “kept people focused.”
127 “Peg Yorkin, Feminist Leader and Philanthropist, Dies at 96,” AP News, June 26, 2023, sec. U.S.
News, https://​apn​ews.com/​arti​cle/​femin​ist-​peg-​yor​kin-​dead-​c8fc3​28b3​8039​6c34​13b2​95ac​d643​438.
128 Charo, “A Political History of RU486,” 72.
129 Eleanor Smeal, interview by Carrie N. Baker, June 16, 2023.
130 Eleanor Smeal, interview by Carrie N. Baker, June 16, 2023.
131 Eleanor Smeal, interview by Carrie N. Baker, June 16, 2023.
132 Lader, RU 486, 111.
133 Lader, 131.
134 Feminist Majority Foundation, “Feminist Majority Foundation Delegation to Roussel Uclaf, Paris
France, 1990,” Facebook, September 25, 2015, https://www.facebook.com/photo/?fbid=10154247228827571
&set=making-history-in-1990-a-feminist-majority-foundation-delegation-comprised-of-fe&locale=ar_AR.
135 Eleanor Smeal, interview by Carrie N. Baker, June 16, 2023.
136 Eleanor Smeal, interview by Carrie N. Baker, June 16, 2023.
137 Jennifer Jackman, interview by Carrie N. Baker, April 5, 2023.
138 Catherine Euvrard, interview by Carrie N. Baker, May 1, 2023.
139 Feminist Majority Foundation, “A Brief Chronology in the Fight to Make RU 486 Available in the US.”
140 Jennifer Jackman, interview by Carrie N. Baker, April 5, 2023.
141 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 25.
142 Lader, RU 486, 19.
143 Lader, 97.
144 Eleanor Smeal, interview by Carrie N. Baker, June 16, 2023.
145 Eleanor Smeal, interview by Carrie N. Baker, June 16, 2023.
146 RU 486: The Import Ban and Its Effect on Medical Research: Hearing before the Subcomm. on
Regulation, Bus. Opportunities, and Energy of the H.R. Comm. on Small Bus., 101st Cong. 31 (1990); The
Safety and Effectiveness of the Abortifacient RU486 in Foreign Markets: Opportunities and Obstacles to U.S.
Commercialization: Hearing before the Subcomm. on Regulation, Bus. Opportunities, and Energy of the H.R.
Comm. on Small Bus., 102nd Cong. 11 (1991); The Effect of Federal Ban of RU 486 on Medical Research, New
Drug Development, and Pharmaceutical Manufacturers: Hearing before the Subcomm. on Regulation, Bus.
Opportunities, and Energy of the H.R. Comm. on Small Bus., 102nd Cong. 76 (1992).
147 RU 486: The Import Ban and Its Effect on Medical Research: Hearing before the Subcomm. on
Regulation, Bus. Opportunities, and Energy of the H.R. Comm. on Small Bus., 101st Cong. 31 (1990), at 2.
148 Schroedel and Corbin, “Gender Relations and Institutional Conflict over Mifepristone,” 41.
149 The Safety and Effectiveness of the Abortifacient RU486 in Foreign Markets: Opportunities and
Obstacles to U.S. Commercialization: Hearing before the Subcomm. on Regulation, Bus. Opportunities, and
Energy of the H.R. Comm. on Small Bus., 102nd Cong. 11 (1991) (testimony of Eleanor Smeal).
150 The Effect of Federal Ban of RU 486 on Medical Research, New Drug Development, and
Pharmaceutical Manufacturers, at 2 (testimony of Ron Wyden).
151 The Effect of Federal Ban of RU 486 on Medical Research, New Drug Development, and
Pharmaceutical Manufacturers, at 12–​15 (testimony of David J. Grow).
152 H.R. 875, 102nd Cong. (1991).
153 Lader, A Private Matter.
154 Lader, 129.
256 • Endnotes

155 Benten v. Kessler, No. CV-​ 92–​

3161(CPS) (U.S. District Court for the Eastern District of
New York 1992).
156 Rachael N. Pine, “Benten v. Kessler: The RU 486 Import Case,” Law, Medicine and Health Care 20,
no. 3 (1992): 238–​42, https://​doi.org/​10.1111/​j.1748-​720X.1992.tb01​196.x.
157 Lader, A Private Matter, 139.
158 Lader, 149.
159 Lader, 146–​47.
160 Lader, 147.
161 Farah Nayeri, “An Abortion Pill May Soon Be on the Market in France,” United Press
International, March 28, 1989, https://​www.upi.com/​Archi​ves/​1987/​03/​28/​Abort​ion-​pill​NEWL​NAn-​
abort​ion-​pill-​may-​soon-​be-​on-​the-​mar​ket-​in-​Fra​nce/​475154​3906​000/​. Research has shown mifepris-
tone is effective for emergency and regular contraception, but no drug company has pursued FDA
approval for these uses.
162 Baulieu and Rosenblum, The “Abortion Pill,” 47.
163 “The Case for Antiprogestins: A Report of the Reproductive Health Technologies Project,” 21.
164 Jill Smolowe, “New, Improved and Ready for Battle,” Time, June 14, 1993.
165 Jackman, “Anatomy of a Feminist Victory,” 92.
166 Charo, “A Political History of RU486,” 43–​93.
167 Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration, No. 2:22-​cv-​00223-​Z
(U.S. District Court for the Northern District of Texas, Amarillo Division April 7, 2023).
168 Christopher M. Gacek, “Politicized Science: The Manipulated Approval of RU-​486 and Its
Dangers to Women’s Health” (Washington, DC: Family Research Council, 2007), https://​downlo​ads.frc.
org/​EF/​EF07​A29.pdf; Life Issues Institute, “FDA Panel Moves on RU 486,” September 1996, https://​lif​eiss​
ues.org/​1996/​09/​fda-​panel-​moves-​on-​ru-​486/​.
169 William Clinton, “Letter to Donna Shalala on Importation of RU 486,” January 22, 1993.
170 Ann Devroy, “Clinton Cancels Abortion Restrictions of Reagan–​Bush Era,” The Washington Post,
January 23, 1993, https://​www.was​hing​tonp​ost.com/​arch​ive/​polit​ics/​1993/​01/​23/​clin​ton-​canc​els-​abort​
ion-​restr​icti​ons-​of-​rea​gan-​bush-​era/​0e145​a5a-​0b37-​4908-​8c4d-​44643​f62b​0a0/​.
171 Cynthia Pearson of NWHN reported she heard Kessler did this because he wanted to stay on as
FDA commissioner and knew that Clinton wanted mifepristone approved. Cynthia Pearson, interview by
Carrie N. Baker, July 5, 2023.
172 Catherine Euvrard, interview by Carrie N. Baker, May 1, 2023.
173 Francine Coeytaux, interview by Carrie N. Baker, April 3, 2023.
174 Beverly Winikoff, interview by Carrie N. Baker, May 22, 2023.
175 William E. Leary, “Maker of Abortion Pill Reaches Licensing Pact with U.S. Group,” The New York
Times, April 21, 1993.
176 Feminist Majority Foundation, “A Brief Chronology in the Fight to Make RU 486 Available in
the US.”
177 Tamar Lewin, “British Offering Abortion Drug to U.S. Women,” The New York Times, February
18, 1994.
178 RU-​486, Status Report on the U.S. Commercialization Project, Transfer of Anti-​progestin Technology
to the United States, 103rd Cong. 6 (1994) at 16 (testimony of Lester Hyman, representing Roussel Uclaf).
179 Edouard Sakiz, letter to Eleanor Smeal, May 30, 1995.
180 Eleanor Smeal, interview by Carrie N. Baker, May 8, 2023.
181 AFP-​Extel News, “Roussel Uclaf Dismisses Planned U.S. Anti-​abortion Groups’ Boycott,” June
2, 1994.
182 Gannett News Service, “RU 486 Company Faces Boycott,” Marin Independent Journal, June 2,
1994, A3.
183 T.J. Raphael, “The Pill Plot,” Cover Up, episode 6 at 5:10, 7:23, accessed August 15, 2023, https://​
podca​sts.apple.com/​us/​podc​ast/​cover-​up-​the-​pill-​plot/​id162​1750​804.
 Endnotes • 257

184 Robert O’Harrow, Jr, “Drug’s U.S. Marketer Remains Elusive,” The Washington Post, October 12,
2000, https://​www.was​hing​tonp​ost.com/​arch​ive/​polit​ics/​2000/​10/​12/​drugs-​us-​marke​ter-​rema​ins-​elus​ive/​
8b7b7​32b-​0f23-​4c96-​9051-​714cd​3d9f​6f8/​.
185 “Status of Mifepristone in the United States” (New York: Population Council, April 1996).
186 Carolyn Ryan, “Clinic Stops Distributing Abortion Pill Brookline Killings Prompt Move,” Patriot
Ledger, January 31, 1995.
187 “Review of Programs, 1995–​1996,” 3.
188 Richard U. Hausknecht, “Methotrexate and Misoprostol to Terminate Early Pregnancy,” New England
Journal of Medicine 333, no. 9 (August 31, 1995): 537–​40, https://​doi.org/​10.1056/​NEJM​1995​0831​3330​901.
189 “The Abortion Drug Arrives,” The Washington Post, September 2, 1995, sec. A.
190 “Harassment-​Free Abortions,” The New York Times, September 1, 1995, sec. A.
191 Elyse Tanouye, “Combined Use of Cancer, Ulcer Drugs to Cause Abortion Stirs Controversy,” The
Wall Street Journal, August 31, 1995.
192 Eric A. Schaff et al., “Combined Methotrexate and Misoprostol for Early Induced Abortion,”
Archives of Family Medicine 4, no. 9 (n.d.): 774–​79.
193 Russell Sabin, “Abortion-​Rights Group Asks to Test RU-​486 Copy/​UCSF Scientists Also Trying
Another Version of Pill,” San Francisco Chronicle, March 14, 1996. Later research revealed that methotrex-
ate caused fetal abnormalities so it was never developed as an abortifacient. Dr. Hausknecht later became
the medical director at Danco.
194 Steven Eisinger, interview with Carrie N. Baker, July 6, 2023. Mitchell Creinin said that metho-
trexate works best in the first seven weeks of pregnancy, but is less effective than mifepristone after that.
Mitchell Creinin, interview with Carrie N. Baker, September 12, 2023.
195 Schaff, “Mifepristone,” 2.
196 Tracy Weitz, interview by Carrie N. Baker, May 25, 2023.
197 US Food and Drug Administration Reproductive Health Advisory Committee, “New Drug
Application for the Use of Mifepristone for Interruption of Early Pregnancy,” July 19, 1996; Bass, “Toward
Coalition: The Reproductive Health Technologies Project,” 267.
198 Sheryl Stolberg, “FDA Panel Call for OK of Abortion Pill,” Los Angeles Times, July 20, 1996.
199 Cynthia Pearson, interview by Carrie N. Baker, July 5, 2023.
200 Carolyn Westhoff, interview by Carrie N. Baker, August 9, 2023.
201 Mitchell Creinin, interview by Carrie N. Baker, September 12, 2023.
202 Mitchell Creinin, interview by Carrie N. Baker, September 12, 2023.
203 T.J. Raphael, “The Pill Plot,” Cover Up, episode 6 at 11:05, accessed August 15, 2023, https://​podca​
sts.apple.com/​us/​podc​ast/​cover-​up-​the-​pill-​plot/​id162​1750​804.
204 T.J. Raphael, “The Pill Plot,” Cover Up, episode 6 at 13:30, accessed August 15, 2023, https://​podca​
sts.apple.com/​us/​podc​ast/​cover-​up-​the-​pill-​plot/​id162​1750​804.
205 Tamar Lewin, “Group Is Intensifying Its Campaign to Distribute Abortion Pill,” The New York
Times, July 2, 1997, sec. U.S., https://​www.nyti​mes.com/​1997/​07/​02/​us/​group-​is-​inten​sify​ing-​its-​campa​
ign-​to-​dis​trib​ute-​abort​ion-​pill.html.
206 Steven Eisinger, interview by Carrie N. Baker, July 6, 2023.
207 Eric A. Schaff et al., “Low-​Dose Mifepristone 200 Mg and Vaginal Misoprostol for Abortion,”
Contraception 59, no. 1 (January 1999): 1–​6, https://​doi.org/​10.1016/​S0010-​7824(98)00150-​4.
208 Andrea Tone, Devices and Desires: A History of Contraceptives in America, 1st ed. (New York: Hill
and Wang, 2001).
209 Klitsch, RU 486: The Science and the Politics, 15.
210 Haussman, Reproductive Rights and the State, 103.
211 Bass, “Toward Coalition: The Reproductive Health Technologies Project,” 256.
212 Tamar Lewin, “FDA Approval Sought for French Abortion Pill,” The New York Times, April 1, 1996.
213 Redstone Strategy Group and David and Lucile Packard Foundation, “Mission Investments at the
Packard Foundation,” October 2015, https://​www.pack​ard.org/​wp-​cont​ent/​uplo​ads/​2015/​10/​Packar​d_​MI​
R_​20​15OC​T51.pdf.
258 • Endnotes

214 Hannah Levintova, “The Abortion Pill’s Secret Money Men,” Mother Jones, April 2023, https://​
www.moth​erjo​nes.com/​polit​ics/​2023/​01/​abort​ion-​pill-​mifep​rist​one-​mifep​rex-​roe-​dobbs-​priv​ate-​equ​ity/​.
215 Carlyle Murphy and Kathleen Day, “Abortion Pill’s U.S. Debut Snagged by Business
Dispute; Sponsor Seeks to Oust Associate for Not Disclosing Disbarment,” The Washington Post, January
12, 1997.
216 Tamar Lewin, “Legal Hurdle Cleared in Sale of French Abortion Pill in U.S.,” The New York Times,
February 13, 1997.
217 Julie Rovner, “US Antiabortionists Boycott Allergy Drug,” The Lancet, April 12, 1997.
218 “ ‘Army of God’ Claims It Bombed Alabama Clinic,” The Washington Post, February 3, 1998.
219 Kathleen Day, “Protest Fears Spur Effort to Keep Name of Abortion Pill’s Maker Secret,” The
Washington Post, September 21, 1996.
220 Irving M. Spitz et al., “Early Pregnancy Termination with Mifepristone and Misoprostol in the
United States,” New England Journal of Medicine 338, no. 18 (April 30, 1998): 1241–​47, https://​doi.org/​
10.1056/​NEJM​1998​0430​3381​801.
221 Schroedel and Corbin, “Gender Relations and Institutional Conflict over Mifepristone,” 46.
222 Lader, RU 486.
223 Feminist Majority Foundation, “Feminist Majority Foundation Declares Victory in 12-​Year
Campaign to Bring RU 486 to the United States” (Arlington, VA: Feminist Majority Foundation, September
28, 2000), https://​femin​ist.org/​news/​press/​femin​ist-​major​ity-​fou​ndat​ion-​decla​res-​vict​ory-​in-​12-​year-​
campa​ign-​to-​bring-​ru-​486-​to-​the-​uni​ted-​sta​tes/​.
224 Eleanor Smeal, interview by Carrie N. Baker, June 16, 2023.
225 Feminist Majority Foundation, “Compassionate Use Program,” accessed March 4, 2023, https://​
femin​ist.org/​our-​work/​mifep​rist​one/​compas​sion​ate-​use-​prog​ram/​.
226 Eleanor Smeal, interview by Carrie N. Baker, May 8, 2023.
227 Eleanor Smeal, interview by Carrie N. Baker, May 8, 2023.
228 Sheryl Gay Stolberg, “FDA Adds Hurdles in Approval of Abortion Pill,” The New York Times, June
8, 2000.
229 Schroedel and Corbin, “Gender Relations and Institutional Conflict over Mifepristone,” 49.
230 Beverly Winikoff, interview by Carrie N. Baker, May 22, 2023.
231 Feminist Majority Foundation, “A Brief Chronology in the Fight to Make RU 486 Available in the US.”
232 Haussman, Reproductive Rights and the State, 103.
233 FDC Reports, “Searle Cytotec Pregnancy Reminder Issued As RU-​486 Action Nears,” The Pink
Sheet, August 28, 2000.
234 “Abortion Pill Maker Revealed,” CBS News, October 13, 2000, https://​www.cbsn​ews.com/​news/​
abort​ion-​pill-​maker-​revea​led/​.
235 Robert O’Harrow, Jr, “Drug’s U.S. Marketer Remains Elusive.”
236 O’Harrow, Jr.
237 Department of Health and Human Services, Public Health Service, Food and Drug Administration,
Center for Drug Evaluation and Research, “Memorandum,” September 28, 2000.
238 Haussman, Reproductive Rights and the State.
239 Kirsten Moore, interview by Carrie N. Baker, May 4, 2023.
240 This claim was made in the lawsuit Alliance for Hippocratic Medicine v. FDA, filed in November
of 2022 (see discussion in Chapter 6).
241 Haussman, Reproductive Rights and the State.
242 Eleanor Smeal, interview by Carrie N. Baker, May 8, 2023.
243 Beverly Winikoff, interview by Carrie N. Baker, May 22, 2023.
244 Beverly Winikoff, interview by Carrie N. Baker, May 22, 2023.
245 Cynthia Pearson, interview by Carrie N. Baker, July 5, 2023.
 Endnotes • 259

246 Emily Langer, “Philip Corfman, Advocate for Women’s Reproductive Health, Dies at 92,” The
Washington Post, March 2, 2019, https://​www.was​hing​tonp​ost.com/​local/​obi​tuar​ies/​phi​lip-​corf​man-​advoc​
ate-​for-​wom​ens-​repro​duct​ive-​hea​lth-​dies-​at-​92/​2019/​02/​28/​78305​ab6-​3aa3-​11e9-​a06c-​3ec​8ed5​09d1​5_​st​
ory.html.
247 Kirsten Moore, interview by Carrie N. Baker, May 4, 2023.
248 Amy Allina, interview by Carrie N. Baker, May 16, 2023.
249 Amy Allina, interview by Carrie N. Baker, May 16, 2023.
250 Eleanor Smeal, interview by Carrie N. Baker, June 16, 2023.
251 Schroedel and Corbin, “Gender Relations and Institutional Conflict over Mifepristone.”
252 Enav Z. Zusman et al., “Dispensing Mifepristone for Medical Abortion in Canada: Pharmacists’
Experiences of the First Year,” Canadian Pharmacists Journal 156, no. 4 (August 2023): 204, https://​doi.org/​
10.1177/​171516​3523​1176​270.
253 Carole Joffe and Susan Yanow, “Advanced Practice Clinicians as Abortion Providers: Current
Developments in the United States,” Reproductive Health Matters 12, no. 24 Suppl (November 2004): 198–​
206, https://​doi.org/​10.1016/​s0968-​8080(04)24008-​3.
254 Talbot, “The Little White Bombshell.”
255 Lader, RU 486, 114–​15.
256 Lader, A Private Matter, 225.
257 Chalker and Downer, A Woman’s Book of Choices, 209.
258 Klitsch, RU 486: The Science and the Politics, 13.
259 Talbot, “The Little White Bombshell.”

Chapter 2
1 Jean Reith Schroedel, “Assessing Medical Abortion in the US: One Year after the FDA Approval of
Mifepristone,” Women & Politics 24, no. 3 (June 2002): 3, https://​doi.org/​10.1300/​J014v2​4n03​_​01.
2 “National Survey of Gynecologists and Family Practice Physicians: Few Offering Mifepristone
One Year after FDA Approval; Indications That Number May Increase in Next Year” (news release) (San
Francisco: Kaiser Family Foundation, September 24, 2001).
3 Rachel Jones and Jenna Jerman, “Abortion Incidence and Service Availability in the United States,”
Perspectives on Sexual and Reproductive Health 46 (2014): 3–​14.
4 Beverly Winikoff and Carolyn Westhoff, “Fifteen Years: Looking Back and Looking Forward,”
Contraception 92, no. 3 (September 2015): 177, https://​doi.org/​10.1016/​j.contra​cept​ion.2015.06.019.
5 Felicia H. Stewart et al., “Early Medical Abortion: Issues for Practice” (San Francisco: UCSF Center
for Reproductive Health Research & Policy, 2001).
6 Elisa Wells, interview by Carrie N. Baker, May 24, 2023.
7 Tracy Weitz, interview by Carrie N. Baker, May 25, 2023.
8 Tracy Weitz, interview by Carrie N. Baker, May 25, 2023.
9 “Our Impact. RHEDI,” accessed May 26, 2023, https://​rhedi.org/​our-​imp​act/​.
10 Emily Godfrey, interview by Carrie N. Baker, May 5, 2023.
11 Emily Godfrey, interview by Carrie N. Baker, May 5, 2023.
12 Tracy Weitz, interview by Carrie N. Baker, May 25, 2023.
13 Carolyn Westhoff, interview by Carrie N. Baker, August 9, 2023.
14 Susan Yanow, interview by Carrie N. Baker, May 25, 2023.
15 Wells had worked with a wide range of organizations, including the global health equity non-​profit
PATH and the Association of Reproductive Health Professionals.
16 Elisa Wells, interview by Carrie N. Baker, May 24, 2023.
17 Trace Weitz, interview by Carrie N. Baker, May 25, 2023.
18 Carolyn Westhoff, interview by Carrie N. Baker, August 9, 2023.
260 • Endnotes

19 Francine Coeytaux, Kirsten Moore, and Lillian Gelberg, “Convincing New Providers to Offer
Medical Abortion: What Will It Take?,” Perspectives on Sexual and Reproductive Health 35, no. 1
(January 2003): 44–​47, https://​doi.org/​10.1363/​3504​403.
20 Coeytaux, Moore, and Gelberg.
21 Coeytaux, Moore, and Gelberg.
22 Coeytaux, Moore, and Gelberg.
23 Emily M. Godfrey et al., “Factors Associated with Successful Implementation of Telehealth
Abortion in 4 United States Clinical Practice Settings,” Contraception 104, no. 1 (July 2021): 82–​91, https://​
doi.org/​10.1016/​j.contra​cept​ion.2021.04.021.
24 Marcel P. Gemperli et al., “A Qualitative Study of Insurers’ Coverage for Mifepristone-​Induced
Abortion,” Managed Care Interface 18, no. 3 (March 2005): 26–​30, 32. Tracy Weitz worked with malprac-
tice carriers to put medication abortion on the family practice page for coverage but they refused to. Tracy
Weitz, interview by Carrie N. Baker, May 25, 2023.
25 Tracy Weitz, interview by Carrie N. Baker, May 25, 2023.
26 Francine Coeytaux, interview by Carrie N. Baker, April 3, 2023.
27 Beverly Winikoff, interview by Carrie N. Baker, May 22, 2023.
28 Beverly Winikoff, interview by Carrie N. Baker, May 22, 2023.
29 Clyde Wilcox and Julia Riches, “Pills in the Public’s Mind: RU 486 and the Framing of the Abortion
Issue,” Women & Politics 24, no. 3 (June 2002): 61–​80, https://​doi.org/​10.1300/​J014v2​4n03​_​04.
30 Schroedel and Corbin, “Gender Relations and Institutional Conflict over Mifepristone,” 50.
31 Schroedel, “Assessing Medical Abortion in the US,” 5.
32 Kati Schindler, Anna E. Jackson, and Charon Asetoyer, “Indigenous Women’s Reproductive
Rights: The Indian Health Service and Its Inconsistent Application of the Hyde Amendment” (Native
American Women’s Health Education Resource Center, October 2002), 5, https://​www.procho​ice.org/​
pubs_​r​esea​rch/​publi​cati​ons/​downlo​ads/​abo​ut_​a​bort​ion/​indig​enou​s_​wo​men.pdf.
33 Feminist Majority Foundation, “Abortion Rights Group Challenges Law Restricting Mifepristone”
(Arlington, VA, March 2, 2001), https://​femin​ist.org/​news/​abort​ion-​rig​hts-​group-​cha​llen​ges-​law-​rest​rict​
ing-​mifep​rist​one/​.
34 Schroedel, “Assessing Medical Abortion in the US,” 6.
35 California Health & Safety Code sec. 439.905 (2001).
36 Schroedel, “Assessing Medical Abortion in the US,” 7.
37 Feminist Majority Foundation, “NAF to Launch $2M Public Ed Campaign on Mifepristone”
(Arlington, VA, May 25, 2001), https://​femin​ist.org/​news/​naf-​to-​lau​nch-​2m-​pub​lic-​ed-​campa​ign-​on-​
mifep​rist​one/​.
38 “Letter to Dr. Mark McClellan, Commissioner of the FDA, from Cynthia Peterson, Executive
Director of the National Women’s Health Network, and Dr. Sidney Wolfe, Director of the Public Citizens’
Health Research Group,” January 21, 2004.
39 “Letter to Members of the Committee on Emerging Clostridial Disease, from Gynuity, Ipas, NAF,
NWHN and RHTP,” May 11, 2006.
40 Amy Allina, email to Carrie N. Baker, May 17, 2023.
41 Elissa Meites, Suzanne Zane, and Carolyn Gould, “Fatal Clostridium Sordellii Infections after
Medical Abortions,” New England Journal of Medicine 363, no. 14 (September 30, 2010): 1382–​83, https://​
doi.org/​10.1056/​NEJMc​1001​014; Beverly Winikoff, “Clostridium Sordellii Infection in Medical Abortion,”
Clinical Infectious Diseases 43, no. 11 (December 1, 2006): 1447–​48, https://​doi.org/​10.1086/​508​895.
42 Centers for Disease Control and Prevention, “Abortion Surveillance—​ United States, 2007,”
Morbidity and Mortality Weekly Report, Surveillance Summaries, Vol. 60, No. 1 (Washington, DC: Centers
for Disease Control and Prevention, February 25, 2011), https://​www.cdc.gov/​mmwr/​pdf/​ss/​ss6​001.pdf.
43 Anna Popinchalk and Gilda Sedgh, “Trends in the Method and Gestational Age of Abortion in
High-​Income Countries,” BMJ Sexual & Reproductive Health 45, no. 2 (April 2019): 95–​103, https://​doi.
org/​10.1136/​bmj​srh-​2018-​200​149.
44 Michelle Cohen, interview by Carrie N. Baker, June 8, 2023.
 Endnotes • 261

45 Michelle Cohen, interview by Carrie N. Baker, June 8, 2023.

46 Michelle Cohen, interview by Carrie N. Baker, June 8, 2023.
47 Michelle Cohen, interview by Carrie N. Baker, June 8, 2023.
48 “Food and Drug Administration Amendments Act of 2007,” Pub. L. No. 110–​85, 121 Stat. 823
(2007), https://​www.congr​ess.gov/​bill/​110th-​congr​ess/​house-​bill/​3580.
49 US Food and Drug Administration, “Risk Evaluation and Mitigation Strategy for Mifeprex,” June
2011, https://​www.fda.gov/​media/​164​648/​downl​oad.
50 Schaff, “Mifepristone.”
51 Elizabeth G. Raymond et al., “First-​Trimester Medical Abortion with Mifepristone 200 Mg and
Misoprostol: A Systematic Review,” Contraception 87, no. 1 (January 2013): 26–​37, https://​doi.org/​10.1016/​
j.contra​cept​ion.2012.06.011.
52 Schaff, “Mifepristone,” 2.
53 Dina Abbas, Erica Chong, and Elizabeth G. Raymond, “Outpatient Medical Abortion Is Safe and
Effective through 70 Days Gestation,” Contraception 92, no. 3 (September 2015): 197–​99, https://​doi.org/​
10.1016/​j.contra​cept​ion.2015.06.018.
54 Ilana Dzuba et al., “Outpatient Mifepristone–​Misoprostol Medical Abortion through 77 Days of
Gestation,” Contraception 94, no. 4 (October 2016): 389, https://​doi.org/​10.1016/​j.contra​cept​ion.2016.07.027.
55 World Health Organization, “Abortion Care Guidance” (Geneva, Switzerland: World Health
Organization, 2022), https://​www.who.int/​publi​cati​ons/​i/​item/​978924​0039​483.
56 Emily Godfrey, interview by Carrie N. Baker, May 5, 2023.
57 Schaff, “Mifepristone,” 3.
58 Schaff, 3.
59 Eric A. Schaff et al., “Vaginal Misoprostol Administered 1, 2, or 3 Days after Mifepristone for
Early Medical Abortion: A Randomized Trial,” JAMA 284, no. 15 (October 18, 2000): 1948, https://​doi.org/​
10.1001/​jama.284.15.1948.
60 Elizabeth G. Raymond et al., “Reaching Women Where They Are: Eliminating the Initial In-​Person
Medical Abortion Visit,” Contraception 92, no. 3 (September 2015): 190–​93, https://​doi.org/​10.1016/​
j.contra​cept​ion.2015.06.020; Marji Gold and Erica Chong, “If We Can Do It for Misoprostol, Why Not for
Mifepristone? The Case for Taking Mifepristone out of the Office in Medical Abortion,” Contraception 92,
no. 3 (September 2015): 194–​96, https://​doi.org/​10.1016/​j.contra​cept​ion.2015.06.011.
61 Gold and Chong, “If We Can Do It for Misoprostol, Why Not for Mifepristone?”; Erica Chong et al.,
“A Prospective, Non-​randomized Study of Home Use of Mifepristone for Medical Abortion in the U.S.,”
Contraception 92, no. 3 (September 1, 2015): 215–​19, https://​doi.org/​10.1016/​j.contra​cept​ion.2015.06.026.
62 María Mercedes Lafaurie et al., “Women’s Perspectives on Medical Abortion in Mexico, Colombia,
Ecuador and Peru: A Qualitative Study,” Reproductive Health Matters 13, no. 26 (January 2005): 75–​83,
https://​
doi.org/​10.1016/​S0968-​ 8080(05)26199-​ 2; Diana Lara et al., “Pharmacy Provision of Medical
Abortifacients in a Latin American City,” Contraception 74, no. 5 (November 2006): 394–​99, https://​doi.
org/​10.1016/​j.contra​cept​ion.2006.05.068.
63 Schaff, “Mifepristone,” 2.
64 Cui-​Lan Li et al., “Effectiveness and Safety of Lower Doses of Mifepristone Combined with
Misoprostol for the Termination of Ultra-​early Pregnancy: A Dose-​Ranging Randomized Controlled
Trial,” Reproductive Sciences 22, no. 6 (June 2015): 706–​11, https://​doi.org/​10.1177/​19337​1911​4557​897.
65 Daniel Grossman et al., “Effectiveness and Acceptability of Medical Abortion Provided through
Telemedicine,” Obstetrics & Gynecology 118, no. 2 (August 2011): 296–​303, https://​doi.org/​10.1097/​
AOG.0b013​e318​224d​110; Kate Grindlay, Kathleen Lane, and Daniel Grossman, “Women’s and Providers’
Experiences with Medical Abortion Provided through Telemedicine: A Qualitative Study,” Women’s Health
Issues 23, no. 2 (March 2013): e117–​22, https://​doi.org/​10.1016/​j.whi.2012.12.002.
66 Angel M. Foster et al., “From Qualified Physician to Licensed Health Care Professional: The Time
Has Come to Change Mifepristone’s Label,” Contraception 92, no. 3 (September 2015): 200–​202, https://​
doi.org/​10.1016/​j.contra​cept​ion.2015.06.022.
262 • Endnotes

67 Daniel Grossman and Philip Goldstone, “Mifepristone by Prescription: A Dream in the United
States but Reality in Australia,” Contraception 92, no. 3 (September 2015): 186–​89, https://​doi.org/​10.1016/​
j.contra​cept​ion.2015.06.014.
68 Richard J. Rovelli, Nicole E. Cieri-​Hutcherson, and Timothy C. Hutcherson, “Systematic Review
of Oral Pharmacotherapeutic Options for the Management of Uterine Fibroids,” Journal of the American
Pharmacists Association 62, no. 3 (May 2022): 674–​682.e5, https://​doi.org/​10.1016/​j.japh.2022.02.004; Ally
Murji et al., “Selective Progesterone Receptor Modulators (SPRMs) for Uterine Fibroids,” ed. Cochrane
Gynaecology and Fertility Group, Cochrane Database of Systematic Reviews 2017, no. 4 (April 26, 2017),
https://​doi.org/​
10.1002/​ 14651​858.CD010​ 770.pub2; Julietta Fiscella et al., “Distinguishing Features of
Endometrial Pathology after Exposure to the Progesterone Receptor Modulator Mifepristone,” Human
Pathology 42, no. 7 (July 2011): 947–​53, https://​doi.org/​10.1016/​j.hump​ath.2010.11.003.
69 Steven Eisinger, interview by Carrie N. Baker, July 6, 2023.
70 Kevin Fiscella, interview by Carrie N. Baker, July 25, 2023.
71 Steven Eisinger, interview by Carrie N. Baker, July 6, 2023.
72 Kevin Fiscella, interview by Carrie N. Baker, July 25, 2023.
73 Steven Eisinger, email to Carrie N. Baker, July 9, 2023.
74 Kevin Fiscella, interview by Carrie N. Baker, July 25, 2023.
75 Kevin Fiscella, interview by Carrie N. Baker, July 25, 2023.
76 Steven Eisinger, interview by Carrie N. Baker, July 6, 2023.
77 Carrie N. Baker, “Anti-​abortion Politics Hinder Access to Important Fibroid Treatment: Mifepristone,”
Ms. magazine, July 14, 2023, https://​msm​agaz​ine.com/​2023/​07/​14/​mifep​rist​one-​fibro​ids/​.
78 Kevin Fiscella, interview by Carrie N. Baker, July 25, 2023.
79 Kevin Discella, interview by Carrie N. Baker, July 25, 2023.
80 Y.X. Zhang, “Effect of Mifepristone in the Different Treatments of Endometriosis,” Clinical and
Experimental Obstetrics & Gynecology 43, no. 3 (2016): 350–​53.
81 Thaddeus S. Block et al., “Combined Analysis of Mifepristone for Psychotic Depression: Plasma
Levels Associated with Clinical Response,” Biological Psychiatry 84, no. 1 (July 2018): 46–​54, https://​doi.
org/​10.1016/​j.biops​ych.2018.01.008.
82 Jocelyn Solis-​Moreira, “Banning the Abortion Pill Would Harm Veterans, Cancer Patients, and
Many Others,” Popular Science (blog), May 1, 2023, https://​www.pop​sci.com/​hea​lth/​abort​ion-​pill-​ban-​
other-​tre​atme​nts/​.
83 Francisco Díaz-​ Castro et al., “Mifepristone for Treatment of Metabolic Syndrome: Beyond
Cushing’s Syndrome,” Frontiers in Pharmacology 11 (2020): 429, https://​doi.org/​10.3389/​fphar.2020.00429.
84 Nathalie Chabbert-​Buffet et al., “Selective Progesterone Receptor Modulators and Progesterone
Antagonists: Mechanisms of Action and Clinical Applications,” Human Reproduction Update 11, no. 3
(May 1, 2005): 293–​307, https://​doi.org/​10.1093/​hum​upd/​dmi​002.
85 Baker, “Abortion Pill Effective for Treating Fibroids, but Anti-​abortion Politics Stymie Access.”
86 Diane S. Aschenbrenner, “FDA Approves First Drug for Endogenous Cushing’s Syndrome,”
American Journal of Nursing 112, no. 6 (June 2012): 26, https://​ doi.org/​
10.1097/​01.NAJ.000​
0415​
123.61735.8e.
87 Sarah Jane Tribble, “How a Drugmaker Turned the Abortion Pill into a Rare-​Disease Profit
Machine,” Washington Post, April 10, 2018, https://​www.was​hing​tonp​ost.com/​natio​nal/​hea​lth-​scie​nce/​
how-​a-​drugma​ker-​tur​ned-​the-​abort​ion-​pill-​into-​a-​rare-​dise​ase-​pro​fit-​mach​ine/​2018/​04/​10/​af989​610-​
3c9f-​11e8-​955b-​7d2​e19b​7996​6_​st​ory.html.
88 Sarah Christopherson and Olivia Snavely, “The FDA’s Convoluted Stance on Abortion Pills Doesn’t
Protect Patients—​It Endangers Them,” National Women’s Health Network, May 8, 2020, https://​nwhn.org/​
the-​fdas-​con​volu​ted-​sta​nce-​on-​abort​ion-​pills-​doe​snt-​prot​ect-​patie​nts-​it-​endang​ers-​them/​.
89 “States Enact Record Number of Abortion Restrictions in 2011” (New York: Guttmacher Institute,
January 2012), https://​www.gut​tmac​her.org/​arti​cle/​2012/​01/​sta​tes-​enact-​rec​ord-​num​ber-​abort​ion-​restr​
icti​ons-​2011.
 Endnotes • 263

90 Francine Coeytaux and Elisa Wells, “A Tale of Two Methods: Applying the Lessons Learned
from Emergency Contraception to Misoprostol for Early Abortion, Briefing Paper Commissioned by the
Reproductive Health Technologies Project” (Washington, DC: Reproductive Health Technologies Project,
July 2016), 4–​5.
91 Morgani Guzzo, “Brasil: As Regras Que Puseram o Misoprostol ‘Na Cadeia,’ ” Futuro Do Cuidado
(blog), August 25, 2021, https://​futu​rodo​cuid​ado.org/​o-​miso​pros​tol-​esta-​na-​cad​eia/​. By 1998, the govern-
ment had criminalized misoprostol in most circumstances and it was unavailable in Brazil. The govern-
ment later blocked the dissemination of information about misoprostol as well.
92 H.L.L. Coêlho et al., “Misoprostol and Illegal Abortion in Fortaleza, Brazil,” The Lancet 341,
no. 8855 (May 1993): 1261–​63, https://​doi.org/​10.1016/​0140-​6736(93)91157-​H; Ilana Löwy and Marilena
Cordeiro Dias Villela Corrêa, “The ‘Abortion Pill’ Misoprostol in Brazil: Women’s Empowerment in a
Conservative and Repressive Political Environment,” American Journal of Public Health 110, no. 5 (May
2020): 677–​84, https://​doi.org/​10.2105/​AJPH.2019.305​562.
93 Mariana Carbajal, “Meet the Latin American Women Who Launched the Global Day for Safe
Abortion,” Open Democracy, September 28, 2021, https://​www.opende​mocr​acy.net/​en/​5050/​safe-​abort​
ion-​day-​bra​zil-​argent​ina/​.
94 M.A. Rosing and C.D. Archbald, “The Knowledge, Acceptability, and Use of Misoprostol for
Self-​Induced Medical Abortion in an Urban US Population,” Journal of the American Medical Women’s
Association (1972) 55, no. 3 Suppl (2000): 183–​85.
95 K. Blanchard, B. Winikoff, and C. Ellertson, “Misoprostol Used Alone for the Termination of
Early Pregnancy. A Review of the Evidence,” Contraception 59, no. 4 (April 1999): 209–​17, https://​doi.org/​
10.1016/​s0010-​7824(99)00029-​3.
96 Vessel, 2014, https://​vessel​thef​ilm.com/​.
97 “Abortion Pills in U.S. Women’s Hands: Bold Action to Meet Women’s Needs, Report on Meeting
Held on 12/​4/​2013 in Washington, D.C.” (Public Health Institute, Ipas, and National Women’s Health
Network, December 2013), 2–​3 (describing the Working Group); Susan Yanow, interview by Carrie
N. Baker, May 25, 2023.
98 Elisa Wells et al., “Surfing for Abortion: An Assessment of the Online Availability of Information
about Misoprostol,” June 29, 2014, 2 (unpublished report).
99 N.L. Moreno-​Ruiz et al., “Alternatives to Mifepristone for Early Medical Abortion,” International
Journal of Gynecology & Obstetrics 96, no. 3 (March 2007): 212–​18, https://​doi.org/​10.1016/​j.ijgo.2006.09.009.
100 Research published in 2006 revealed that in one Latin American city, pharmacists often pre-
scribed misoprostol, but their knowledge about proper dosing regimens was low. Researchers interviewed
staff at a random sample of 102 pharmacies in the Latin American city and dispatched mystery clients
to the same pharmacies to ascertain prescribing practices and counseling. Sixty percent of pharmacists
reported recommending misoprostol and 39 percent of the mystery client encounters resulted in a miso-
prostol prescription, but few of the pharmacists (6 percent in the survey and 17 percent in the mystery
client encounters) recommended a misoprostol dosing regimen that was potentially effective. Lara et al.,
“Pharmacy Provision of Medical Abortifacients in a Latin American City.”
101 Eleanor J. Bader, “A Miscarriage of Justice for Dominican Immigrant,” The Indypendent, April 13,
2007, https://​indy​pend​ent.org/​2007/​04/​a-​misc​arri​age-​of-​just​ice-​for-​domini​can-​immigr​ant/​.
102 Yadira Betances, “Lawrence Teen Accused of Inducing Abortion Given Pretrial Probation,” Eagle-​
Tribune, June 3, 2008, https://​www.eagle​trib​une.com/​news/​loc​al_​n​ews/​lawre​nce-​teen-​accu​sed-​of-​induc​
ing-​abort​ion-​given-​pretr​ial-​probat​ion/​artic​le_​b​abe7​8b6-​70f5-​5aab-​9bd7-​5ba79​c630​942.html; Susan
Yanow, interview by Carrie N. Baker, May 25, 2023.
103 Susan Yanow, “The Best Defense Is a Good Offense: Misoprostol, Abortion, and the Law,
Conference Summary and Strategic Recommendations” (New York: Gynuity Health Projects and the
Reproductive Health Technologies Project, August 2009), https://​gynu​ity.org/​ass​ets/​resour​ces/​Goldm​an_​
b​est_​defe​nse_​web.pdf; Susan Yanow, interview by Carrie N. Baker, May 25, 2023.
104 Yanow.
264 • Endnotes

105 Beverly Winikoff, interview by Carrie N. Baker, May 22, 2023.

106 Daniel Grossman et al., “Self-​Induction of Abortion among Women in the United States,”
Reproductive Health Matters 18, no. 36 (January 2010): 136–​ 46, https://​ doi.org/​ 10.1016/​ S0968-​
8080(10)36534-​7; “Abortion Pills in U.S. Women’s Hands: Bold Action to Meet Women’s Needs, Report on
Meeting Held on 12/​4/​2013 in Washington, D.C.,” 3–​4.
107 Susan Yanow, interview by Carrie N. Baker, May 25, 2023.
108 Susan Yanow, interview by Carrie N. Baker, May 25, 2023.
109 Rachel K. Jones, “How Commonly Do US Abortion Patients Report Attempts to Self-​Induce?,”
American Journal of Obstetrics & Gynecology 204, no. 1 (January 1, 2011): 23.e1–​23.e4, https://​doi.org/​
10.1016/​j.ajog.2010.08.019.
110 Emily Bazelon, “A Mother in Jail for Helping Her Daughter Have an Abortion,” The New York
Times, September 22, 2014, sec. Magazine, https://​www.nyti​mes.com/​2014/​09/​22/​magaz​ine/​a-​mot​her-​in-​
jail-​for-​help​ing-​her-​daugh​ter-​have-​an-​abort​ion.html.
111 Helen Davidson, “Texas Abortion Bill Defeated by Wendy Davis Filibuster and Public Protest,”
The Guardian, June 26, 2013, sec. US news, https://​www.theg​uard​ian.com/​world/​2013/​jun/​26/​texas-​abort​
ion-​vote-​defea​ted-​deadl​ine-​wendy-​davis.
112 Diana Lugo-​Martinez, interview by Carrie N. Baker, July 24, 2023.
113 Erik Eckholm, “A Pill Available in Mexico Is a Texas Option for Abortion,” The New York Times,
July 13, 2013, sec. U.S., https://​www.nyti​mes.com/​2013/​07/​14/​us/​in-​mexi​can-​pill-​a-​texas-​opt​ion-​for-​an-​
abort​ion.html.
114 Diana Lugo-​Martinez, interview by Carrie N. Baker, July 24, 2023.
115 Marlene Gerber Fried, interview by Carrie N. Baker, May 18, 2023.
116 “Abortion Pills in U.S. Women’s Hands: Bold Action to Meet Women’s Needs, Report on Meeting
Held on 12/​4/​2013 in Washington, D.C.,” 1. The states involved were California, Georgia, Massachusetts,
North Carolina, New York, Oklahoma, Tennessee, Texas, Washington, and the District of Columbia.
117 Some women saw the process of using misoprostol as more natural than procedural abortion,
likening it to miscarriage.
118 Francine Coeytaux noted that when mifepristone was first introduced in the United States, many
providers believed the medication was an inferior method to evacuation abortion.
119 Wells et al., “Surfing for Abortion.”
120 “Abortion Pills in U.S. Women’s Hands: Bold Action to Meet Women’s Needs, Report on Meeting
Held on 12/​4/​2013 in Washington, D.C.”
121 Francine Coeytaux et al., “Facilitating Women’s Access to Misoprostol through Community-​
Based Advocacy in Kenya and Tanzania,” International Journal of Gynecology & Obstetrics 125, no. 1 (April
2014): 53–​55, https://​doi.org/​10.1016/​j.ijgo.2013.10.004.
122 Elisa Wells, interview by Carrie N. Baker, May 24, 2023.
123 Elisa Wells, email to Carrie N. Baker, June 9, 2023.
124 Barbara Pillsbury, Francine Coeytaux, and Andrea Johnston, “From Secret to Shelf: How
Collaboration Is Bringing Emergency Contraception to Women” (Los Angeles: Pacific Institute Health,
1999), 24.
125 Pillsbury, Coeytaux, and Johnston, 24.
126 Pillsbury, Coeytaux, and Johnston, 28.
127 DKT is one of the largest private providers of family planning products in the world.
128 Elisa Wells, interview by Carrie N. Baker, May 24, 2023.
129 Francine Coeytaux, interview by Carrie N. Baker, January 23, 2023.
130 Francine Coeytaux, interview by Carrie N. Baker, April 3, 2023.
131 Coeytaux and Wells, “A Tale of Two Methods: Applying the Lessons Learned from Emergency
Contraception to Misoprostol for Early Abortion, Briefing Paper Commissioned by the Reproductive
Health Technologies Project,” 33.
 Endnotes • 265

132 Francine Coeytaux, Leila Hessini, and Amy Allina, “Bold Action to Meet Women’s Needs: Putting
Abortion Pills in U.S. Women’s Hands,” Women’s Health Issues 25, no. 6 (November 2015): 608–​11, https://​
doi.org/​10.1016/​j.whi.2015.08.004.
133 Coeytaux, Hessini, and Allina.
134 Francine Coeytaux, interview by Carrie N. Baker, April 3, 2023.
135 Jenifer McKenna, interview by Carrie N. Baker, July 18, 2023.
136 Coeytaux and Wells, “A Tale of Two Methods: Applying the Lessons Learned from Emergency
Contraception to Misoprostol for Early Abortion, Briefing Paper Commissioned by the Reproductive
Health Technologies Project,” 2.
137 Coeytaux and Wells, 4.
138 Coeytaux and Wells, 24–​30.
139 Coeytaux and Wells, 31.
140 “Introducing the SIA Legal Team” (Berkeley, CA: UC Berkeley School of Law, 2015), www.law.
berke​ley.edu/​wp-​cont​ent/​uplo​ads/​2016/​01/​SIA-​Legal-​Team-​Broch​ure.pdf.
141 “About Reproaction | Reproaction,” accessed June 16, 2023, https://​repr​oact​ion.org/​about/​.
142 Pamela Merritt, interview by Carrie N. Baker, June 14, 2023.
143 Pamela Merritt, interview by Carrie N. Baker, June 14, 2023.
144 Later published as Coeytaux and Wells, “A Tale of Two Methods: Applying the Lessons Learned
from Emergency Contraception to Misoprostol for Early Abortion, Briefing Paper Commissioned by the
Reproductive Health Technologies Project.”
145 Amy Allina, interview by Carrie N. Baker, May 16, 2023.
146 Elisa Wells, personal correspondence, November 13, 2023.
147 Amy Allina, interview by Carrie N. Baker, May 16, 2023.
148 Chelsea Conaboy, “She Started Selling Abortion Pills Online. Then the Feds Showed Up,” Mother
Jones, April 2019, https://​www.moth​erjo​nes.com/​polit​ics/​2019/​02/​she-​star​ted-​sell​ing-​abort​ion-​pills-​onl​
ine-​then-​the-​feds-​sho​wed-​up/​; Sydney Calkin, Abortion Pills Go Global: Reproductive Freedom across
Borders (Oakland: University of California Press, 2023), 73.
149 Conaboy.
150 Department of Justice, “New York Woman Sentenced for Selling Abortion-​Inducing Pills Illegally
Smuggled into US,” July 10, 2020, https://​www.just​ice.gov/​usao-​wdwi/​pr/​new-​york-​woman-​senten​ced-​sell​
ing-​abort​ion-​induc​ing-​pills-​illega​lly-​smugg​led-​us.
151 Schaff et al., “Low-​Dose Mifepristone 200 Mg and Vaginal Misoprostol for Abortion.”
152 Agata Bodie, “Off-​Label Use of Prescription Drugs,” Summary (Washington, DC: Congressional
Research Service, February 23, 2021), https://​sgp.fas.org/​crs/​misc/​R45​792.pdf; Schaff, “Mifepristone,” 3.
153 Rachel K. Jones and Heather D. Boonstra, “The Public Health Implications of the FDA Update to
the Medication Abortion Label” (Washington, DC: Guttmacher Institute, June 2016).
154 Ushma D. Upadhyay et al., “Comparison of Outcomes before and after Ohio’s Law Mandating Use
of the FDA-​Approved Protocol for Medication Abortion: A Retrospective Cohort Study,” ed. Joel G. Ray,
PLOS Medicine 13, no. 8 (August 30, 2016): e1002110, https://​doi.org/​10.1371/​jour​nal.pmed.1002​110.
155 Ushma D. Upadhyay et al., “Sociodemographic Characteristics of Women Able to Obtain
Medication Abortion before and after Ohio’s Law Requiring Use of the Food and Drug Administration
Protocol,” Health Equity 2, no. 1 (July 2018): 122–​30, https://​doi.org/​10.1089/​heq.2018.0002.
156 Francine Coeytaux, interview by Carrie N. Baker, April 3, 2023.
157 Beverly Winikoff, interview by Carrie N. Baker, May 22, 2023.
158 Beverly Winikoff, interview by Carrie N. Baker, May 22, 2023.
159 Kirsten Moore, interview by Carrie N. Baker, May 4, 2023. On the other hand, Tracy Weitz sug-
gested that removal of the REMS maybe would have decreased advocates’ efforts to encourage the develop-
ment of a generic. Tracy Weitz, interview by Carrie N. Baker, May 25, 2023.
160 Carolyn Westhoff, interview by Carrie N. Baker, August 9, 2023.
161 Cynthia Pearson, interview by Carrie N. Baker, July 14, 2023.
266 • Endnotes

162 Carolyn Westhoff, interview by Carrie N. Baker, August 9, 2023.

163 Mitchell Creinin, interview by Carrie N. Baker, September 12, 2023.
164 Mitchell Creinin, interview by Carrie N. Baker, September 12, 2023.
165 Center for Drug Evaluation and Research, “Medical Review(s) for Application 020687Orig1s020”
(Washington, DC: US Food and Drug Administration, March 29, 2016), https://​www.acc​essd​ata.fda.gov/​
drug​satf​da_​d​ocs/​nda/​2016/​0206​87Or​ig1s​020M​edR.pdf.
166 Joint Stipulation of Facts, Chelius v. Becerra, Civ. No. 1:17-​cv-​00493-​JAO-​RT, April 15, 2021,
https://​www.aclu.org/​sites/​defa​ult/​files/​fie​ld_​d​ocum​ent/​dkt._​140_​-​_​joint_​stipulations_​of_​facts_​with​_​
exh​ibit​s_​ap​ril_​15_​2​021.pdf.
167 Beverly Winikoff and Carolyn Westhoff, “Fifteen Years: Looking Back and Looking Forward,”
Contraception 92, no. 3 (September 2015): 177–​78, https://​doi.org/​10.1016/​j.contra​cept​ion.2015.06.019.
168 US Food and Drug Administration, “Risk Evaluation and Mitigation Strategy for Mifeprex,”
March 2016, https://​www.fda.gov/​media/​164​649/​downl​oad.
169 Kirsten Moore, interview by Carrie N. Baker, May 4, 2023.
170 Christopherson and Snavely, “The FDA’s Convoluted Stance on Abortion Pills Doesn’t Protect
Patients—​It Endangers Them.”
171 Elizabeth Raymond et al., “TelAbortion: Evaluation of a Direct to Patient Telemedicine Abortion
Service in the United States,” Contraception 100, no. 3 (September 2019): 173–​77, https://​doi.org/​10.1016/​
j.contra​cept​ion.2019.05.013.
172 Carolyn Westhoff, interview by Carrie N. Baker, August 9, 2023.
173 Rachel K. Jones et al., “Medication Abortion Now Accounts for More Than Half of All US
Abortions” (Washington, DC: Guttmacher Institute, February 2022), https://​www.gut​tmac​her.org/​arti​cle/​
2022/​02/​med​icat​ion-​abort​ion-​now-​accou​nts-​more-​half-​all-​us-​aborti​ons.
174 Chloe Murtagh et al., “Exploring the Feasibility of Obtaining Mifepristone and Misoprostol
from the Internet,” Contraception 97, no. 4 (April 2018): 287–​91, https://​doi.org/​10.1016/​j.contra​cept​
ion.2017.09.016.
175 Francine Coeytaux, interview by Carrie N. Baker, April 3, 2023.
176 Elisa Wells, interview by Carrie N. Baker, May 31, 2023.
177 Elisa Wells and Francine Coeytaux, “Mail-​Order Abortion: The Future Is Now,” Rewire News
Group, November 8, 2016, https://​rewi​rene​wsgr​oup.com/​2016/​11/​08/​mail-​order-​abort​ion-​fut​ure-​now/​.
178 ACLU Hawaii, Chelius v. Azar, United States District Court for the District of Hawaii, October 3,
2017, https://​www.acl​uhi.org/​en/​cases/​chel​ius-​v-​azar.
179 Kirsten Moore, interview by Carrie N. Baker, May 10, 2021.
180 “Ending the Risk Evaluation and Mitigation Strategy (REMS) Policy on Mifepristone (Mifeprex),
Policy H-​100.948” (American Medical Association, 2018), https://​www.ama-​assn.org/​sites/​ama-​assn.org/​
files/​corp/​media-​brow​ser/​pub​lic/​hod/​a18-​reso​luti​ons.pdf.
181 Kirsten Moore, interview by Carrie N. Baker, May 10, 2021.
182 “Food and Drug Administration, Information on Mifeprex Labeling Changes and Ongoing
Monitoring Efforts” (Washington, DC: United States Government Accountability Office, March 2018),
https://​www.gao.gov/​ass​ets/​gao-​18-​292.pdf.
183 Courtney A. Schreiber et al., “Mifepristone Pretreatment for the Medical Management of Early
Pregnancy Loss,” The New England Journal of Medicine 378, no. 23 (June 7, 2018): 2161–​70, https://​doi.org/​
10.1056/​NEJMoa​1715​726.
184 “Improving Access to Mifepristone for Reproductive Health Indications, Position Statement”
(Washington, DC: American College of Obstetricians and Gynecologists, June 2018), https://​www.acog.
org/​clini​cal-​info​rmat​ion/p​ ol​icy-a​ nd-​posit​ion-​sta​teme​nts/​posit​ion-​sta​teme​nts/​2018/​improv​ing-​acc​ess-​to-​
mifep​rist​one-​for-​repro​duct​ive-​hea​lth-​indi​cati​ons.
185 “Removing REMS Categorization on Mifepristone, Res. R1-​401” (Kansas City, MO: American
Academy of Family Physicians, August 2018), https://​www.aafp.org/​dam/​AAFP/​docume​nts/​eve​nts/​nc/​
congr​ess/​nc18-​ncfmr-​acti​ons-​referr​als.pdf.
 Endnotes • 267

186 Francine Coeytaux, Elisa Wells, and Sophia Yen, “Reproductive Health Care by Mail,” Stanford
Social Innovation Review 16, no. 2 (Spring 2018): 61–​62, https://​doi.org/​10.48558/​JNW3-​2E38.
187 Coeytaux, Wells, and Yen.
188 Francine Coeytaux, interview by Carrie N. Baker, April 11, 2023.
189 Carrie N. Baker, “Why Order Abortion Pills Online? Affordability, Privacy and Convenience,
Says New Study,” Ms. magazine, May 27, 2021, https://​msm​agaz​ine.com/​2021/​05/​27/​order-​abort​ion-​pills-​
med​icat​ion-​abort​ion-​onl​ine-​afford​abil​ity-​priv​acy-​conv​enie​nce-​aid-​acc​ess/​.
190 Rebecca Gomperts, interview by Carrie N. Baker, February 11, 2022.
191 Abigail R.A. Aiken, Jennifer E. Starling, and Rebecca Gomperts, “Factors Associated with Use
of an Online Telemedicine Service to Access Self-​Managed Medical Abortion in the US,” JAMA Network
Open 4, no. 5 (May 21, 2021): e2111852, https://​doi.org/​10.1001/​jama​netw​orko​pen.2021.11852.
192 Elisa Wells, email to Carrie N. Baker, June 29, 2023.
193 Francine Coeytaux, interview by Carrie N. Baker, April 11, 2023.
194 Abigail R.A. Aiken et al., “Safety and Effectiveness of Self-​Managed Medication Abortion
Provided Using Online Telemedicine in the United States: A Population Based Study,” The Lancet Regional
Health—​Americas 10 (June 2022): 100200, https://​doi.org/​10.1016/​j.lana.2022.100​200.
195 Abigail Aiken, interview by Carrie N. Baker, February 23, 2022.
196 Abigail Aiken, interview by Carrie N. Baker, February 23, 2022.
197 Carrie N. Baker and Emily Bellanca, “Safe and Supported: Inside the DIY Abortion Movement,”
Ms. magazine, January 26, 2018, https://​msm​agaz​ine.com/​2018/​01/​26/​safe-​suppor​ted-​ins​ide-​diy-​abort​
ion-​movem​ent/​.
198 Francine Coeytaux, interview by Carrie N. Baker, April 11, 2023; SASS, Safe Abortion with Pills,
What Everyone Should Know about Medical Abortion, June 2019.
199 Cherel, “Abortion without Provider Involvement: Exercising Autonomy beyond Partisan Politics,”
The Women’s Health Activist, April 2017.
200 Cherel.
201 Lauren Ralph et al., “Prevalence of Self-​Managed Abortion among Women of Reproductive
Age in the United States,” JAMA Network Open 3, no. 12 (December 18, 2020): e2029245, https://​doi.org/​
10.1001/​jama​netw​orko​pen.2020.29245.
202 Ushma D. Upadhyay, Alice F. Cartwright, and Daniel Grossman, “Barriers to Abortion Care
and Incidence of Attempted Self-​Managed Abortion among Individuals Searching Google for Abortion
Care: A National Prospective Study,” Contraception 106 (February 2022): 49–​56, https://​doi.org/​10.1016/​
j.contra​cept​ion.2021.09.009.
203 Anonymous, interview by Carrie N. Baker, July 10, 2023.
204 Elizabeth G. Raymond, Margo S. Harrison, and Mark A. Weaver, “Efficacy of Misoprostol Alone
for First-​Trimester Medical Abortion: A Systematic Review,” Obstetrics & Gynecology 133, no. 1 (January
2019): 137–​47, https://​doi.org/​10.1097/​AOG.00000​0000​0003​017.
205 FDA, Personal Importation, accessed April 11, 2023, https://​www.fda.gov/​indus​try/​imp​ort-​bas​
ics/​perso​nal-​impo​rtat​ion.
206 If/​When/​How: Lawyering for Reproductive Justice, “Fulfilling Roe’s Promise: 2019 Update,” 2019,
https://​www.ifwhen​how.org/​resour​ces/​roes-​unf​inis​hed-​prom​ise-​2019-​upd​ate/​.
207 If/​When/​How: Lawyering for Reproductive Justice, “If/​When/​How and the SIA Legal Team
Unite: Introducing the New Leading Edge in Lawyering for Reproductive Justice,” March 13, 2019, https://​
www.ifwhen​how.org/​sia-​legal-​team-​mer​ger-​annou​ncem​ent-​if-​when-​how/​.
208 If/​When/​How: Lawyering for Reproductive Justice, “Fulfilling Roe’s Promise: 2019 Update.”
209 April Lockley, interview by Carrie N. Baker, March 2, 2022.
210 Deborah Oyer, email to Carrie N. Baker, July 1, 2023.
211 Godfrey et al., “Factors Associated with Successful Implementation of Telehealth Abortion in 4
United States Clinical Practice Settings.”
268 • Endnotes

212 Emily M. Godfrey et al., “Family Medicine Provision of Online Medication Abortion in Three
US States during COVID-​19,” Contraception 104, no. 1 (July 2021): 54–​60, https://​doi.org/​10.1016/​j.contra​
cept​ion.2021.04.026.
213 Francine Coeytaux, interview by Carrie N. Baker, April 3, 2023.
214 Susheela Singh et al., “The Incidence of Abortion and Unintended Pregnancy in India, 2015,” The
Lancet Global Health 6, no. 1 (January 2018): e111–​20, https://​doi.org/​10.1016/​S2214-​109X(17)30453-​9.
215 Guttmacher Institute, “National Estimate of Abortion in India Released,” News Release, December
11, 2017, https://​www.gut​tmac​her.org/​news-​rele​ase/​2017/​natio​nal-​estim​ate-​abort​ion-​india-​relea​sed.
216 Raymond et al., “TelAbortion.”
217 Ushma D. Upadhyay, Alice F. Cartwright, and Nicole E. Johns, “Access to Medication Abortion
among California’s Public University Students,” Journal of Adolescent Health 63, no. 2 (August 2018): 249–​
52, https://​ doi.org/​ 10.1016/​ j.jad​
ohea​
lth.2018.04.009; Melody Gutierrez, “Abortion Medication to Be
Available at California’s College Health Centers under New Law,” Los Angeles Times, October 11, 2019, sec.
California, https://​www.lati​mes.com/​cal​ifor​nia/​story/​2019-​10-​11/​abort​ion-​med​icat​ion-​cal​ifor​nia-​coll​
ege-​hea​lth-​cent​ers-​legi​slat​ion.
218 “About GenBioPro Prescriber,” GenBioPro, accessed October 24, 2023, https://​genbio​pro.com/​
about-​genbio​pro-​pre​scri​ber/​.
219 Kirsten Moore, interview by Carrie N. Baker, May 4, 2023.
220 US Food and Drug Administration, “Risk Evaluation and Mitigation Strategy, Single Shared
System for Mifepristone,” April 2019, https://​www.fda.gov/​media/​164​650/​downl​oad.
221 Francine Coeytaux, interview by Carrie N. Baker, April 3, 2023.
222 Kirsten Moore, email to Carrie N. Baker, July 10, 2023.
223 Mitchell Creinin, interview by Carrie N. Baker, September 12, 2023.
224 US Food and Drug Administration, “Warning Letter to AidAccess.Org,” March 8, 2019, https://​
www.fda.gov/​insp​ecti​ons-​com​plia​nce-​enfo​rcem​ent-​and-​crimi​nal-​inv​esti​gati​ons/​warn​ing-​lett​ers/​aidac​
cess​org-​575​658-​03082​019.
225 Carrie N. Baker, “Telemedicine Abortion Provider Rebecca Gomperts Gets Abortion Pills into
the Hands of Those Who Need Them: ‘It’s a Privilege,’ ” Ms. magazine, February 23, 2023, https://​msm​agaz​
ine.com/​2022/​02/​23/​telem​edic​ine-​abort​ion-​rebe​cca-​gompe​rts-​abort​ion-​pills/​.
226 Gomperts v. Azar, Verified Complaint, United States District Court for the District of Ohio,
September 8, 2019, https://​www.docume​ntcl​oud.org/​docume​nts/​6390​359-​Acc​ess-​Aid-​Verif​ied-​Compla​
int-​With-​Exhib​its.html.
227 “Missouri Forcing Invasive Pelvic Exam on Women Seeking Abortions,” Rachel Maddow Show,
NBC, June 6, 2019, https://​www.msnbc.com/​rac​hel-​mad​dow/​watch/​misso​uri-​forc​ing-​invas​ive-​pel​vic-​
exam-​on-​women-​seek​ing-​abort​ion-​6146​2597​599.
228 Michael B. Thomas, “Missouri Health Director Tracked Menstrual Periods of Planned Parenthood
Patients,” NBC News, October 29, 2019, https://​www.nbcn​ews.com/​news/​us-​news/​misso​uri-​hea​lth-​direc​
tor-​trac​ked-​menstr​ual-​peri​ods-​plan​ned-​par​enth​ood-​patie​nts-​n1073​701.
229 Pamela Merritt, interview by Carrie N. Baker, June 14, 2023.
230 “US States Have Enacted 1,381 Abortion Restrictions Since Roe v. Wade Was Decided in 1973,”
Guttmacher Institute, June 28, 2022, https://​www.gut​tmac​her.org/​info​grap​hic/​2022/​us-​sta​tes-​have-​enac​
ted-​1381-​abort​ion-​restr​icti​ons-​roe-​v-​wade-​was-​deci​ded-​1973.
231 Jones et al., “Medication Abortion Now Accounts for More Than Half of All US Abortions.”

Chapter 3
1 Carrie N. Baker, “Telemedicine Abortion: What It Is and Why We Need It Now More Than Ever,”
Ms. magazine, March 26, 2020, https://​msm​agaz​ine.com/​2020/​03/​26/​telem​edic​ine-​abort​ion-​what-​it-​is-​
and-​why-​we-​need-​it-​now-​more-​than-​ever/​.
 Endnotes • 269

2 “DEA’s Response to COVID-​19” (Washington, DC: US Department of Justice Drug Enforcement

Administration, March 20, 2020), https://​www.dea.gov/​press-​relea​ses/​2020/​03/​20/​deas-​respo​nse-​covid-​
19; Kirsten Moore, interview by Carrie N. Baker, May 10, 2021.
3 Elizabeth G. Raymond et al., “Commentary: No-​test Medication Abortion: A Sample Protocol for
Increasing Access during a Pandemic and beyond,” Contraception 101, no. 6 (June 2020): 361–​66, https://​
doi.org/​10.1016/​j.contra​cept​ion.2020.04.005.
4 Emily Godfrey, interview by Carrie N. Baker, May 5, 2023.
5 Elizabeth G. Raymond et al., “Simplified Medical Abortion Screening: A Demonstration Project,”
Contraception 97, no. 4 (April 2018): 292–​96, https://​doi.org/​10.1016/​j.contra​cept​ion.2017.11.005.
6 Jamila Perritt, interview by Carrie N. Baker, May 11, 2022.
7 Baker, “Telemedicine Abortion: What It Is and Why We Need It Now More Than Ever.”
8 Baker.
9 Elisa Wells, email to Carrie N. Baker, June 29, 2023.
10 ACOG, COVID-​19 FAQs for Obstetrician–​Gynecologists, Gynecology, March 30, 2020. Washington,
DC: ACOG.
11 Carrie N. Baker, “Feminist Multi-​Front Battle to End FDA’s Abortion Pill Restriction,” Ms. maga-
zine, May 20, 2020, https://​msm​agaz​ine.com/​2020/​05/​20/​femin​ist-​multi-​front-​bat​tle-​to-​end-​fdas-​abort​
ion-​pill-​rest​rict​ion/​.
12 Baker.
13 Baker.
14 Baker.
15 Xavier Bacerra, “Letter to Secretary Alex M. Azar II and Commissioner Stephen Hahn,” March 30,
2020, https://​ag.ny.gov/​sites/​defa​ult/​files/​final_​ag_​letter_​h​hs_​m​edic​atio​n_​ab​orti​on_​2​020.pdf.
16 “Attorney General James Pushes to Increase Abortion Access by Medication during Coronavirus
Pandemic,” Press Release (Office of the New York Attorney General, March 30, 2020), https://​ag.ny.gov/​
press-​rele​ase/​2020/​attor​ney-​gene​ral-​james-​pus​hes-​incre​ase-​abort​ion-​acc​ess-​med​icat​ion-​dur​ing.
17 National Women’s Health Network et al., “Letter to Dr. Stephen Hahn,” April 6, 2020, https://​www.
nwhn.org/​wp-​cont​ent/​uplo​ads/​2020/​04/​2020-​04-​06-​FDA-​mifep​rist​one-​REMS-​let​ter-​FINAL-​1.pdf.
18 Susan F. Wood and Cynthia F. Pearson, “The UK Allows Home Use of the Abortion Pill—​the US
Should Do the Same,” The Hill, April 27, 2020, https://​theh​ill.com/​opin​ion/​hea​lthc​are/​494​914-​the-​uk-​all​
ows-​home-​use-​of-​the-​abort​ion-​pill-​the-​us-​sho​uld-​do-​the-​same/​.
19 Baker, “Telemedicine Abortion: What It Is and Why We Need It Now More Than Ever.”
20 Cynthia Pearson, interview by Carrie N. Baker, July 14, 2023.
21 Elizabeth Warren, “Letter to FDA Commissioner Stephen Hahn,” April 14, 2020, https://​www.
war​ren.sen​ate.gov/​imo/​media/​doc/​2020.04.14%20Let​ter%20to%20FDA%20re%20Med​icat​ion%20A​bort​
ion.pdf.
22 Diana DeGette, “Letter to FDA Commissioner Stephen Hahn,” June 16, 2020, https://​press​ley.
house.gov/​sites/​press​ley.house.gov/​files/​Mifep​rist​one%20Let​ter%20to%20FD​A_​6.16.2020.pdf.
23 Sarah Christopherson, interview by Carrie N. Baker, August 9, 2023.
24 Francine Coeytaux, interview by Carrie N. Baker, April 11, 2023.
25 Anna E. Fiastro et al., “Remote Delivery in Reproductive Health Care: Operation of Direct-​to-​
Patient Telehealth Medication Abortion Services in Diverse Settings,” The Annals of Family Medicine 20,
no. 4 (July 2022): 336–​42, https://​doi.org/​10.1370/​afm.2821.
26 University of Washington and Plan C, “Access, Delivered: A Toolkit for Providers Offering
Medication Abortion” (Seattle: University of Washington, 2020).
27 Elisa Wells, interview by Carrie N. Baker, May 24, 2023.
28 “ACOG Suit Petitions Court to Remove FDA’s Burdensome Barriers to Reproductive Care during
COVID-​19” (American College of Obstetricians and Gynecologists, May 27, 2020), https://​www.acog.org/​
news/​news-​relea​ses/​2020/​05/​acog-​suit-​petiti​ons-​the-​fda-​to-​rem​ove-​bur​dens​ome-​barri​ers-​to-​repro​duct​
ive-​care-​dur​ing-​covid-​19.
270 • Endnotes

29 Carrie N. Baker, “The Abortion Pill Mifepristone Just Became Easier to Get,” Ms. magazine, July
21, 2020, https://​msm​agaz​ine.com/​2020/​07/​21/​the-​abort​ion-​pill-​mifep​rist​one-​just-​bec​ame-​eas​ier-​to-​get/​.
30 Patrick Adams, “Amid Covid-​19, a Call for M.D.s to Mail the Abortion Pill,” The New York Times,
May 12, 2020, https://​www.nyti​mes.com/​2020/​05/​12/​opin​ion/​covid-​abort​ion-​pill.html.
31 Elisa Wells, interview by Carrie N. Baker, May 10, 2020.
32 Jones et al., “Medication Abortion Now Accounts for More Than Half of All US Abortions.”
33 Memorandum Opinion, ACOG v. FDA, Civil Action No. TDC-​20-​1320, July 13, 2020, https://​
www.aclu.org/​cases/​ameri​can-​coll​ege-​obstet​rici​ans-​and-​g yneco​logi​sts-​v-​us-​food-​and-​drug-​adm​inis​
trat​ion?docum​ent=​prel​imin​ary-​inj​unct​ion-​gran​ted.
34 Baker, “The Abortion Pill Mifepristone Just Became Easier to Get.”
35 “American College of Obstetricians and Gynecologists v. U.S. Food and Drug Administration,”
American Civil Liberties Union (blog), accessed July 8, 2023, http://​www.aclu.org/​cases/​ameri​can-​coll​ege-​
obstet​rici​ans-​and-​gyneco​logi​sts-​v-​us-​food-​and-​drug-​adm​inis​trat​ion.
36 Julie Amaon, interview by Carrie N. Baker, November 11, 2020.
37 Cindy Adam, interview by Carrie N. Baker, November 12, 2020.
38 Julie Amaon, interview by Carrie N. Baker, November 11, 2020.
39 Lauren Dubey, interview by Carrie N. Baker, November 12, 2020.
40 Lauren Dubey, interview by Carrie N. Baker, November 12, 2020.
41 Aisha Wagner, interview by Carrie N. Baker, November 12, 2020.
42 Aisha Wagner, interview by Carrie N. Baker, November 12, 2020.
43 Aisha Wagner, interview by Carrie N. Baker, November 12, 2020.
44 Cindy Adam and Lauren Dubey, interview by Carrie N. Baker, December 30, 2021.
45 Morgan Love, interview by Carrie N. Baker, November 11, 2020.
46 Phoebe Abramowitz, interview by Carrie N. Baker, November 11, 2020.
47 Morgan Love, interview by Carrie N. Baker, November 11, 2020.
48 Melissa Grant, interview by Carrie N. Baker, January 18, 2022; Leah Coplon, interview by Carrie
N. Baker, January 6, 2021.
49 Melissa Grant, interview by Carrie N. Baker, November 12, 2020.
50 Shelly Kaller et al., “Abortion Service Availability during the COVID-​19 Pandemic: Results from
a National Census of Abortion Facilities in the U.S.,” Contraception: X 3 (2021): 100067, https://​doi.org/​
10.1016/​j.conx.2021.100​067; Ushma D. Upadhyay et al., “Outcomes and Safety of History-​Based Screening
for Medication Abortion: A Retrospective Multicenter Cohort Study,” JAMA Internal Medicine 182, no. 5
(May 1, 2022): 482, https://​doi.org/​10.1001/​jamain​tern​med.2022.0217.
51 Order, ACOG v. FDA, Civil Action No. TDC-​20-​1320, United States District Court, District of
Maryland, August 19, 2020 (Judge Theodore J. Chuang).
52 Elisa Wells, email to Carrie N. Baker, June 9, 2023.
53 Abigail Abrams, “Meet the Pharmacist Expanding Access to Medication Abortion,” Time, June 13,
2022, https://​time.com/​6183​395/​abort​ion-​pills-​honey​bee-​hea​lth-​onl​ine-​pharm​acy/​.
54 Carrie N. Baker, “U.S.-​Based Online Pharmacy First to Ship Abortion Pills to Patients inside
the U.S.,” Ms. magazine, September 30, 2020, https://​msm​agaz​ine.com/​2020/​09/​30/​honey​bee-​hea​lth-​us-​
based-​onl​ine-​pharm​acy-​first-​to-​ship-​abort​ion-​pills-​to-​patie​nts-​ins​ide-​the-​u-​s/​.
55 Abrams, “Meet the Pharmacist Expanding Access to Medication Abortion.”
56 Baker, “U.S.-​Based Online Pharmacy First to Ship Abortion Pills to Patients inside the U.S.”
57 Elisa Wells, interview by Carrie N. Baker, November 5, 2020.
58 Plan C at www.pla​ncpi​lls.org (accessed November 15, 2020).
59 Carrie N. Baker, “People Are Getting Creative Obtaining Abortion Pills Online,” Ms. magazine,
February 7, 2022, https://​msm​agaz​ine.com/​2022/​02/​07/​how-​to-​get-​abort​ion-​pills-​onl​ine-​telem​edic​ine-​
abort​ion/​.
60 University of Washington and Plan C, “Access, Delivered: A Toolkit for Providers Offering
Medication Abortion.”
 Endnotes • 271

61 Melissa Grant, interview by Carrie N. Baker, November 12, 2020.

62 Ted Cruz, “Letter to Stephen Hahn,” September 1, 2020, https://​www.cruz.sen​ate.gov/​files/​docume​
nts/​Lett​ers/​2020.09.01%20-​-​%20Pro-​Life%20M​ifep​rex%20Let​ter%20to%20FDA%20-​%20FSV.pdf.
63 FDA v. ACOG, 592 U.S. _​_​_​ (2021), https://​www.supre​meco​urt.gov/​opini​ons/​20pdf/​20a​34_​3​
f14.pdf.
64 FDA v. ACOG, 592 _​_​_​(2021), at 12.
65 FDA v. ACOG, 592 _​_​_​(2021), at 8.
66 Carrie N. Baker, “SCOTUS Blocks Access to Abortion Pill by Mail during Pandemic. Advocates
Look to Biden Administration to Reverse Trump Policy,” Ms. magazine, January 13, 2021, https://​msm​agaz​
ine.com/​2021/​01/​13/​supr​eme-​court-​abort​ion-​pill-​trump-​biden/​.
67 Baker.
68 Baker.
69 Baker.
70 Baker.
71 Julie Amaon, interview by Carrie N. Baker, January 14, 2022.
72 Emily Bazelon, “Risking Everything to Offer Abortions across State Lines,” The New York Times,
October 4, 2022, sec. Magazine, 32, https://​www.nyti​mes.com/​2022/​10/​04/​magaz​ine/​abort​ion-​int​erst​ate-​
tra​vel-​post-​roe.html.
73 Hanna Kim, interview by Carrie N. Baker, March 16, 2022; Christie Pitney, interview by Carrie
N. Baker, January 17, 2022.
74 Tara Shochet, interview by Carrie N. Baker, January 12, 2021.
75 Rachel K. Jones et al., “Long-​Term Decline in US Abortions Reverses, Showing Risking Need for
Abortion as Supreme Court Is Poised to Overturn Roe v. Wade” (Washington, DC: Guttmacher Institute,
June 15, 2022), https://​www.gut​tmac​her.org/​arti​cle/​2022/​06/​long-​term-​decl​ine-​us-​aborti​ons-​rever​ses-​
show​ing-​ris​ing-​need-​abort​ion-​supr​eme-​court.
76 Jones et al.
77 Rosalyn Schroeder et al., “Trends in Abortion Care in the United States, 2017–​2021” (San
Francisco: Advancing New Standards in Reproductive Health, 2022), https://​www.drop​box.com/​s/​30zi​
y4nl​1o0w​clf/​ANSIRH​_​tre​nds-​in-​abort​ion-​care-​rep​ort-​v3.pdf?dl=​0.
78 Schroder et al.
79 Carrie N. Baker, “Abortion on Our Own Terms: ‘Supreme Court Justices Can’t Put Abortion Pills
Back in the Bottle,’ ” Ms. magazine, June 16, 2022, https://​msm​agaz​ine.com/​2022/​06/​16/​abort​ion-​pills-​
abort​ion-​on-​our-​own-​terms-​supr​eme-​court/​; Amy Allina, interview by Carrie N. Baker, May 16, 2023.
80 “GLC Membership Documents” (Generative Learning Community, December 2020), 1.
81 “GLC Membership Documents,” 1.
82 Francine Coeytaux, interview by Carrie N. Baker, May 3, 2023.
83 Kirsten Moore, interview by Carrie N. Baker, May 3, 2023.
84 Kirsten Moore, interview by Carrie N. Baker, November 13, 2020.
85 “First Priorities: Executive and Agency Actions Blueprint for Sexual and Reproductive Health,
Rights, and Justice” (Reproductive Blueprint, September 2020), https://​rep​robl​uepr​int.org/​wp-​cont​ent/​
uplo​ads/​2020/​09/​First-​Pri​orit​ies-​Execut​ive-​Age​ncy-​Acti​ons-​Incom​ing-​Adm​inis​trat​ion-​Bluepr​int.pdf.
86 Herminia Palacio and Daniel Grossman, “How the Biden Administration Should Stand Up for
Abortion Rights,” The Washington Post, January 27, 2021, https://​www.was​hing​tonp​ost.com/​opini​ons/​
2021/​01/​27/​biden-​abort​ion-​rig​hts-​ord​ers-​hea​lthc​are/​.
87 Sarah Christopherson, interview by Carrie N. Baker, August 9, 2023.
88 Dr. Woodcock took over as acting head of the FDA hours after Biden took office.
89 Carolyn Maloney et al., “Letter to Janet Woodcock, Acting Director of the FDA,” February 9, 2021.
90 ACLU et al., “Letter to Honorable Joseph R. Biden, Jr.,” March 18, 2021, https://​www.aclu.org/​let​
ter/​repro​duct​ive-​hea​lth-​rig​hts-​and-​just​ice-​gro​ups-​let​ter-​biden-​adm​inis​trat​ion-​mifep​rist​one.
272 • Endnotes

91 US Food and Drug Administration, “Risk Evaluation and Mitigation Strategy, Single Shared
System for Mifepristone,” April 2021, https://​www.fda.gov/​media/​164​651/​downl​oad.
92 Janet Woodcock, “Letter to Maureen G. Phipps and William Grobman,” April 12, 2021, https://​
www.aclu.org/​let​ter/​fda-​respo​nse-​acog-​april-​2021.
93 American College of Obstetricians and Gynecologists, “ACOG Applauds the FDA for Its Action on
Mifepristone Access during the COVID-​19 Pandemic,” April 12, 2021, https://​www.acog.org/​news/​news-​
relea​ses/​2021/​04/​acog-​appla​uds-​fda-​act​ion-​on-​mifep​rist​one-​acc​ess-​dur​ing-​covid-​19-​pande​mic.
94 Sarah Christopherson, interview by Carrie N. Baker, August 9, 2023.
95 Carrie N. Baker, “FDA Allows Telemedicine Abortion during Pandemic,” Ms. magazine, April 19,
2021, https://​msm​agaz​ine.com/​2021/​04/​19/​fda-​telem​edic​ine-​abort​ion-​pill-​mifep​rist​one/​.
96 Elisa Wells, interview by Carrie N. Baker, April 13, 2021.
97 Baker, “FDA Allows Telemedicine Abortion during Pandemic.”
98 Joint Motion to Stay Case Pending Agency Review, Chelius v. Becerra, United States District Court
for the District of Hawaii, Civ. No. 1:17-​00493 JAO-​RT, May 7, 2021, https://​www.aclu.org/​cases/​chel​ius-​v-​
bece​rra?docum​ent=​joint-​mot​ion-​stay-​case-​pend​ing-​age​ncy-​rev​iew.
99 Dr. Jamie Phifer, interview by Carrie N. Baker, May 18, 2021.
100 Dr. Razel Ramon, interview by Carrie N. Baker, February 22, 2022.
101 Hanna Kim, interview by Carrie N. Baker, March 16, 2022.
102 Christie Pitney, interview by Carrie N. Baker, January 17, 2022.
103 Robin Tucker, interview by Carrie N. Baker, December 24, 2021.
104 Dr. Deborah Oyer, interview by Carrie N. Baker, December 29, 2021.
105 Michele Gomez, interview by Carrie N. Baker, December 29, 2021.
106 Alison Case, interview by Carrie N. Baker, February 2, 2022.
107 Emily M. Godfrey et al., “Patient Perspectives Regarding Clinician Communication during
Telemedicine Compared with In-​Clinic Abortion,” Obstetrics & Gynecology Publish Ahead of Print (May
4, 2023), https://​doi.org/​10.1097/​AOG.00000​0000​0005​192.
108 Godfrey et al., 13.
109 Emily Godfrey, email to Carrie N. Baker, May 5, 2023.
110 Michele Gomez, interview by Carrie N. Baker, December 29, 2021.
111 “Availability of Telehealth Services for Medication Abortion in the U.S., 2020–​2022,” Issue
Brief (Advancing New Standards in Reproductive Health, June 2023).
112 Katherine Ehrenreich, M. Antonia Biggs, and Daniel Grossman, “Making the Case for Advance
Provision of Mifepristone and Misoprostol for Abortion in the United States,” BMJ Sexual & Reproductive
Health 48, no. 4 (October 2022): 238–​42, https://​doi.org/​10.1136/​bmj​srh-​2021-​201​321.
113 Carrie N. Baker, “Abortion Pills in Your Medicine Cabinet? Advance Provision Medication to
End Early Pregnancies,” Ms. magazine, December 14, 2021, https://​msm​agaz​ine.com/​2021/​12/​14/​abort​
ion-​pill-​end-​early-​pregna​ncy-​at-​home/​.
114 Baker.
115 M. Antonia Biggs et al., “Support for and Interest in Alternative Models of Medication Abortion
Provision among a National Probability Sample of U.S. Women,” Contraception 99, no. 2 (February
2019): 118–​24, https://​doi.org/​10.1016/​j.contra​cept​ion.2018.10.007.
116 Ehrenreich, Biggs, and Grossman, “Making the Case for Advance Provision of Mifepristone and
Misoprostol for Abortion in the United States.”

Chapter 4
1 Elizabeth Nash and Lauren Cross, “2021 Is on Track to Become the Most Devastating Antiabortion
State Legislative Session in Decades” (New York: Guttmacher Institute, April 2021), https://​www.gut​tmac​
her.org/​arti​cle/​2021/​04/​2021-​track-​bec​ome-​most-​deva​stat​ing-​antia​bort​ion-​state-​legi​slat​ive-​sess​ion-​
deca​des.
 Endnotes • 273

2 Abigail R. A. Aiken et al., “Demand for Self-​Managed Online Telemedicine Abortion in the United
States during the Coronavirus Disease 2019 (COVID-​19) Pandemic,” Obstetrics & Gynecology 136, no. 4
(October 2020): 835–​37, https://​doi.org/​10.1097/​AOG.00000​0000​0004​081.
3 Elisa Wells, interview by Carrie N. Baker, May 15, 2021.
4 S.B. 8, Texas 87th Legislature, 2021–​2022, https://​legis​can.com/​TX/​text/​SB8/​id/​2395​961.
5 Carrie N. Baker, “Educating Texans on How to Get Abortion Pills Online: ‘Your Nearest Provider Is
in Your Pocket,’ ” Ms. magazine, August 31, 2021, https://​msm​agaz​ine.com/​2021/​08/​31/​how-​to-​get-​abort​
ion-​pills-​onl​ine-​texas/​.
6 Baker.
7 Elisa Wells, interview by Carrie N. Baker, August 19, 2021.
8 Elisa Wells, interview by Carrie N. Baker, August 19, 2021.
9 Whole Woman’s Health v. Jackson, 594 U.S. _​_​_​(2021), https://​www.supre​meco​urt.gov/​opini​ons/​
20pdf/​21a​24_​8​759.pdf.
10 Elisa Wells, interview by Carrie N. Baker, September 25, 2021.
11 Carrie N. Baker, “Texas Law Prohibiting Mailing Abortion Pills Won’t Stop Texans Seeking Pills
Online,” Ms. magazine, October 11, 2021, https://​msm​agaz​ine.com/​2021/​10/​11/​texas-​mail-​abort​ion-​pills-​
onl​ine-​plan-​c-​sb4/​.
12 Abigail R. A. Aiken et al., “Association of Texas Senate Bill 8 with Requests for Self-​Managed
Medication Abortion,” JAMA Network Open 5, no. 2 (February 25, 2022): e221122, https://​doi.org/​10.1001/​
jama​netw​orko​pen.2022.1122.
13 Abigail Aiken, interview by Carrie N. Baker, February 26, 2022.
14 Aiken et al., “Association of Texas Senate Bill 8 with Requests for Self-​Managed Medication
Abortion.”
15 Aiken et al.
16 Aiken et al.
17 Michelle Cohen, interview by Carrie N. Baker, June 8, 2023.
18 Abigail Aiken, interview by Carrie N. Baker, February 26, 2022.
19 Baker, “Texas Law Prohibiting Mailing Abortion Pills Won’t Stop Texans Seeking Pills Online.”
20 Elisa Wells, interview by Carrie N. Baker, October 9, 2021.
21 Abigail Aiken, interview by Carrie N. Baker, February 26, 2022.
22 Abigail Aiken, interview by Carrie N. Baker, May 25, 2021.
23 Abigail Aiken, interview by Carrie N. Baker, May 25, 2021.
24 Abigail Aiken, interview by Carrie N. Baker, May 25, 2021.
25 Aiken, Starling, and Gomperts, “Factors Associated with Use of an Online Telemedicine Service to
Access Self-​Managed Medical Abortion in the US.”
26 Abigail Aiken, interview by Carrie N. Baker, May 25, 2021.
27 Abigail Aiken, interview by Carrie N. Baker, May 25, 2021.
28 Abigail Aiken, interview by Carrie N. Baker, May 25, 2021.
29 Abigail Aiken et al., “Effectiveness, Safety and Acceptability of No‐test Medical Abortion
(Termination of Pregnancy) Provided via Telemedicine: A National Cohort Study,” BJOG: An International
Journal of Obstetrics & Gynaecology 128, no. 9 (August 2021): 1464–​ 74, https://​ doi.org/​
10.1111/​
1471-​0528.16668.
30 Abigail Aiken, interview by Carrie N. Baker, February 17, 2021.
31 Abigail Aiken et al., “Effectiveness, Safety and Acceptability of No‐test Medical Abortion
(Termination of Pregnancy) Provided via Telemedicine.”
32 Abigail Aiken, interview by Carrie N. Baker, February 17, 2021.
33 Aiken et al., “Effectiveness, Safety and Acceptability of No‐test Medical Abortion (Termination of
Pregnancy) Provided via Telemedicine.”
34 Abigail Aiken, interview by Carrie N. Baker, February 17, 2021.
274 • Endnotes

35 Abigail R. A. Aiken et al., “Demand for Self-​Managed Online Telemedicine Abortion in Eight
European Countries during the COVID-​19 Pandemic: A Regression Discontinuity Analysis,” BMJ Sexual
& Reproductive Health 47, no. 4 (October 2021): 238–​45, https://​doi.org/​10.1136/​bmj​srh-​2020-​200​880.
36 Abigail Aiken, interview by Carrie N. Baker, February 17, 2021.
37 Holly A. Anger et al., “Clinical and Service Delivery Implications of Omitting Ultrasound before
Medication Abortion Provided via Direct-​to-​Patient Telemedicine and Mail in the U.S,” Contraception 104,
no. 6 (December 2021): 659–​65, https://​doi.org/​10.1016/​j.contra​cept​ion.2021.07.108; Erica Chong et al.,
“Expansion of a Direct-​to-​Patient Telemedicine Abortion Service in the United States and Experience
during the COVID-​19 Pandemic,” Contraception 104, no. 1 (July 2021): 43–​48, https://​doi.org/​10.1016/​
j.contra​cept​ion.2021.03.019.
38 Ushma D. Upadhyay, Leah R. Koenig, and Karen R. Meckstroth, “Safety and Efficacy of Telehealth
Medication Abortions in the US during the COVID-​19 Pandemic,” JAMA Network Open 4, no. 8 (August
24, 2021): e2122320, https://​doi.org/​10.1001/​jama​netw​orko​pen.2021.22320.
39 Ushma Upadhyay, interview by Carrie N. Baker, August 19, 2021.
40 Ushma Upadhyay, interview by Carrie N. Baker, August 19, 2021.
41 Kelly Cleland et al., “Contraception Special Issue on the Mifepristone Risk Evaluation and
Mitigation Strategy (REMS),” Contraception 104, no. 1 (July 2021): 1–​3, https://​doi.org/​10.1016/​j.contra​
cept​ion.2021.05.012.
42 Julia Kaye, Rachel Reeves, and Lorie Chaiten, “The Mifepristone REMS: A Needless and Unlawful
Barrier to Care,” Contraception 104, no. 1 (July 2021): 12–​ 15, https://​
doi.org/​
10.1016/​j.contra​
cept​
ion.2021.04.025.
43 Kirsten Moore, interviewed by Carrie N. Baker, May 10, 2021.
44 “Expressing the Sense of the House of Representatives That Policies Governing Access to
Medication Abortion Care in the United States Should Be Equitable and Based on Science,” Pub. L. No.
H. Res. 589 (2021), https://​www.congr​ess.gov/​bill/​117th-​congr​ess/​house-​res​olut​ion/​589/​cos​pons​ors?r=​
2&s=​3.
45 “Pressley, Maloney, Degette and Lee Announce Resolution in Support of Equitable, Science-​Based
Access to Medication Abortion Care,” Press Release (Office of Congresswoman Ayanna Pressley, August 19,
2021), https://​press​ley.house.gov/​2021/​08/​19/​press​ley-​malo​ney-​dege​tte-​lee-​and-​press​ley-​annou​nce​res​
olut​ion-​supp​ort-​equita​ble/​.
46 Daniel Grossman et al., “Medication Abortion with Pharmacist Dispensing of Mifepristone,”
Obstetrics & Gynecology 137, no. 4 (April 2021): 613–​22, https://​doi.org/​10.1097/​AOG.00000​0000​0004​312.
47 Carrie N. Baker, “FDA Lifts Some Abortion Pill Restrictions, Leaves Others in Place: ‘Ignores the
Science and Smacks of Political Interference,’ ” Ms. magazine, December 17, 2021, https://​msm​agaz​ine.
com/​2021/​12/​17/​fda-​abort​ion-​pill-​med​icat​ion-​biden-​mifep​rist​one/​.
48 Baker.
49 Baker.
50 Baker.
51 Baker.
52 Baker.
53 Kathryn Kolbert and Julie F. Kay, Controlling Women: What We Must Do Now to Save Reproductive
Freedom, 1st ed. (New York: Hachette Books, 2021), 189.
54 Baker, “FDA Lifts Some Abortion Pill Restrictions, Leaves Others in Place: ‘Ignores the Science and
Smacks of Political Interference.’ ”
55 Baker.
56 Emily Godfrey, interview by Carrie N. Baker, May 5, 2023.
57 Baker, “FDA Lifts Some Abortion Pill Restrictions, Leaves Others in Place.”
58 “Medication Abortion” (Guttmacher Institute, March 2022).
59 Elizabeth Nash, Lauren Cross, and Joerg Dreweke, “2022 State Legislative Sessions: Abortion Bans
and Restrictions on Medication Abortion Dominate.” (New York: Guttmacher Institute, March 2022).
 Endnotes • 275

60 “Potential Legal Flaws in State Restrictions Targeting Mifepristone” (New York: American Civil
Liberties Union, 2022), https://​www.aclu.org/​other/​potent​ial-​legal-​flaws-​state-​restr​icti​ons-​target​ing-​
mifep​rist​one.
61 Carrie N. Baker, “Self-​Managed Abortion Pill Ads Launch in 250 NYC Subway Stations,” Ms. mag-
azine, April 15, 2022, https://​msm​agaz​ine.com/​2022/​04/​15/​self-​mana​ged-​abort​ion-​pill-​ads-​nyc-​sub​way-​
plan-​c-​med​icat​ion-​abort​ion/​.
62 Elisa Wells, interview by Carrie N. Baker, April 13, 2022.
63 Elisa Wells, interview by Carrie N. Baker, April 13, 2022.
64 Elisa Wells, interview by Carrie N. Baker, April 13, 2022.
65 April Lockley, interview by Carrie N. Baker, March 14, 2022.
66 Kara Mailman, interview by Carrie N. Baker, November 28, 2021.
67 Kara Mailman, interview by Carrie N. Baker, November 28, 2021.
68 SASS, Instagram post, September 2, 2021, https://​www.instag​ram.com/​p/​CTV2​Iktg​gMG/​?utm​_​
med​ium=​copy_​l​ink.
69 Peggy Cooke, interview by Carrie N. Baker, November 28, 2021.
70 Peggy Cooke, interview by Carrie N. Baker, November 28, 2021.
71 Center for Countering Digital Hate, “Petition,” accessed November 30, 2021, https://​act.coun​terh​
ate.com/​page/​89325/​petit​ion/​1.
72 Reproaction, “Facebook and Instagram: Stop Hiding Abortion Information,” accessed November
30, 2021, https://​repr​oact​ion.org/​act​ion/​tell-​faceb​ook-​and-​instag​ram-​to-​stop-​hid​ing-​fact-​based-​abort​
ion-​info​rmat​ion/​.
73 Carrie N. Baker and Carly Thomsen, “Facebook Profits from Anti-​Abortion Misinformation
While Suppressing Medically Accurate Abortion Facts,” Ms. magazine, November 30, 2021, https://​msm​
agaz​ine.com/​2021/​11/​30/​faceb​ook-​anti-​abort​ion-​mis​info​rmat​ion-​abort​ion-​pill-​rever​sal/​.
74 Francine Coeytaux, interview by Carrie N. Baker, April 7, 2023.
75 Elisa Wells, interview by Carrie N. Baker, March 29, 2022.
76 Beverly Winikoff, interview by Carrie N. Baker, March 29, 2022.
77 Carrie N. Baker, “Is It Legal to Order Abortion Pills Online?,” Ms. magazine, December 22, 2021,
https://​msm​agaz​ine.com/​2021/​12/​22/​is-​it-​legal-​to-​order-​med​icat​ion-​abort​ion-​pills-​onl​ine/​.
78 Layal Liverpool, “ ‘Abortion Tests’ Developed in Poland Spark Concern,” Nature, October 11, 2023,
https://​doi.org/​10.1038/​d41​586-​023-​03129-​9.
79 Nash and Cross, “2021 Is on Track to Become the Most Devastating Antiabortion State Legislative
Session in Decades.”
80 US Food and Drug Administration, “Is It Legal for Me to Personally Import Drugs?” (FDA, June
28, 2021), https://​www.fda.gov/​about-​fda/​fda-​bas​ics/​it-​legal-​me-​per​sona​lly-​imp​ort-​drugs.
81 Elisa Wells, interview by Carrie N. Baker, September 25, 2021.
82 If/​When/​How: Lawyering for Reproductive Justice, “Fulfilling Roe’s Promise: 2019 Update.”
83 McCormack v. Hiedeman, Nos. 11-​36010 (9th Circuit, September 11, 2012), https://​case​law.find​
law.com/​us-​9th-​circ​uit/​1611​625.html.
84 Paltrow, “Roe v Wade and the New Jane Crow.”
85 Carrie N. Baker, “New Repro Legal Defense Fund Supports Self-​Managed Abortion,” Ms. maga-
zine, June 16, 2021, https://​msm​agaz​ine.com/​2021/​06/​16/​repro-​legal-​defe​nse-​fund-​if-​when-​how-​suppo​
rts-​self-​mana​ged-​abort​ion-​med​icat​ion-​abort​ion-​pill-​law​yer-​laws​uit/​.
86 Tina Vásquez, “American Bar Association’s Resolution Opposes Criminalization of Abortion or
Miscarriage,” Prism, March 9, 2021, https://​prism​repo​rts.org/​2021/​03/​09/​ameri​can-​bar-​assoc​iati​ons-​res​
olut​ion-​oppo​ses-​crim​inal​izat​ion-​of-​abort​ion-​or-​misc​arri​age/​.
87 Baker, “New Repro Legal Defense Fund Supports Self-​Managed Abortion.”
88 American College of Obstetricians and Gynecologists, “Opposition to Criminalization of Individuals
during Pregnancy and the Postpartum Period, Statement of Policy” (Washington, DC: American College
of Obstetricians and Gynecologists, 2020), https://​www.acog.org/​clini​cal-​info​rmat​ion/​pol​icy-​and-​posit​
276 • Endnotes

ion-​sta​teme​nts/​sta​teme​nts-​of-​pol​icy/​2020/​opp​osit​ion-​crim​inal​izat​ion-​of-​indi​vidu​als-​pregna​ncy-​and-​pos​
tpar​tum-​per​iod.
89 Elisa Wells, interview by Carrie N. Baker, December 19, 2021.
90 Pamela Merritt, interview by Carrie N. Baker, June 14, 2023.
91 Carrie N. Baker, “Woman Arrested for Abortion in Texas, Held on Half-​Million-​Dollar Bond: ‘This
Arrest Is Inhumane,’ ” Ms. magazine, April 9, 2022, https://​msm​agaz​ine.com/​2022/​04/​09/​woman-​arres​ted-​
abort​ion-​texas-​mex​ico-​mur​der-​lize​lle-​herr​era/​.
92 Carrie N. Baker, “Texas Woman Lizelle Herrera’s Arrest Foreshadows Post-​Roe Future,” Ms. maga-
zine, April 16, 2022, https://​msm​agaz​ine.com/​2022/​04/​16/​texas-​woman-​lize​lle-​herr​era-​arr​est-​mur​der-​
roe-​v-​wade-​abort​ion/​.
93 Stephen Vladeck, interview by Carrie N. Baker, April 7, 2022.
94 Lynn Paltrow, interview by Carrie N. Baker, April 14, 2022.
95 Lynn Paltrow, interview by Carrie N. Baker, April 14, 2022.
96 Paltrow, “Roe v Wade and the New Jane Crow.”
97 Lynn Paltrow, interview by Carrie N. Baker, April 14, 2022.
98 Lynn Paltrow, interview by Carrie N. Baker, April 14, 2022.
99 Lynn Paltrow, interview by Carrie N. Baker, April 14, 2022.
100 Stephen Vladeck, interview by Carrie N. Baker, April 13, 2022.
101 “Abortion in America: How Legislative Overreach Is Turning Reproductive Rights into Criminal
Wrongs” (Washington, DC: National Association of Criminal Defense Lawyers, 2021), 2, https://​www.
nacdl.org/​getatt​achm​ent/​ce089​9a0-​3588-​42d0-​b351-​23b97​90f3​bb8/​abort​ion-​in-​amer​ica-​how-​legi​slat​ive-​
overre​ach-​is-​turn​ing-​repro​duct​ive-​rig​hts-​into-​crimi​nal-​wro​ngs.pdf.
102 Elisa Wells, interview by Carrie N. Baker, June 1, 2022.
103 Elisa Wells, interview by Carrie N. Baker, June 1, 2022.
104 Abrams, “Meet the Pharmacist Expanding Access to Medication Abortion.”
105 Jessica Sarah Flaum, interview by Carrie N. Baker, May 25, 2022; Carrie N. Baker, “ ‘Abortion: Add
to Cart’ Envisions a Future for Safe Self-​Managed Abortion Post-​Roe,” Ms. magazine, May 27, 2022, https://​
msm​agaz​ine.com/​2022/​05/​24/​abort​ion-​add-​to-​cart-​docu​ment​ary-​film-​abort​ion-​pills/​.
106 Carrie N. Baker, “Abortion on Our Own Terms: ‘Supreme Court Justices Can’t Put Abortion Pills
Back in the Bottle,’ ” Ms. magazine, June 16, 2022, https://​msm​agaz​ine.com/​2022/​06/​16/​abort​ion-​pills-​
abort​ion-​on-​our-​own-​terms-​supr​eme-​court/​.
107 Erin Matson, interview by Carrie N. Baker, June 13, 2022.
108 Erin Matson, interview by Carrie N. Baker, June 13, 2022.
109 Sylvia Ghazarian, interview by Carrie N. Baker, May 27, 2022.
110 Sylvia Ghazarian, interview by Carrie N. Baker, May 27, 2022.
111 Upadhyay et al., “Outcomes and Safety of History-​Based Screening for Medication Abortion.”
112 Aiken et al., “Safety and Effectiveness of Self-​Managed Medication Abortion Provided Using
Online Telemedicine in the United States.”
113 World Health Organization, “Abortion Care Guidance.”
114 M. Antonia Biggs et al., “A Cross-​Sectional Survey of U.S. Abortion Patients’ Interest in Obtaining
Medication Abortion over the Counter,” Contraception 109 (May 2022): 25–​31, https://​doi.org/​10.1016/​
j.contra​cept​ion.2022.01.010.
115 Antonia Biggs, interview by Carrie N. Baker, February 7, 2022.
116 Karlin et al., “Greasing the Wheels.”
117 Biggs et al., “A Cross-​Sectional Survey of U.S. Abortion Patients’ Interest in Obtaining Medication
Abortion over the Counter.”
118 Antonio Biggs, interview by Carrie N. Baker, February 7, 2022.
119 Antonio Biggs, interview by Carrie N. Baker, February 7, 2022.
120 Antonio Biggs, interview by Carrie N. Baker, February 7, 2022.
 Endnotes • 277

Chapter 5
1 Linda Prine, interview by Carrie N. Baker, January 17, 2023.
2 Harmeet Kaur, “Why Tribal Lands Are Unlikely to Become Abortion Sanctuaries,” CNN, June 26,
2022, https://​www.cnn.com/​2022/​06/​26/​us/​tri​bal-​lands-​abort​ion-​safe-​hav​ens-​roe-​cec/​index.html.
3 The White House, “Executive Order on Protecting Access to Reproductive Healthcare Services,”
The White House, July 8, 2022, https://​www.whi​teho​use.gov/​brief​ing-​room/​presi​dent​ial-​acti​ons/​2022/​07/​
08/​execut​ive-​order-​on-​pro​tect​ing-​acc​ess-​to-​repro​duct​ive-​hea​lthc​are-​servi​ces/​.
4 Office for Civil Rights (OCR), “HHS Issues Guidance to the Nation’s Retail Pharmacies Clarifying
Their Obligations to Ensure Access to Comprehensive Reproductive Health Care Services,” HHS.gov, July
13, 2022, https://​www.hhs.gov/​about/​news/​2022/​07/​13/​hhs-​iss​ues-​guida​nce-​nati​ons-​ret​ail-​pha​rmac​ies-​
cla​rify​ing-​their-​obli​gati​ons-​ens​ure-​acc​ess-​compre​hens​ive-​repro​duct​ive-​hea​lth-​care-​servi​ces.html.
5 The White House, “Executive Order on Securing Access to Reproductive and Other Healthcare
Services,” The White House, August 3, 2022, https://​www.whi​teho​use.gov/​brief​ing-​room/​presi​dent​ial-​acti​
ons/​2022/​08/​03/​execut​ive-​order-​on-​secur​ing-​acc​ess-​to-​repro​duct​ive-​and-​other-​hea​lthc​are-​servi​ces/​.
6 “#WeCount Report April to August 2022 Findings” (Society of Family Planning, October 28, 2022),
https://​doi.org/​10.46621/​UKAI6​324.
7 Aatish Bhatia, Claire Cain Miller, and Margot Sanger-​Katz, “A Surge of Overseas Abortion Pills
Blunted the Effects of State Abortion Bans,” The New York Times, November 1, 2022, sec. The Upshot,
https://​www.nyti​mes.com/​2022/​11/​01/​ups​hot/​abort​ion-​pills-​mail-​overs​eas.html.
8 Abigail R. A. Aiken et al., “Requests for Self-​Managed Medication Abortion Provided Using Online
Telemedicine in 30 US States before and after the Dobbs v Jackson Women’s Health Organization Decision,”
JAMA 328, no. 17 (November 1, 2022): 1768, https://​doi.org/​10.1001/​jama.2022.18865.
9 Carrie N. Baker, “Self-​Managed Abortions Soar Post-​Dobbs,” Ms. magazine, November 7, 2022,
https://​msm​agaz​ine.com/​2022/​11/​07/​abort​ion-​pills-​roe-​v-​wade-​dobbs/​.
10 Charlotte Alter, “This Group Wants to Teach You How to Get Abortions Even Where They’re
Banned,” Time, December 9, 2022, https://​time.com/​6239​573/​may​day-​hea​lth-​abort​ion-​pills/​.
11 Baker, “Self-​Managed Abortions Soar Post-​Dobbs.”
12 Aiken et al., “Requests for Self-​Managed Medication Abortion Provided Using Online Telemedicine
in 30 US States before and after the Dobbs v Jackson Women’s Health Organization Decision.”
13 Abigail R.A. Aiken, interviewed by Carrie N. Baker, November 5, 2022.
14 Carrie N. Baker, “Mexican Telehealth Abortion Provider Now Serves U.S. Women: ‘We Are Here
for You!’,” Ms. magazine, July 26, 2022, https://​msm​agaz​ine.com/​2022/​07/​26/​mex​ico-​abort​ion-​pills-​us-​bor​
der-​tele​fem-​tel​ehea​lth/​.
15 Paula Rita Rivera, interviewed by Carrie N. Baker, July 24, 2022.
16 Carrie N. Baker, “What Clinicians Want You to Know about Getting Abortion Pills in Anti-​
Abortion States,” Ms. magazine, March 14, 2023.
17 Baker.
18 Baker.
19 Baker.
20 Baker.
21 Baker.
22 Baker.
23 Laura Huss, Farah Diaz-​ Tello, and Goleen Samari, “Self-​ Care, Criminalized: August 2022
Preliminary Findings” (If/​When/​How: Lawyering for Reproductive Justice, 2022), https://​www.ifwhen​
how.org/​downl​oad/​?key=​vL4​3kFF​axm.
24 Purvaja S. Kavattur et al., “The Rise of Pregnancy Criminalization: A Pregnancy Justice Report”
(Washington, DC: Pregnancy Justice, September 2023), https://​www.pre​gnan​cyju​stic​eus.org/​rise-​of-​
pregna​ncy-​crim​inal​izat​ion-​rep​ort/​.
25 Linda Prine, interview by Carrie N. Baker, March 12, 2023.
278 • Endnotes

26 Eleanor Klibanoff, “Three Texas Women Are Sued for Wrongful Death after Allegedly Helping
Friend Obtain Abortion Medication,” The Texas Tribune, March 10, 2023, https://​www.texas​trib​une.org/​
2023/​03/​10/​texas-​abort​ion-​laws​uit/​.
27 Poppy Noor, “Republicans Push Wave of Bills That Would Bring Homicide Charges for Abortion,”
The Guardian, March 10, 2023, sec. US news, https://​www.theg​uard​ian.com/​us-​news/​2023/​mar/​10/​rep​
ubli​can-​wave-​state-​bills-​homic​ide-​char​ges.
28 Rebecca Wang, interview by Carrie N. Baker, March 13, 2023.
29 Patrick Adams, “Opinion | In Poland, Testing Women for Abortion Drugs Is a Reality. It Could
Happen Here,” The New York Times, September 14, 2023, sec. Opinion, https://​www.nyti​mes.com/​2023/​
09/​14/​opin​ion/​abort​ion-​pills-​test​ing-​pol​and.html; Liverpool, “ ‘Abortion Tests’ Developed in Poland
Spark Concern.”
30 Ibis Reproductive Health, “Feminist Medication Abortion Accompaniment 101” (Cambridge,
MA, November 2021), https://​www.ibi​srep​rodu​ctiv​ehea​lth.org/​sites/​defa​ult/​files/​files/​publi​cati​ons/​Abort​
ion%20ac​comp​anim​ent%20101.pdf.
31 Heidi Moseson et al., “Effectiveness of Self-​Managed Medication Abortion with Accompaniment
Support in Argentina and Nigeria (SAFE): A Prospective, Observational Cohort Study and Non-​inferiority
Analysis with Historical Controls,” The Lancet Global Health 10, no. 1 (January 2022): e105–​13, https://​
doi.org/​10.1016/​S2214-​109X(21)00461-​7; Caitlin Gerdts et al., “Effect of a Smartphone Intervention on
Self-​Managed Medication Abortion Experiences among Safe-​Abortion Hotline Clients in Indonesia: A
Randomized Controlled Trial,” International Journal of Gynaecology and Obstetrics: The Official Organ of
the International Federation of Gynaecology and Obstetrics 149, no. 1 (April 2020): 48–​55, https://​doi.org/​
10.1002/​ijgo.13086.
32 Heidi Moseson et al., “Effectiveness of Self-​Managed Medication Abortion between 13 and 24
Weeks Gestation: A Retrospective Review of Case Records from Accompaniment Groups in Argentina,
Chile, and Ecuador,” Contraception 102, no. 2 (August 2020): 91–​98, https://​doi.org/​10.1016/​j.contra​
cept​ion.2020.04.015; Caitlin Gerdts et al., “Second-​Trimester Medication Abortion outside the Clinic
Setting: An Analysis of Electronic Client Records from a Safe Abortion Hotline in Indonesia,” BMJ Sexual
& Reproductive Health 44, no. 4 (July 18, 2018): 286–​91, https://​doi.org/​10.1136/​bmj​srh-​2018-​200​102.
33 “Red Compañera,” accessed November 12, 2023, https://​redcom​pafe​mini​sta.org/​; “MAMA
Network,” accessed November 12, 2023, https://​mama​netw​ork.org/​.
34 Lara Islinger, interview with Carrie N. Baker, November 12, 2023.
35 Ibis Reproductive Health, “Feminist Medication Abortion Accompaniment 101.”
36 Stephania Taladrid, “The Post-​Roe Abortion Underground,” The New Yorker, October 10, 2022,
https://​www.newyor​ker.com/​magaz​ine/​2022/​10/​17/​the-​post-​roe-​abort​ion-​unde​rgro​und.
37 “Find Abortion Pill Access in Your State | Plan C,” accessed April 18, 2023, https://​www.pla​ncpi​lls.
org/​find-​pills.
38 Francine Coeytaux, interviewed by Carrie N. Baker, April 11, 2023.
39 “An Act Expanding Protections for Reproductive and Gender Affirming Care,” Chapter 127 of the
Acts of 2022, https://​malegi​slat​ure.gov/​Laws/​Sess​ionL​aws/​Acts/​2022/​Cha​pter​127.
40 Massachusetts General Assembly, “An Act Expanding Protections for Reproductive and Gender-​
Affirming Care” (2022), https://​malegi​slat​ure.gov/​Laws/​Sess​ionL​aws/​Acts/​2022/​Cha​pter​127.
41 Carrie N. Baker, “Groundbreaking Massachusetts Abortion Law Repeals Parental Consent for
Older Teens,” Ms. magazine, December 29, 2020, https://​msm​agaz​ine.com/​2020/​12/​29/​massac​huse​tts-​
abort​ion-​law-​roe-​act/​.
42 David S. Cohen, Greer Donley, and Rachel Rebouché, “The New Abortion Battleground,” Columbia
Law Review 123, no. 1 (2022): 1–​100, 35, 82.
43 Elisa Wells, interview by Carrie N. Baker, May 31, 2023.
44 The White House, “Readout of Vice President Kamala Harris’s Meeting with Governor Baker,
Massachusetts State Legislators, and Advocates on Reproductive Rights,” The White House, August 5,
 Endnotes • 279

2022, https://​www.whi​teho​use.gov/​brief​ing-​room/​sta​teme​nts-​relea​ses/​2022/​08/​04/​read​out-​of-​vice-
​presid​ent-​kam​ala-​harr​iss-​meet​ing-​with-​gover​nor-​baker-​massac​huse​tts-​state-​legi​slat​ors-​and-​advoca​tes-​
on-​repro​duct​ive-​rig​hts/​.
45 Linda Prine, interview by Carrie N. Baker, August 16, 2022.
46 “SB-​345 Health Care Services: Legally Protected Health Care Activities,” accessed April 18, 2023,
https://​legi​nfo.legi​slat​ure.ca.gov/​faces/​billNa​vCli​ent.xhtml?bill​_​id=​202​3202​40SB​345.
47 Carrie N. Baker, “New York Shield Law Would Protect Clinicians Mailing Abortion Pills to Patients
in Red States,” Ms. magazine, January 19, 2023, https://​msm​agaz​ine.com/​2023/​01/​19/​new-​york-​shi​eld-​
law-​abort​ion-​pills/​.
48 Linda Prine, interview by Carrie N. Baker, January 17, 2023.
49 “Tell NYS Legislators to Protect Telemab,” Reproductive Health Access Project, accessed April 18,
2023, https://​www.rep​rodu​ctiv​eacc​ess.org/​get-​invol​ved/​12-​22-​nys-​leg​isla​tor-​let​ter/​.
50 Linda Prine, interview by Carrie N. Baker, January 17, 2023.
51 Bazelon, “Risking Everything to Offer Abortions across State Lines,” 28.
52 Linda Prine, interview by Carrie N. Baker, January 17, 2023.
53 Linda Prine, interview by Carrie N. Baker, January 17, 2023.
54 Elisa Wells, interview by Carrie N. Baker, May 31, 2023.
55 “An Act Relating to Protecting Access to Reproductive Health Care Services and Gender-​Affirming
Treatment in Washington State, 68th Legislature” (2023), https://​legis​can.com/​WA/​text/​HB1​469/​2023.
56 Francine Coeytaux, interview by Carrie N. Baker, May 2, 2023.
57 Elisa Wells, interview by Carrie N. Baker, May 31, 2023.
58 Pamela Belluck and Emily Bazelon, “New York Passes Bill to Shield Abortion Providers Sending
Pills into States with Bans,” The New York Times, June 20, 2023, sec. Health, https://​www.nyti​mes.com/​
2023/​06/​20/​hea​lth/​abort​ion-​shi​eld-​law-​new-​york.html.
59 Carrie N. Baker, “California Becomes the Sixth State to Legally Protect Telehealth Abortion and
Gender-​Care Providers,” Ms. magazine, October 3, 2023, https://​msm​agaz​ine.com/​2023/​10/​03/​cal​ifor​nia-​
shi​eld-​law-​tel​ehea​lth-​abort​ion-​pills-​trans-​gen​der-​affirm​ing-​care/​.
60 Caroline Kitchener et al., “A Fragile New Phase of Abortion in America,” The Washington Post,
accessed June 23, 2023, https://​www.was​hing​tonp​ost.com/​polit​ics/​inte​ract​ive/​2023/​roe-​v-​wade-​rul​ing-​
one-​year-​anni​vers​ary/​.
61 “Blue-​State Doctors Launch Abortion Pill Pipeline into States with Bans,” Washington Post, July
20, 2023, https://​www.was​hing​tonp​ost.com/​polit​ics/​2023/​07/​19/​doct​ors-​northe​ast-​lau​nch-​abort​ion-​pill-​
pipel​ine-​into-​sta​tes-​with-​bans/​.
62 Anonymous, interview by Carrie N. Baker, July 20, 2023.
63 Julie F. Kay, interview by Carrie N. Baker, July 20, 2023.
64 Elisa Wells, interview by Carrie N. Baker, May 31, 2023. Abuzz Health at https://​www.abuz​zhea​
lth.com/​.
65 Michelle Cohen, interview by Carrie N. Baker, June 8, 2023.
66 Julie F. Kay, email to Carrie N. Baker, October 2, 2023.
67 Hey Jane, “One Year since Dobbs: How Medication Abortion Has Changed Post-​Roe | Hey Jane,”
accessed June 21, 2023, https://​www.heyj​ane.com/​artic​les/​abort​ion-​chan​ges-​post-​roe.
68 “Medication Abortion Access Project,” Cambridge Reproductive Health Consultants, accessed
October 4, 2023, https://​www.cambridgere​prod​ucti​vehe​alth​cons​ulta​nts.org/​map.
69 Maggie Carpenter, interview with Carrie N. Baker, October 10, 2023.
70 Maggie Carpenter, interview with Carrie N. Baker, October 10, 2023.
71 Cohen, Donley, and Rebouché, “The New Abortion Battleground,” 3.
72 Bazelon, “Risking Everything to Offer Abortions across State Lines,” 30.
73 Julie F. Kay, interview by Carrie N. Baker, July 20, 2023.
74 Julie F. Kay, interview by Carrie N. Baker, July 20, 2023.
75 Julie F. Kay, interview by Carrie N. Baker, July 20, 2023.
280 • Endnotes

76 Cohen, Donley, and Rebouché, “The New Abortion Battleground,” 44–​45.

77 The Associated Press, “Judge Temporarily Blocks Wyoming’s 1st-​in-​the-​Nation Abortion Pill Ban,”
NPR, June 23, 2023, sec. National, https://​www.npr.org/​2023/​06/​23/​118​3924​567/​judge-​temp​orar​ily-​blo​
cks-​wyomi​ngs-​1st-​in-​the-​nat​ion-​abort​ion-​pill-​ban.
78 “Medication Abortion,” Guttmacher Institute, June 1, 2023, https://​www.gut​tmac​her.org/​state-​pol​
icy/​expl​ore/​med​icat​ion-​abort​ion.
79 Greer Donley, interview by Carrie N. Baker, June 1, 2022.
80 Zogenix, Inc. v. Patrick, Civil Action No. 14-​11689-​RWZ (July 8, 2014).
81 Cohen, Donley, and Rebouché, “The New Abortion Battleground,” 43–​59; Rachel Rebouché, inter-
view by Carrie N. Baker, May 31, 2022.
82 “Attorney General Merrick B. Garland Statement on Supreme Court Ruling in Dobbs v. Jackson
Women’s Health Organization, Department of Justice, Office of Public Affairs,” June 24, 2022, https://​
www.just​ice.gov/​opa/​pr/​attor​ney-​gene​ral-​merr​ick-​b-​garl​and-​statem​ent-​supr​eme-​court-​rul​ing-​dobbs-​v-​
jack​son-​women-​s.
83 GenBioPro, Inc. v. Dobbs, No. 3:2020cv00652, accessed April 25, 2023.
84 GenBioPro v. Sorsaia and Morrisey, No. 2:23-​cv-​11111 (US District Court for the Southern District
of West Virginia, Huntington Division January 25, 2023).
85 Carrie N. Baker, “Two New Lawsuits Challenge State Restrictions on Abortion Pill Access, Arguing
Federal Law Preempts State Laws,” Ms. magazine, January 25, 2023, https://​msm​agaz​ine.com/​2023/​01/​25/​
lawsu​its-​state-​law-​abort​ion-​pill-​fede​ral-​fda/​.
86 GenBioPro v. Raynes and Morrisey, Civil Action No.: 3:23-​cv-​00058 (S.D. West Va., 2023).
87 Baker, “Two New Lawsuits Challenge State Restrictions on Abortion Pill Access, Arguing Federal
Law Preempts State Laws.”
88 Baker.
89 Amy Friedrich-​Karnik, Emma Stoskopf-​Ehrlich, and Rachel K. Jones, “Medication Abortion
within and outside the Formal US Health Care System: What You Need to Know,” Guttmacher Institute,
February 2024, https://​www.gut​tmac​her.org/​2024/​02/​med​icat​ion-​abort​ion-​wit​hin-​and-​outs​ide-​for​mal-​
us-​hea​lth-​care-​sys​tem-​what-​you-​need-​know.
90 Memorandum and Order, Amy Bryant v. Joshua H. Stein, 1:23-​CV-​77, United States District Court
for the Middle District of North Carolina, April 30, 2024.
91 Emails to author from Kirsten Moore and Francine Coeytaux, May 1, 2024.
92 Gutierrez, “Abortion Medication to Be Available at California’s College Health Centers under
New Law.”
93 Carrie N. Baker, “Increasing Gender Equity through Abortion Pills on Campus,” Ms. magazine, July
7, 2021, https://​msm​agaz​ine.com/​2021/​07/​07/​abort​ion-​pill-​coll​ege-​cam​pus-​uni​vers​ity-​massac​huse​tts/​.
94 Carrie N. Baker and Julia Mathis, “Barriers to Medication Abortion among Massachusetts
Public University Students,” Contraception 109 (May 2022): 32–​36, https://​doi.org/​10.1016/​j.contra​cept​
ion.2021.12.010.
95 Tessa Holtzman et al., “Reproductive Health and Community College Students: Building
Momentum toward Holistic Approaches to Student Success,” IWPR (blog), November 4, 2019, https://​iwpr.
org/​media/​in-​the-​lead/​repro​duct​ive-​hea​lth-​and-​commun​ity-​coll​ege-​stud​ent-​succ​ess/​; Mary Prentice,
Chelsey Storin, and Gail Robinson, “Make It Personal: How Pregnancy Planning and Prevention Help
Students Complete College” (Washington, DC: American Association of Community Colleges, 2012);
Lawrence B. Finer et al., “Reasons U.S. Women Have Abortions: Quantitative and Qualitative Perspectives,”
Perspectives on Sexual and Reproductive Health 37 (September 1, 2005): 110–​18.
96 Carrie N. Baker, “Groundbreaking Massachusetts Law Protects Telemedicine Abortion Providers
Serving Patients Located in States Banning Abortion,” Ms. magazine, August 18, 2022, https://​msm​agaz​ine.
com/​2022/​08/​18/​massac​huse​tts-​abort​ion-​law/​.
97 Carrie N. Baker, “Students Rally for Medication Abortion at University Health Centers in
N.Y.: ‘Direct, Unfettered and Accessible,’ ” Ms. magazine, December 21, 2022, https://​msm​agaz​ine.com/​
2022/​12/​21/​abort​ion-​pills-​new-​york-​coll​ege-​uni​vers​ity-​hea​lth/​.
 Endnotes • 281

98 Baker.
99 Baker.
100 Baker.
101 Baker.
102 Baker.
103 Baker.
104 Kayla Bamberger, “New York Takes Steps to Assure Access to Abortion Pills on Public College
Campuses,” New York Daily News, April 28, 2023, https://​www.nyda​ilyn​ews.com/​new-​york/​educat​ion/​ny-​
new-​york-​posed-​to-​offer-​abort​ion-​pills-​on-​pub​lic-​coll​ege-​campu​ses-​20230​428-​duc​rtnl​wwbd​y5ip​qsdb​
jbyp​da4-​story.html.
105 Baker, “Students Rally for Medication Abortion at University Health Centers in N.Y.: ‘Direct,
Unfettered and Accessible.’ ”
106 “On Eve of Dobbs Decision Anniversary, Governor Hochul Signs Legislation Strengthening
Access to Reproductive Health Care,” June 23, 2023, https://​www.gover​nor.ny.gov/​news/​eve-​dobbs-​decis​
ion-​anni​vers​ary-​gover​nor-​hoc​hul-​signs-​legi​slat​ion-​streng​then​ing-​acc​ess.
107 Carrie N. Baker, “Citizen Petition to FDA Requests Lifting Restrictions on Mifepristone for
Miscarriage Use,” Ms. magazine, October 20, 2022, https://​msm​agaz​ine.com/​2022/​10/​20/​fda-​mifep​rist​
one-​misc​arri​age/​.
108 Kirsten Moore, interview by Carrie N. Baker, October 18, 2022.
109 Schreiber et al., “Mifepristone Pretreatment for the Medical Management of Early Pregnancy Loss.”
110 “Alabama HB261 | TrackBill,” accessed April 18, 2023, https://​trackb​ill.com/​bill/​alab​ama-​house-​
bill-​261-​abort​ion-​ban-​non-​surgi​cal-​chemi​cal-​aborti​ons-​crimi​nal-​penalt​ies-​alab​ama-​chemi​cal-​abort​ion-​
proh​ibit​ion-​act/​2217​015/​; “HB2811 Unlawful Abortion Medication, Arizona State Legislature” (2022),
https://​www.azleg.gov/​legt​ext/​55leg/​2r/​bills/​hb28​11p.htm.
111 Carrie N. Baker, “Citizen Petition to FDA Requests Lifting Restrictions on Mifepristone for
Miscarriage Use,” Ms. magazine, October 20, 2022, https://​msm​agaz​ine.com/​2022/​10/​20/​fda-​mifep​rist​
one-​misc​arri​age/​.
112 Kirsten Moore, interview by Carrie N. Baker, October 18, 2022.
113 Kirsten Moore, interview by Carrie N. Baker, October 18, 2022.
114 Danielle Calloway, Debra B. Stulberg, and Elizabeth Janiak, “Mifepristone Restrictions and
Primary Care: Breaking the Cycle of Stigma through a Learning Collaborative Model in the United States,”
Contraception 104, no. 1 (July 2021): 24–​28, https://​doi.org/​10.1016/​j.contra​cept​ion.2021.04.002; Sara
Neill, Alisa Goldberg, and Elizabeth Janiak, “Medication Management of Early Pregnancy Loss: The Impact
of the U.S. Food and Drug Administration Risk Evaluation and Mitigation Strategy [A289],” Obstetrics &
Gynecology 139 (May 2022): 83S, https://​doi.org/​10.1097/​01.AOG.000​0825​716.77939.40.
115 ACOG et al., “Citizen Petition to Lauren Roth, Associate Commissioner for Policy, U.S. Food
and Drug Administration,” October 4, 2022, https://​emaa​proj​ect.org/​wp-​cont​ent/​uplo​ads/​2022/​10/​Citi​
zen-​Petit​ion-​from-​the-​Ameri​can-​Coll​ege-​of-​Obste​tric​ian-​and-​Gyneco​logi​sts-​et-​al-​10.3.22-​EMAA-​webs​
ite.pdf.
116 Kirsten Moore, interview by Carrie N. Baker, October 18, 2022.
117 Patritzia Cavazzoni, “Agency Response Letter from FDA CDER to American College
of Obstetricians and Gynecologists,” January 5, 2023, https://​ www.regu​lati​
ons.gov/​docum​ ent/​
FDA-​2022-​P-​2425-​0003.
118 “Open Letter to the Senior Leadership and Board of Directors of Danco Laboratories, LLC
from Senators Mazie K. Hirono, Margaret Wood Hassan, Elizabeth Warren, Richard Blumenthal, Jeanne
Shaheen, Ron Wyden, Kirsten Gillibrand and Alex Padilla,” February 1, 2023, https://​www.hir​ono.sen​ate.
gov/​imo/​media/​doc/​2023.02.01_​FI​NAL_​Misc​arri​age%20Man​agem​ent%20M​ifep​rist​one%20La​bel.pdf.
119 “Open Letter to the Senior Leadership and Board of Directors of Danco Laboratories, LLC
from Senators Mazie K. Hirono, Margaret Wood Hassan, Elizabeth Warren, Richard Blumenthal, Jeanne
Shaheen, Ron Wyden, Kirsten Gillibrand and Alex Padilla.”
282 • Endnotes

120 Elise W. Boos et al., “Trends in the Use of Mifepristone for Medical Management of Early
Pregnancy Loss from 2016 to 2020,” JAMA 330, no. 8 (August 22, 2023): 766–​68, https://​doi.org/​10.1001/​
jama.2023.13628.
121 Kirsten Moore, interview by Carrie N. Baker, February 1, 2023.
122 Patritzia Cavazzoni, “Letter from Director of the Center for Drug Evaluation and Research of the U.S.
Food and Drug Administration to Graham Chelius of the Society of Family Planning,” December 16, 2021.
123 Kirsten Moore, interview by Carrie N. Baker, January 4, 2023.
124 Carrie N. Baker, “FDA Allows Pharmacies to Sell Abortion Pills—​but Requires Unnecessary and
Burdensome Certification Process,” Ms. magazine, January 6, 2023, https://​msm​agaz​ine.com/​2023/​01/​06/​
fda-​pha​rmac​ies-​abort​ion-​pills/​.
125 Kirsten Moore, interview by Carrie N. Baker, January 4, 2023.
126 Baker, “FDA Allows Pharmacies to Sell Abortion Pills—​ but Requires Unnecessary and
Burdensome Certification Process.”
127 Carrie N. Baker, “Anti-​Abortion Groups Try to Intimidate Pharmacies Planning to Dispense
Abortion Pills,” Ms. magazine, January 31, 2023, https://​msm​agaz​ine.com/​2023/​01/​31/​anti-​abort​ion-​prot​
est-​pha​rmac​ies-​abort​ion-​pills/​.
128 duVergne Gaines, interview by Carrie N. Baker, January 29, 2023.
129 Baker, “Anti-​Abortion Groups Try to Intimidate Pharmacies Planning to Dispense Abortion Pills.”
130 The White House, “Memorandum on Further Efforts to Protect Access to Reproductive
Healthcare Services,” The White House, January 22, 2023, https://​www.whi​teho​use.gov/​brief​ing-​room/​
presi​dent​ial-​acti​ons/​2023/​01/​22/​mem​oran​dum-​on-​furt​her-​effo​rts-​to-​prot​ect-​acc​ess-​to-​repro​duct​ive-​hea​
lthc​are-​servi​ces/​.
131 duVergne Gaines, interview by Carrie N. Baker, January 29, 2023.
132 Carrie N. Baker, “After Backlash, Walgreens Re-​pledges to Sell Abortion Pill Mifepristone,” Ms.
magazine, March 3, 2023, https://​msm​agaz​ine.com/​2023/​03/​03/​fda-​pha​rmac​ies-​abort​ion-​pills/​.
133 Baker.
134 Carrie N. Baker, “Brick-​and-​Mortar Pharmacies Begin Dispensing Abortion Pills across the U.S.,”
Ms. magazine, October 11, 2023, https://​msm​agaz​ine.com/​2023/​10/​11/​pha​rmac​ies-​abort​ion-​pill-​mifep​
rist​one/​.
135 Caroline Lewis, “NYC’s Public Hospitals to Offer Abortion Pills via Mail and Telehealth,”
Gothamist, October 2, 2023, https://​gotham​ist.com/​news/​nyc-​pub​lic-​hospit​als-​to-​offer-​abort​ion-​pills-​
via-​tel​ehea​lth-​desp​ite-​unce​rtai​nty-​in-​cou​rts.
136 As of July 11, 2023, AccessMA served Alabama, all US Territories, Louisiana, Missouri, Texas,
Wisconsin, Utah; WeSaveUs served Indiana, Kentucky, Ohio; IdahoAccess served Idaho, Nebraska, North
and South Dakota; ARTogether served Arkansas; and OKAccess served Oklahoma.
137 Anonymous, interview by Carrie N. Baker, July 11, 2023.
138 In July of 2023, Las Libres served Georgia, Mississippi, North Carolina, Puerto Rico, South
Carolina, Tennessee, and West Virginia.
139 Alhelí Calderón-​Villarreal et al., “Accompaniment on the Edge: What Can the US Learn from
Latin America about Contested Abortion Care?,” ed. Julia Robinson, PLOS Global Public Health 3, no. 5
(May 22, 2023): e0001922, https://​doi.org/​10.1371/​jour​nal.pgph.0001​922.
140 Decca Muldowney, “Inside the Secretive Network of Abortion Pill Vigilantes,” The Daily Beast,
May 23, 2023, sec. us-​news, https://​www.thedai​lybe​ast.com/​abort​ion-​pill-​vig​ilan​tes-​are-​operat​ing-​a-​cov​
ert-​netw​ork-​from-​mex​ico-​to-​rep​ubli​can-​sta​tes.
141 Lorena Ríos and Daniela Dib, “How Feminist Groups in Mexico Are Aiding Abortion Seekers
in the U.S.,” Rest of World, May 8, 2023, https://​rest​ofwo​rld.org/​2023/​mexi​can-​women-​help-​us-​abort​ion-​
seek​ers/​. Las Libres served Georgia, Mississippi, North Carolina, Puerto Rico, South Carolina, Tennessee,
and West Virginia.
142 Alhelí Calderón-​Villarreal et al., “Accompaniment on the Edge: What Can the US Learn from
Latin America about Contested Abortion Care?,” ed. Julia Robinson, PLOS Global Public Health 3, no. 5
(May 22, 2023): e0001922, https://​doi.org/​10.1371/​jour​nal.pgph.0001​922.
 Endnotes • 283

143 Lara Islinger, interview with Carrie N. Baker, November 13, 2023.
144 Lara Islinger, interview with Carrie N. Baker, November 11, 2023.
145 Lara Islinger, interview with Carrie N. Baker, November 11, 2023.
146 Email from Red State Access, October 19, 2023 (on file with author).
147 Pam Belluck, “Religious Freedom Arguments Underpin Wave of Challenges to Abortion Bans,”
The New York Times, June 28, 2023, sec. Health, https://​www.nyti​mes.com/​2023/​06/​28/​hea​lth/​abort​ion-​
religi​ous-​free​dom.html.
148 Allison McCann, “Inside the Online Market for Overseas Abortion Pills,” The New York Times,
April 13, 2023, sec. U.S., https://​www.nyti​mes.com/​inte​ract​ive/​2023/​04/​13/​us/​abort​ion-​pill-​order-​onl​ine-​
mifep​rist​one.html.
149 Elisa Wells, interview by Carrie N. Baker, July 13, 2023.
150 Elisa Wells, interview by Carrie N. Baker, July 13, 2023.
151 Elisa Wells, interview by Carrie N. Baker, July 13, 2023. These companies were located in a range
of countries, including the Canada, UK, Russia, and the United States.
152 Anonymous, interview by Carrie N. Baker, July 14, 2023.
153 Elisa Wells, interview by Carrie N. Baker, May 24, 2023.
154 Francine Coeytaux, interview by Carrie N. Baker, May 23, 2023.
155 Allison McCann, “Inside the Online Market for Overseas Abortion Pills,” The New York Times,
April 13, 2023, sec. U.S., https://​www.nyti​mes.com/​inte​ract​ive/​2023/​04/​13/​us/​abort​ion-​pill-​order-​onl​ine-​
mifep​rist​one.html.
156 Susan Yanow, interview by Carrie N. Baker, May 25, 2023.
157 Kitchener et al., “A Fragile New Phase of Abortion in America.”
158 Michelle Cohen, interview by Carrie N. Baker, June 8, 2023.
159 Pamela Merritt, interview by Carrie N. Baker, June 14, 2023.
160 Pamela Merritt, interview by Carrie N. Baker, June 14, 2023.
161 Pamela Merritt, interview by Carrie N. Baker, June 14, 2023.
162 Pamela Merritt, interview by Carrie N. Baker, June 14, 2023.
163 Pamela Merritt, interview by Carrie N. Baker, June 14, 2023.
164 “#WeCount Report April 2022 to June 2023” (The Society of Family Planning, October 24, 2023),
https://​doi.org/​10.46621/​21856​9qkg​mbl.
165 Leah R. Koenig et al., “The Role of Telehealth in Promoting Equitable Abortion Access in the
United States: Spatial Analysis,” JMIR Public Health and Surveillance 9, no. 1 (November 7, 2023): e45671,
https://​doi.org/​10.2196/​45671.
166 Michelle Cohen, interview by Carrie N. Baker, June 8, 2023.
167 “The Issue of Tissue | Myanetwork,” accessed April 18, 2023, https://​mya​netw​ork.org/​the-​issue-​
of-​tis​sue/​.
168 Michele Gomez, interviewed by Carrie N. Baker, November 2, 2022.
169 Michele Gomez, interviewed by Carrie N. Baker, November 2, 2022.
170 Michele Gomez, interviewed by Carrie N. Baker, November 2, 2022.
171 Michele Gomez, interviewed by Carrie N. Baker, November 2, 2022.
172 “The Issue of Tissue | Myanetwork.”
173 @auntiekilljoy, #greenscreen they need to show these images at every political debate about abor-
tion #feminism #abortion #fyp ♬ original sound –​Jessica Valenti; @whitneywithheart Replying to @this.
is.my.brain.69 ♬ Cornfield Chase –​Dorian Marko.
174 Michele Gomez, interviewed by Carrie N. Baker, November 2, 2022.
175 Mary Ann Castle et al., “Listening and Learning from Women about Mifepristone: Implications
for Counseling and Health Education,” Women’s Health Issues 5, no. 3 (September 1995): 132–​33, https://​
doi.org/​10.1016/​1049-​3867(95)00044-​5.
176 Teresa DePiñeres, interviewed by Carrie N. Baker, October 18, 2022.
177 Wendy R. Sheldon et al., “Exploring Potential Interest in Missed Period Pills in Two US States,”
Contraception 102, no. 6 (December 2020): 414–​20, https://​doi.org/​10.1016/​j.contra​cept​ion.2020.08.014.
284 • Endnotes

178 Teresa DePiñeres, interviewed by Carrie N. Baker, October 18, 2022.

179 Sheldon et al., “Exploring Potential Interest in Missed Period Pills in Two US States,” 20.
180 Carrie N. Baker, “Period Pills: Another Option for Fertility Control,” Ms. magazine, October 20,
2022, https://​msm​agaz​ine.com/​2022/​10/​20/​mis​sed-​per​iod-​pills-​fertil​ity-​cont​rol/​.
181 “National Working Group on Period Pills in the United States,” Period Pills, n.d., https://​www.peri​
odpi​lls.org/​natio​nal-​work​ing-​group-​on-​per​iod-​pills.
182 Baker, “Period Pills.”
183 Teresa DePiñeres, interviewed by Carrie N. Baker, October 18, 2022.
184 Carrie N. Baker, “A Once-​a-​Week Contraceptive Pill, without Side Effects? Yes, Mifepristone,”
Ms. magazine, February 8, 2024, https://​msm​agaz​ine.com/​2024/​02/​08/​contra​cept​ive-​pill-​mifep​rist​one/​;
Erin Snodgrass, “Mifepristone in Moldova: Women on Waves Founder Wants to Use the Abortion Pill as
Contraception in the Wake of Roe v. Wade Reversal,” Business Insider, June 30, 2022, https://​www.busi​ness​
insi​der.com/​women-​on-​waves-​foun​der-​abort​ion-​pill-​roe-​v-​wade-​ove​rtur​ned-​2022-​6.
185 “Medication Abortion among Asian Americans, Native Hawaiians, and Pacific
Islanders: Knowledge, Access, and Attitudes” (National Asian Pacific American Women’s Forum and
Ibis Reproductive Health, May 2023), https://​www.nap​awf.org/​ass​ets/​downl​oad/​med-​abort​ion-​aan​hpi-​
study.pdf.
186 “About,” RHITES, accessed June 10, 2023, https://​www.rhi​tes.org/​about.
187 Carrie N. Baker and Ramona Flores, “Jex Blackmore Swallows Abortion Pill on Fox News: ‘It’s
Literally This Easy,’ ” Ms. magazine, February 1, 2022, https://​msm​agaz​ine.com/​2022/​02/​01/​jex-​blackm​
ore-​abort​ion-​pill-​live-​tv-​fox-​news-​med​icat​ion-​abort​ion/​.
188 Amy Allina, interview by Carrie N. Baker, May 16, 2023.
189 Tracy Droz Tragos, interview by Carrie N. Baker, Sundance Film Festival, Park City, Utah, January
23, 2023.
190 Francine Coeytaux, interview by Carrie N. Baker, Sundance Film Festival, Park City, Utah,
January 23, 2023.
191 Elisa Wells, interview by Carrie N. Baker, Sundance Film Festival, Park City, Utah, January
23, 2023.
192 Amy Merrill, interview by Carrie N. Baker, Sundance Film Festival, Park City, Utah, January
23, 2023.
193 Elisa Wells, interview by Carrie N. Baker, Sundance Film Festival, Park City, Utah, January
23, 2023.
194 Amy Merrill, interview by Carrie N. Baker, January 23, 2023.
195 Red State Access, Instagram, https://​www.instag​ram.com/​p/​Cwgk​4jPJ​s6I/​.
196 Red State Access, Instagram, https://​www.instag​ram.com/​p/​CkwZ​oqEJ​uI9/​.

Chapter 6
1 “Tracking the States Where Abortion Is Now Banned,” The New York Times, April 14, 2023, sec. U.S.,
https://​www.nyti​mes.com/​inte​ract​ive/​2022/​us/​abort​ion-​laws-​roe-​v-​wade.html.
2 “#WeCount Report April to December 2022 Findings” (Society of Family Planning, April 11, 2023),
https://​doi.org/​10.46621/​14372​9dhc​syz.
3 Paul Dans and Steven Groves, eds., Mandate for Leadership: The Conservative Promise, 9th ed.
(Heritage Foundation, 2023), 458–​59.
4 Shaila Dewan and Sheera Frenkel, “A Mother, a Daughter and an Unusual Abortion Prosecution in
Nebraska,” The New York Times, August 18, 2022, https://​www.nyti​mes.com/​2022/​08/​18/​us/​abort​ion-​pros​
ecut​ion-​nebra​ska.html. The mother and daughter eventually pled guilty. Susan Rinkunas, “Nebraska Mom
Pleads Guilty to Giving Abortion Pills to Her Teen Daughter,” Jezebel, July 10, 2023, https://​jeze​bel.com/​
nebra​ska-​mom-​ple​ads-​gui​lty-​to-​giv​ing-​abort​ion-​pills-​to-​185​0621​217.
 Endnotes • 285

5 “People in Alabama Can Be Prosecuted for Taking Abortion Pills, State Attorney General Says,”
CBS News, January 11, 2023, https://​www.cbsn​ews.com/​news/​abort​ion-​pills-​alab​ama-​pros​ecut​ion-​steve-​
marsh​all/​.
6 “Texas Lawmakers Neglect Preborn Children in First Legislative Session after Roe, Yet Improve
Protections for Vulnerable Patients,” May 29, 2023, https://​mail​chi.mp/​texas​righ​ttol​ife/​052​923-​sess​ion-​
recap?e=​9b7​1165​fb9.
7 Lorena O’Neil, “Louisiana Lawmakers Move to Criminalize Possession of Abortion Pills,” Rolling
Stone, May 1, 2024, https://​www.rolli​ngst​one.com/​polit​ics/​polit​ics-​featu​res/​louisi​ana-​crim​inal​ize-​pos​sess​
ion-​abort​ion-​pills-​123​5013​039/​.
8 Huss, Diaz-​Tello, and Samari, “Self-​Care, Criminalized: August 2022 Preliminary Findings.”
9 Abigail R. A. Aiken et al., “Factors Associated with Knowledge and Experience of Self-​Managed
Abortion among Patients Seeking Care at 49 US Abortion Clinics,” JAMA Network Open 6, no. 4 (April 18,
2023): e238701, https://​doi.org/​10.1001/​jama​netw​orko​pen.2023.8701.
10 Mary Szoch, “The Next Abortion Battleground: Chemical Abortion” (Family Research Council,
February 2022), https://​downlo​ads.frc.org/​EF/​EF19​L05.pdf.
11 American College of Obstetricians and Gynecologists, “Induced Abortion and Breast Cancer Risk,”
June 2009, https://​www.acog.org/​clini​cal/​clini​cal-​guida​nce/​­commit​tee-​opin​ion/​artic​les/​2009/​06/​indu​ced-​
abort​ion-​and-​bre​ast-​can​cer-​risk.
12 “Restricting Access to Abortion Likely to Lead to Mental Health Harms, APA Asserts,” American
Psychological Association, accessed April 20, 2023, https://​www.apa.org/​news/​press/​relea​ses/​2022/​05/​rest​
rict​ing-​abort​ion-​men​tal-​hea​lth-​harms; Diana Greene Foster, The Turnaway Study: Ten Years, a Thousand
Women, and the Consequences of Having―or Being Denied―an Abortion (New York: Scribner, 2020),
https://​www.goodre​ads.com/​book/​show/​49680​209-​the-​turna​way-​study.
13 “Safety and Effectiveness of First-​Trimester Medication Abortion in the United States” (Advancing
New Standards in Reproductive Health, June 2021), https://​www.ans​irh.org/​sites/​defa​ult/​files/​2021-​06/​
med​icat​ion-​abort​ion-​safety​_​202​1_​FI​NAL.pdf.
14 Kristi Hamrick, “SFL Action & SFLA Launch a Campus, State, & Federal Campaign Asking,
‘What’s In the Water?,’ ” November 23, 2022, https://​stud​ents​forl​ife.org/​2022/​11/​23/​sflact​ion-​sfla-​lau​nch-​
a-​cam​pus-​state-​fede​ral-​campa​ign-​ask​ing-​whats-​in-​the-​water/​.
15 Kristan Hawkins and Hamrick Kristi, “Students for Life Citizen Petition to the FDA,” April 19,
2023, https://​thi​sisc​hemi​cala​bort​ion.com/​wp-​cont​ent/​uplo​ads/​2023/​04/​Citi​zen-​Petit​ion-​3-​ESA-​AS-​
FILED.pdf; Alice Miranda Ollstein, “Anti-​abortion Group Launches New Pill Challenge as SCOTUS Mulls
Sweeping Restrictions,” POLITICO, April 19, 2023, https://​www.polit​ico.com/​news/​2023/​04/​19/​stude​nts-​
for-​life-​abort​ion-​sco​tus-​00092​771.
16 “Crisis Pregnancy Center Map & Finder,” CPC Map, accessed June 26, 2023, https://​crisi​spre​gnan​
cyce​nter​map.com/​.
17 Sonya Borrero, Susan Frietsche, and Christine Dehlendorf, “Crisis Pregnancy Centers: Faith
Centers Operating in Bad Faith,” Journal of General Internal Medicine 34, no. 1 (January 1, 2019): 144–​45,
https://​doi.org/​10.1007/​s11​606-​018-​4703-​4.
18 American College of Obstetricians and Gynecologists, “Medication Abortion ‘Reversal’ Is Not
Supported by Science,” accessed April 20, 2023, https://​www.acog.org/​advoc​acy/​facts-​are-​import​ant/​med​
icat​ion-​abort​ion-​rever​sal-​is-​not-​suppor​ted-​by-​scie​nce.
19 Daniel Grossman et al., “Continuing Pregnancy after Mifepristone and ‘Reversal’ of First-​Trimester
Medical Abortion: A Systematic Review,” Contraception 92, no. 3 (September 2015): 206–​11, https://​doi.
org/​10.1016/​j.contra​cept​ion.2015.06.001.
20 American College of Obstetricians and Gynecologists, “Medication Abortion ‘Reversal’ Is Not
Supported by Science.”
21 “Endangering Women for Profit” (Center for Countering Digital Hate, 2021), https://​coun​terh​ate.
com/​resea​rch/​enda​nger​ing-​women-​for-​pro​fit/​.
22 Pamela Merritt, interview by Carrie N. Baker, June 19, 2023.
286 • Endnotes

23 Tara Murta and Jenifer McKenna, “Designed to Deceive: A Study of the Crisis Pregnancy Center
Industry in Nine States” (The Alliance: State Advocates for Women’s Equality and Gender Justice, February
1, 2022), https://​all​ianc​esta​tead​voca​tes.org/​wp-​cont​ent/​uplo​ads/​sites/​107/​All​ianc​e_​CP​C_​Re​port​_​FIN​
AL2-​1-​22.pdf.
24 American College of Obstetricians and Gynecologists, “Induced Abortion and Breast Cancer Risk.”
25 Murta and McKenna, “Designed to Deceive: A Study of the Crisis Pregnancy Center Industry in
Nine States.”
26 Carrie N. Baker and Juliet Schulman-​Hall, “Feminists Fight Fake Abortion Clinics: ‘No One
Should Be Lied to,’ ” Ms. magazine, August 8, 2021, https://​msm​agaz​ine.com/​2021/​08/​08/​femini​sts-​fight-​
fake-​abort​ion-​clin​ics-​no-​one-​sho​uld-​be-​lied-​to/​.
27 Brendan Pierson, “Judge Declines to Block Colorado from Banning Medication Abortion Reversal,”
Reuters, April 28, 2023, sec. Legal, https://​www.reut​ers.com/​legal/​judge-​decli​nes-​block-​color​ado-​bann​
ing-​med​icat​ion-​abort​ion-​rever​sal-​2023-​04-​28/​.
28 John Ingold, “Federal Judge Blocks Colorado’s New Law Banning Abortion Pill ‘Reversal,’ ” The
Colorado Sun, October 22, 2023, http://​colo​rado​sun.com/​2023/​10/​22/​judge-​blo​cks-​color​ado-​abort​ion-​
pill-​rever​sal/​.
29 Sara K. Redd et al., “Medication Abortion ‘Reversal’ Laws: How Unsound Science Paved the Way
for Dangerous Abortion Policy,” American Journal of Public Health 113, no. 2 (February 2023): 202–​12,
https://​doi.org/​10.2105/​AJPH.2022.307​140.
30 “H.1783 An Act Relative to Abortion Pill Reversal; Informed Consent,” Massachusetts Citizens for
Life, accessed April 30, 2023, https://​www.mass​citi​zens​forl​ife.org/​hd_​1383_​an_​act_​relative_​to_​abortion_​
pil​l_​re​vers​al_​i​nfor​med_​cons​ent.
31 Carrie N. Baker and Carly Thomsen, “The Anti-​Abortion Movement’s Digital Strategies to Track
Pregnant Women—​Women’s Media Center,” December 15, 2021, https://​womens​medi​acen​ter.com/​news-​
featu​res/​the-​anti-​abort​ion-​moveme​nts-​digi​tal-​str​ateg​ies-​to-​track-​pregn​ant-​women; “Privacy and Sexual
and Reproductive Health in the Post-​Roe World” (Privacy International, July 2022), http://​priva​cyin​tern​
atio​nal.org/​long-​read/​4937/​priv​acy-​and-​sex​ual-​and-​repro​duct​ive-​hea​lth-​post-​roe-​world.
32 “The CPC Industry as a Surveillance Tool of the Post-​Roe State” (The Alliance: State Advocates for
Women’s Equality and Gender Justice, February 2022), https://​all​ianc​esta​tead​voca​tes.org/​wp-​cont​ent/​uplo​
ads/​sites/​107/​Alliance_​CPC_​Repo​rt_​F​eb20​22_​U​rgen​tBri​ef2-​10-​22.pdf.
33 “The CPC Industry as a Surveillance Tool of the Post-​Roe State.”
34 Albert Fox Cahn and Eleni Manis, “Pregnancy Panopticon: Abortion Surveillance after Roe”
(New York: Surveillance Technology Oversight Project, May 24, 2022), https://​www.sto​pspy​ing.org/​pregna​
ncy-​pan​opti​con.
35 Geofencing is a virtual boundary that triggers an ad on a mobile device when a user enters or exits
that boundary.
36 Cahn and Manis, “Pregnancy Panopticon: Abortion Surveillance after Roe.”
37 Carrie N. Baker, “Enforcing Criminal Abortion Bans Post-​ Roe: ‘A Massive Escalation of
Surveillance,’ ” Ms. magazine, June 7, 2022, https://​msm​agaz​ine.com/​2022/​06/​07/​pol​ice-​abort​ion-​bans-​
roe-​v-​wade-​surve​illa​nce/​.
38 Baker.
39 Thomas, “Missouri Health Director Tracked Menstrual Periods of Planned Parenthood Patients.”
40 “Abortion Surveillance in Oklahoma 2002–​2021” (Oklahoma Department of Health, August
5, 2022).
41 “Every Mother Counts Act,” Pub. L. No. 1167 (n.d.), http://​ www.oklegi​slat​
ure.gov/​
BillI​
nfo.
aspx?Bill=​sb1​167&Sess​ion=​2200.
42 Carrie N. Baker, “Democrats in Congress Introduce Bill to Crack Down on Fake Clinics and Anti-​
abortion Disinformation,” Ms. magazine, June 28, 2022, https://​msm​agaz​ine.com/​2022/​06/​28/​democr​ats-​
congr​ess-​sad-​act-​fake-​clin​ics-​anti-​abort​ion-​cpc-​dis​info​rmat​ion/​.
 Endnotes • 287

43 Carrie N. Baker, “Senators Introduce Bill to Protect Reproductive Health Data: ‘My Body, My
Data,’ ” Ms. magazine, June 23, 2022, https://​msm​agaz​ine.com/​2022/​06/​23/​repro​duct​ive-​hea​lth-​my-​body-​
my-​data-​act/​.
44 Carrie N. Baker, “New California Law Protects Digital Privacy of Abortion Seekers Nationwide,”
Ms. magazine, September 12, 2022, https://​msm​agaz​ine.com/​2022/​09/​12/​cal​ifor​nia-​law-​digi​tal-​priv​acy-​
abort​ion-​seek​ers/​.
45 Elisa Wells, interviewed by Carrie N. Baker, September 10, 2022.
46 Carrie N. Baker, “Proposed California Law Would Block Digital Surveillance of People Seeking
Abortion and Gender-​Affirming Care,” Ms. magazine, February 17, 2023, https://​msm​agaz​ine.com/​2023/​
02/​17/​cal​ifor​nia-​law-​digi​tal-​surve​illa​nce-​abort​ion-​gen​der-​affirm​ing-​care/​.
47 Baker.
48 Alanna Vagianos, “2 States Introduce Radical Bills to Prosecute Pregnant People for Abortions,”
Huffington Post, January 20, 2023, https://​www.huffp​ost.com/​entry/​sta​tes-​introd​uce-​radi​cal-​bills-​to-​
prosec​ute-​pregn​ant-​peo​ple-​for-​abortions​_​n_​6​3cad​58be​4b0c​2b49​ad52​898.
49 Baker, “New California Law Protects Digital Privacy of Abortion Seekers Nationwide.”
50 Carrie N. Baker, “Anti-​abortion Groups Ask Trump-​Appointed Judge to Ban Mailing Abortion
Pills,” Ms. magazine, November 23, 2022, https://​msm​agaz​ine.com/​2022/​11/​23/​texas-​laws​uit-​abort​ion-​
pills-​mifep​rist​one-​fifth-​circ​uit-​court/​.
51 Stephen Young, “Trump-​Nominated Plano Religious Hardliner One Step away from North Texas
Federal Bench,” January 19, 2018, https://​www.dal​laso​bser​ver.com/​news/​anti-​lgbtq-​law​yer-​matt​hew-​
kacsma​ryk-​nomina​ted-​by-​trump-​one-​step-​from-​fede​ral-​bench-​10275​809.
52 Matthew Kacsmaryk, “The Abolition of Man…and Woman | National Catholic Register,” National
Catholic Register, June 24, 2015, https://​www.ncr​egis​ter.com/​news/​the-​abolit​ion-​of-​man-​and-​woman-​
tpnrd​gjq.
53 Young, “Trump-​Nominated Plano Religious Hardliner One Step away from North Texas Federal
Bench.”
54 Baker, “Anti-​abortion Groups Ask Trump-​Appointed Judge to Ban Mailing Abortion Pills.”
55 Kirsten Moore, interview by Carrie N. Baker, November 21, 2022.
56 General Counsel, United States Postal Service, “Application of the Comstock Act to the Mailing
of Prescription Drugs That Can Be Used for Abortions,” December 23, 2022, https://​www.just​ice.gov/​olc/​
opin​ion/​file/​1560​596/​downl​oad.
57 Ron Wyden, “Wyden Delivers Floor Speech Calling on President Biden and the FDA to Keep
Mifepristone on the Market, Regardless of Outcome in Texas Case,” February 16, 2023, https://​www.
wyden.sen​ate.gov/​news/​press-​relea​ses/​wyden-​deliv​ers-​floor-​spe​ech-​call​ing-​on-​presid​ent-​biden-​and-​the-​
fda-​to-​keep-​mifep​rist​one-​on-​the-​mar​ket-​reg​ardl​ess-​of-​outc​ome-​in-​texas-​case.
58 Wyden.
59 Carrie N. Baker, “Lawmaker Urges Biden to ‘Ignore’ Texas Judge Who May Order FDA to Ban
Mifepristone and Abortion Pill by Mail,” Ms. magazine, February 24, 2023, https://​msm​agaz​ine.com/​2023/​
02/​24/​abort​ion-​pills-​mifep​rist​one-​texas-​judge/​.
60 Wyden, “Wyden Delivers Floor Speech Calling on President Biden and the FDA to Keep
Mifepristone on the Market, Regardless of Outcome in Texas Case.”
61 “Food and Drug Administration: Information on Mifeprex Labeling Changes and Ongoing
Monitoring Efforts.”
62 US Food and Drug Administration, “Response Letter to American Association of Pro-​Life
Obstetricians and Gynecologists and American College of Pediatricians,” December 17, 2021, https://​www.
regu​lati​ons.gov/​docum​ent/​FDA-​2019-​P-​1534-​0016.
63 Wyden, “Wyden Delivers Floor Speech Calling on President Biden and the FDA to Keep
Mifepristone on the Market, Regardless of Outcome in Texas Case.”
64 Wyden.
288 • Endnotes

65 Carolyn Kitchener and Ann E. Marimow, “The Texas Judge Who Could Take Down the Abortion
Pill,” The Washington Post, February 25, 2023, https://​www.was​hing​tonp​ost.com/​polit​ics/​2023/​02/​25/​
texas-​judge-​abort​ion-​pill-​decis​ion/​.
66 Christine Fernando, “A Texas Judge Could Soon Force a Major Abortion Pill off the Market
Nationwide,” USA Today, February 9, 2023, https://​eu.usato​day.com/​story/​news/​nat​ion/​2023/​02/​09/​texas-​
judge-​fda-​abort​ion-​pill-​med​icat​ion-​abort​ion-​mifep​rist​one/​1120​3396​002/​.
67 Kaiser Health News, “One Texas Judge Will Decide Fate of Abortion Pill Used by Millions of
American Women,” The Denver Post (blog), March 1, 2023, https://​www.den​verp​ost.com/​2023/​03/​01/​
texas-​abort​ion-​pill-​case-​laws​uit-​mifep​rist​one/​.
68 David S. Cohen, Greer Donley, and Rachel Rebouché, “Actually, One Texas Judge Is Not the Final
Decision-​Maker on Medication Abortion,” Slate, February 28, 2023, https://​slate.com/​news-​and-​polit​ics/​
2023/​02/​texas-​judge-​abort​ion-​case-​actua​lly-​limi​ted-​mifep​rist​one.html.
69 David Cohen, interview by Carrie N. Baker, March 2, 2023.
70 David Cohen, interview by Carrie N. Baker, March 2, 2023.
71 “Misoprostol-​Alone Medication Abortion Is Safe and Effective” (Cambridge, MA: Ibis Reproductive
Health, November 2021), https://​www.ibi​srep​rodu​ctiv​ehea​lth.org/​sites/​defa​ult/​files/​files/​publi​cati​ons/​
Miso​pros​tol-​alone%20med​icat​ion%20a​bort​ion%20is%20s​afe%20and%20ef​fect​ive.pdf.
72 Johnson et al., “Safety and Effectiveness of Self‐managed Abortion Using Misoprostol Alone
Acquired from an Online Telemedicine Service in the United States.”
73 Dana Johnson, interview by Carrie N. Baker, February 12, 2023.
74 Dana Johnson, interview by Carrie N. Baker, February 12, 2023.
75 Heidi Moseson et al., “Effectiveness of Self-​Managed Medication Abortion with Accompaniment
Support in Argentina and Nigeria (SAFE): A Prospective, Observational Cohort Study and Non-​inferiority
Analysis with Historical Controls,” The Lancet Global Health 10, no. 1 (January 2022): e105–​13, https://​doi.
org/​10.1016/​S2214-​109X(21)00461-​7.
76 Dana Johnson, interview by Carrie N. Baker, February 12, 2023.
77 Dana Johnson, interview by Carrie N. Baker, February 12, 2023.
78 Online Abortion Resource Squad at https://​www.aborti​onsq​uad.org/​.
79 Laura E. Jacobson et al., “Understanding the Abortion Experiences of Young People to Inform
Quality Care in Argentina, Bangladesh, Ethiopia, and Nigeria,” Youth & Society 54, no. 6 (September
2022): 957–​81, https://​doi.org/​10.1177/​004411​8X21​1011​015.
80 Susan Rinkunas, “If the Main Abortion Pill Is Banned This Week, Providers Are Prepared to Go
Off-​Label,” Jezebel, February 7, 2023, https://​jeze​bel.com/​mifep​rist​one-​ban-​miso​pros​tol-​only-​aborti​ons-​
in-​the-​us-​185​0083​070.
81 “Clinical Policy Guidelines for Abortion Care” (Washington, DC: National Abortion Federation,
2022), https://​procho​ice.org/​wp-​cont​ent/​uplo​ads/​2022-​CPGs.pdf.
82 “Abortion Care Guidance” (Geneva, Switzerland: World Health Organization, 2022), https://​srhr.
org/​abort​ionc​are/​.
83 Johnson et al., “Safety and Effectiveness of Self‐managed Abortion Using Misoprostol Alone
Acquired from an Online Telemedicine Service in the United States.”
84 Carolyn Westhoff, interview by Carrie N. Baker, August 9, 2023.
85 Carrie N. Baker, “Democratic AGs File Counter-​Lawsuit to Expand Access to Abortion Pills,” Ms.
magazine, February 27, 2023, https://​msm​agaz​ine.com/​2023/​02/​27/​dem​ocra​tic-​attor​ney-​gene​ral-​laws​uit-​
abort​ion-​pills-​mifep​rist​one-​fda/​.
86 Baker.
87 Complaint, Washington et al. v. FDA, No. 1:23-​cv-​03026 (United States District Court for the
Eastern District of Washington February 23, 2023).
88 Complaint, Washington et al. v. FDA.
89 “AG Ferguson Challenges FDA over Unlawful, Unnecessary Restrictions on Medication Abortion
Drug | Washington State,” accessed April 26, 2023, https://​www.atg.wa.gov/​news/​news-​relea​ses/​ag-​fergu​
son-​cha​llen​ges-​fda-​over-​unlaw​ful-​unne​cess​ary-​restr​icti​ons-​med​icat​ion.
 Endnotes • 289

90 “AG Ferguson Challenges FDA over Unlawful, Unnecessary Restrictions on Medication Abortion
Drug | Washington State.”
91 “AG Ferguson Challenges FDA over Unlawful, Unnecessary Restrictions on Medication Abortion
Drug | Washington State.”
92 Complaint, Washington et al. v. FDA.
93 Baker, “Democratic AGs File Counter-​Lawsuit to Expand Access to Abortion Pills.”
94 Katherine A. Rafferty and Tessa Longbons, “#AbortionChangesYou: A Case Study to Understand
the Communicative Tensions in Women’s Medication Abortion Narratives,” Health Communication 36,
no. 12 (October 15, 2021): 1485–​94, https://​doi.org/​10.1080/​10410​236.2020.1770​507.
95 David C. Reardon et al., “Deaths Associated with Pregnancy Outcome: A Record Linkage Study of
Low Income Women,” Southern Medical Journal 95, no. 8 (August 2002): 834–​41.
96 Lauren Weber et al., “Unpacking the Flawed Science Cited in the Texas Abortion Pill Ruling,”
The Washington Post, April 14, 2023, https://​www.was​hing​tonp​ost.com/​hea​lth/​2023/​04/​13/​abort​ion-​pill-​
saf​ety/​.
97 Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration.
98 Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration at 43.
99 Baker, “Supreme Court Blocks Fifth Circuit Ruling, Allowing Mifepristone to Stay on the Market
as Case Proceeds,” Ms. magazine, April 14, 2023, https://​msm​agaz​ine.com/​2023/​04/​14/​abort​ion-​pill-​was​
hing​ton-​supr​eme-​court-​fda/​.
100 Washington et al. v. U.S. Food and Drug Administration et al., No. 1:23-​cv-​03026-​TOR (U.S.
District Court for the Eastern District of Washington April 7, 2023).
101 Carrie N. Baker, “Federal Courts in Texas and Washington Release Contradictory Rulings.
Abortion Pills Remain on the Market—​for Now,” Ms. magazine, April 7, 2023, https://​msm​agaz​ine.com/​
2023/​04/​07/​texas-​was​hing​ton-​abort​ion-​pill-​ruli​ngs/​.
102 Baker.
103 Baker.
104 Sarah McCammon, “Washington State Stockpiles Thousands of Abortion Pills,” NPR, April 4,
2023, sec. National, https://​www.npr.org/​2023/​04/​04/​116​7867​948/​was​hing​ton-​state-​sto​ckpi​les-​thousa​
nds-​of-​abort​ion-​pills.
105 Matt Stout and Mike Damiano, “Healey, in Bid to ‘Ride out’ Legal Challenge, Moves to Stockpile
15,000 Mifepristone Doses in Massachusetts,” Boston Globe, April 10, 2023, https://​www.bost​ongl​obe.com/​
2023/​04/​10/​metro/​abort​ion-​pill-​rul​ing-​hea​ley-​plan-​prot​ect-​acc​ess-​massac​huse​tts/​.
106 “Oregon Secures 3-​Year Supply of Abortion-​Inducing Medication,” AP News, April 21, 2023, sec.
Medication, https://​apn​ews.com/​arti​cle/​ore​gon-​abort​ion-​pills-​mifep​rist​one-​05b7d​0060​1cd3​d431​a0c4​
3034​ca55​729.
107 “In Support of FDA’s Authority to Regulate Medicines,” n.d., https://​docs​end.com/​view/​2ahvm​
wy8d​jzxa​x3g.
108 Alliance for Hippocratic Medicine et al. v. U.S. Food and Drug Administration et al., No. No. 23-​
10632 (Fifth Circuit Court of Appeals April 12, 2023).
109 Carrie N. Baker, “Circuit Court Rules Abortion Pill Can Remain on the Market, but with
Limitations That Could Restrict Access,” Ms. magazine, April 13, 2023, https://​msm​agaz​ine.com/​2023/​04/​
13/​mifep​rist​one-​abort​ion-​pill-​fifth-​circ​uit-​court/​.
110 Emergency Application for a Stay of Preliminary Injunction Pending Appeal in Alliance of
Hippocratic Medicine v. FDA (Supreme Court of the United States April 14, 2023).
111 Baker, “Circuit Court Rules Abortion Pill Can Remain on the Market, but with Limitations That
Could Restrict Access.”
112 Carrie N. Baker and Roxy Szal, “As Supreme Court Weighs Next Steps on Abortion Pill, Protesters
Rally in Support of Abortion Rights,” Ms. magazine, April 17, 2023, https://​msm​agaz​ine.com/​2023/​04/​17/​
supr​eme-​court-​abort​ion-​pill-​prot​est-​rally-​march/​.
113 “Democratic Women’s Caucus Joins House and Senate Dems to File Amicus Brief Urging
Appeals Court to Prevent Dangerous Ruling Threatening Access to Mifepristone from Taking Effect,”
290 • Endnotes

Democratic Women’s Caucus, April 12, 2023, http://​dem​ocra​ticw​omen​scau​cus-​fran​kel.house.gov/​

media/​press-​relea​s es/​dem​o cra​t ic-​wom​ens-​cau​c us-​j oins-​house-​and-​s en​ate-​dems-​f ile-​ami​c us-​brief-​
urg​ing.
114 Stephen Neukam, “69 Republicans Ask Appeals Court to Allow Ban on Abortion Pill to Go
Forward,” The Hill, April 12, 2023, https://​theh​ill.com/​pol​icy/​hea​lthc​are/​3945​256-​repu​blic​ans-​appe​als-​
court-​abort​ion-​pill-​texas/​.
115 Carrie N. Baker, “GenBioPro Sues FDA to Keep Generic Mifepristone on the Market,” Ms. maga-
zine, April 20, 2023, https://​msm​agaz​ine.com/​2023/​04/​20/​genbio​pro-​sues-​fda-​mifep​rist​one-​abort​ion-​
pill/​.
116 Baker.
117 Danco Laboratories v. Alliance for Hippocratic Medicine et al.; U.S. Food and Drug Administration
et al. v. Alliance for Hippocratic Medicine at al., 598 U.S. _​_​(United States Supreme Court 2023).
118 Carrie N. Baker, “Supreme Court Blocks Fifth Circuit Ruling, Allowing Mifepristone to Stay on
the Market as Case Proceeds.”
119 Elisa Wells, Plan C Statement: SCOTUS preserves status quo for now, but access to abortion is still
lacking in the US, email dated April 22, 2023.
120 Amy Schoenfeld Walker et al., “Are Abortion Pills Safe? Here’s the Evidence,” The New York
Times, April 1, 2023, sec. Health, https://​www.nyti​mes.com/​inte​ract​ive/​2023/​04/​01/​hea​lth/​abort​ion-​pill-​
saf​ety.html.
121 Center for Drug Evaluation and Research, “Questions and Answers on Mifepristone for Medical
Termination of Pregnancy through Ten Weeks Gestation,” FDA, January 19, 2023, https://​www.fda.gov/​
drugs/​pos​tmar​ket-​drug-​saf​ety-​info​rmat​ion-​patie​nts-​and-​provid​ers/​questi​ons-​and-​answ​ers-​mifep​rist​
one-​medi​cal-​term​inat​ion-​pregna​ncy-​thro​ugh-​ten-​weeks-​gestat​ion.
122 Brief of Amici Curiae Medical and Public Health Societies in Opposition to Plaintiffs’ Motion,
Alliance for Hippocratic Medicine v. FDA, Civil Action No. 2:22-​cv-​00223-​Z, United States District Court
for the Northern District of Texas, Amarillo Division, February 10, 2023, https://​www.acog.org/​-​/​media/​
proj​ect/​acog/​acog​org/​files/​advoc​acy/​ami​cus-​bri​efs/​mifep​rist​one-​ami​cus-​brief-​21023.pdf.
123 Brief of Amici Curiae Medical and Public Health Societies in Opposition to Plaintiffs’ Motion.
124 “Improving Access to Mifepristone for Reproductive Health Indications, Position Statement”
(Washington, DC: American College of Obstetricians and Gynecologists, June 2018), https://​www.
acog.org/​clini​c al-​i nfo​r mat​i on/​p ol​i cy-​and-​p osit​i on-​sta​teme​nts/​p osit​i on-​sta​teme​nts/​2 018/​i mprov​
ing-​acc​ess-​to-​mifep​rist​one-​for-​repro​duct​ive-​hea​lth-​indi​cati​ons; American Medical Association, “H-​
100.948 Supporting Access to Mifepristone (Mifeprex),” accessed April 28, 2023, https://​polic​ysea​
rch.ama-​assn.org/​polic​yfin​der/​det​ail/​mifep​rist​one?uri=​%2FAMA​Doc%2FHOD.xml-​H-​100.948.xml;
American Academy of Family Physicians, “Summary of Actions of the 2018 National Congress of
Family Medicine Residents,” 2018.
125 Carrie N. Baker, “Far-​Right Fifth Circuit Judges Appear Determined to Remove Access to
Abortion Pill Mifepristone,” Ms. magazine, May 18, 2023, www.msm​agaz​ine.com/​2023/​05/​18/​fifth-​circ​
uit-​abort​ion-​mifep​rist​one/​.
126 Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration, No. 23-​10362 (Fifth
Circuit Court of Appeals August 16, 2023).
127 Chris Geidner, “Three GOP AGs Seek to Join Medication Abortion Lawsuit, Raising SCOTUS
Questions,” August 8, 2023, https://​www.lawd​ork.com/​p/​gop-​ags-​seek-​inter​vent​ion-​mife​pris​one-​case;
Order, Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration, 2:22-​CV-​223-​Z, January
1, 2024, https://​fin​gfx.tho​mson​reut​ers.com/​gfx/​legald​ocs/​zgvo​kmqd​ovd/​abort​ion%20p​ill%20i​nter​vent​
ion%20or​der%201-​12.pdf.
128 Ann E. Marimow and Caroline Kitchener, “Supreme Court Skeptical of Efforts to Restrict Access
to Abortion Pill,” The Washington Post, March 26, 2024, https://​www.was​hing​tonp​ost.com/​polit​ics/​2024/​
03/​26/​supr​eme-​court-​abort​ion-​pill-​mifep​rist​one/​.
 Endnotes • 291

129 NARAL Pro-​ Choice America, “Medication Abortion Disinformation Trends Surrounding
Alliance for Hippocratic Medicine v. FDA,” June 15, 2023, https://​reprod​ucti​vefr​eedo​mfor​all.org/​wp-​cont​
ent/​uplo​ads/​2023/​06/​Med​icat​ion-​Abort​ion-​Dis​info​rmat​ion-​Tre​nds-​Surr​ound​ing-​Allia​nce-​for-​Hipp​ocra​
tic-​Medic​ine-​v.-​FDA.pdf.
130 Sarah McCammon, “In New Mexico, Anti-​abortion Activists Take Abortion Restrictions Local,”
NPR, April 29, 2023, sec. Law, https://​www.npr.org/​2023/​04/​29/​117​2918​575/​in-​new-​mex​ico-​anti-​abort​
ion-​activi​sts-​take-​abort​ion-​restr​icti​ons-​local.
131 Elise Kaplan and Dan Boyd, “A Small Southeastern New Mexico City Passed an Ordinance
Restricting Abortion Access. Now It’s Suing the AG, Gov.,” Albuquerque Journal, April 17, 2023, https://​
www.abq​jour​nal.com/​2591​584/​eun​ice-​new-​mex​ico-​city-​pas​sed-​an-​ordina​nce-​rest​rict​ing-​abort​ion-​acc​
ess-​now-​its-​suing-​the-​attor​ney-​gene​ral-​gover​nor.html.
132 Sharon Zhang, “Republicans Are Quietly Moving to Limit Mifepristone Access Nationwide,”
Truthout, May 22, 2023, https://​truth​out.org/​artic​les/​repu​blic​ans-​are-​quie​tly-​mov​ing-​to-​limit-​mifep​rist​
one-​acc​ess-​nat​ionw​ide/​.
133 “HB 2690, Texas House of Representatives, 2023,” 26, accessed May 17, 2023, https://​capi​tol.texas.
gov/​Bil​lLoo​kup/​Hist​ory.aspx?LegS​ess=​88R&Bill=​HB2​690.
134 Carrie N. Baker, “North Carolina Legislature Overrides Governor’s Veto of 12-​Week Abortion
Ban,” Ms. magazine, May 17, 2023, https://​msm​agaz​ine.com/​2023/​05/​17/​north-​carol​ina-​abort​ion/​.
135 Bazelon, “Risking Everything to Offer Abortions across State Lines,” 62.
136 Maya Miller, “These Billboards Want You to Know How to Get Abortion Pills—​Even If Your
State Banned Abortions,” Mississippi Public Broadcasting, March 2, 2023, https://​www.mpbonl​ine.org/​
blogs/​news/​these-​bil​lboa​rds-​want-​you-​to-​know-​how-​to-​get-​abort​ion-​pills-​even-​if-​your-​state-​ban​ned-​
aborti​ons/​.
137 Michelle Cohen of SHERo in Mississippi explained: “What Mayday does not get, nor do I believe
they care about, is that during that process, they’re going to fuck shit up for those of us, like myself, who are
here in Mississippi, who are barely getting by, all because they want to be lauded as this liberal, progressive
group. I don’t partner with Mayday. They’re problematic. The simple fact is that they don’t respect local
people. They’re here basically for their own notoriety.” Michelle Cohen, interview by Carrie N. Baker, June
8, 2023.
138 Jennifer Habercorn and Josh Gerstein, “Abortion Pill Manufacturer to Pay $765K to U.S. to Settle
Suit over Incorrect Labeling,” POLITICO, April 17, 2023, https://​www.polit​ico.com/​news/​2023/​04/​17/​
abort​ion-​pill-​manuf​actu​rer-​set​tlem​ent-​00092​448.
139 Isaac Maddow-​Zimet and Candice Gibson, “Despite Bans, Number of Abortions in the United
States Increased in 2023,” Guttmacher Institute, March 2024, https://​www.gut​tmac​her.org/​2024/​03/​desp​
ite-​bans-​num​ber-​aborti​ons-​uni​ted-​sta​tes-​increa​sed-​2023.
140 Rachel K. Jones and Amy Friedrich-​Karnik, “Medication Abortion Accounted for 63% of All US
Abortions in 2023—​An Increase from 53% in 2020,” Guttmacher Institute, March 2024, https://​www.gut​
tmac​her.org/​2024/​03/​med​icat​ion-​abort​ion-​accoun​ted-​63-​all-​us-​aborti​ons-​2023-​incre​ase-​53-​2020.
141 Carrie N. Baker, “Abortion Pill Revolution: CVS and Walgreens Now Selling Abortion Pills, While
Telehealth Abortion Soars,” Ms. magazine, March 6, 2024, https://​msm​agaz​ine.com/​2024/​03/​06/​pharm​
acy-​mifep​rist​one-​abort​ion-​pills-​cvs-​­walgre​ens-​order-​abort​ion-​onl​ine/​.
142 Society of Family Planning, “#WeCount Public Report, April 2022 to December 2023,” May 14,
2024, https://​doi.org/​10.46621/​97037​1hxr​bsk.
143 Email from Elisa Wells, May 14, 2024.
144 Carrie N. Baker, “Healthcare Across Borders: Funding Telemedicine Abortion for People in
Abortion-​Ban States,” Ms. magazine, February 22, 2024, https://​msm​agaz​ine.com/​2024/​02/​22/​pay-​abort​
ion-​pills-​telem​edic​ine-​abort​ion-​ban-​sta​tes-​shi​eld-​law/​.
145 Maine State Legislature, “An Act Regarding Legally Protected Health Care Activity in the State,
April 22, 2024,” https://​legi​slat​ure.maine.gov/​bills/​get​PDF.asp?paper=​HP0​148&item=​3&snum=​131.
292 • Endnotes

146 Abigail R.A. Aiken et al., “Provision of Medications for Self-​Managed Abortion before and after
the Dobbs v Jackson Women’s Health Organization Decision,” Journal of the American Medical Association,
March 25, 2024 (advance publication online), https://​jama​netw​ork.com/​journ​als/​jama/​arti​cle-​abstr​
act/​2816​817; Abigail R.A. Aiken et al., “The Supply of Pill Packs for Self-​managed Abortion Increased
Substantially after the U.S. Supreme Court Eliminated the Constitutional Right to Choose Abortion,”
University of Texas at Austin Population Research Center Research Brief 9, no. 2, https://​doi.org/​10.26153/​
tsw/​51546.
147 Email to author from Red State Access, May 1, 2024.
148 Email to author from Plan C, December 2023.
149 Email to author from Plan C, May 4, 2024.
150 Interview with Roopan Gill, May 1, 2024 and May 13, 2024; see https://​hola.aya​cont​igo.org/​.
151 Navigator Research, “Public Opinion on Medication Abortion,” March 26, 2024, 2, https://​naviga​
torr​esea​rch.org/​wp-​cont​ent/​uplo​ads/​2024/​03/​Naviga​tor-​Int​eres​ted-​Part​ies-​Memo-​Med​icat​ion-​Abort​ion-​
03.26.2024.pdf.

Conclusion
1 Cynthia Pearson, interview by Carrie N. Baker, July 14, 2023.
2 Winikoff and Westhoff, “Fifteen Years.”
3 Winikoff and Westhoff, “Fifteen Years.”
4 Klitsch, RU 486: The Science and the Politics, 14.
5 The David and Lucile Packard Foundation, “Grants and Mission Investments,” accessed May 26,
2023, https://​www.pack​ard.org/​gra​nts-​and-​inve​stme​nts/​gra​nts-​datab​ase/​; Hewlett Foundation, “Grants,”
Hewlett Foundation (blog), March 20, 2023, https://​hewl​ett.org/​gra​nts/​; Tracy Weitz, interview by Carrie
N. Baker, May 24, 2023.
6 Francine Coeytaux, interview by Carrie N. Baker, May 24, 2023.
7 Rosenfeld, “Conception of a Controversy: The French Doctor and His Pill to Prevent Pregnancy”;
Fraser, “Pill Politics.”
8 Lader, RU 486, 97.
9 Collins, “The Complicated Life of the Abortion Pill.”
10 Reagan, When Abortion Was a Crime.
11 Lynn M. Morgan and Meredith W. Michaels, Fetal Subjects, Feminist Positions
(Philadelphia: University of Pennsylvania, 1999).
12 Carrie N. Baker, “Online Abortion Provider and ‘Activist Physician’ Michele Gomez Is Expanding
Early Abortion Options into Primary Care,” Ms. Magazine, January 19, 2022, https://​msm​agaz​ine.com/​
2022/​01/​19/​onl​ine-​abort​ion-​prim​ary-​care-​doc​tor-​mich​ele-​gomez-​mya-​netw​ork/​.
13 Emily Godfrey, interview by Carrie N. Baker, May 5, 2023.
14 “ExPAND Mifepristone, Department of Family Medicine, The University of Chicago,” accessed
May 14, 2023, https://​fam​ilym​edic​ine.uchic​ago.edu/​resea​rch/​exp​and-​mifep​rist​one-​learn​ing-​collab​orat​ive.
15 Carrie N. Baker, “Telemedicine Abortion Provider Dr. Deborah Oyer Supports Patient Autonomy
and Control: ‘No Different Than When They’re in Clinic,’ ” Ms. Magazine, January 12, 2022, https://​msm​agaz​
ine.com/​2022/​01/​12/​telem​edic​ine-​abort​ion-​debo​rah-​oyer-​cedar-​river-​clin​ics-​seat​tle-​was​hing​ton-​idaho/​.
16 Carrie N. Baker, “Online Abortion Provider Julie Amaon of Just the Pill Is ‘Making Abortion as
Easy as Possible for People,’ ” Ms. Magazine, January 26, 2022, https://​msm​agaz​ine.com/​2022/​01/​26/​onl​
ine-​abort​ion-​provi​der-​julie-​amaon-​just-​the-​pill/​.
17 Carrie N. Baker, “Online Abortion Providers Cindy Adam and Lauren Dubey of Choix: “We’re
Really Excited About the Future of Abortion Care”,” Ms. Magazine, January 14, 2022, https://​msm​agaz​ine.
com/​2022/​01/​14/​abort​ion-​pills-​cal​ifor​nia-​color​ado-​illin​ois-​onl​ine-​abort​ion-​cindy-​adam-​lau​ren-​dubey-​
choix/​.
18 “#WeCount Report April to March 2023 Findings” (Society of Family Planning, June 20, 2023),
https://​doi.org/​10.46621/​XBAZ6​145.
 Endnotes • 293

19 Bazelon, “Risking Everything to Offer Abortions across State Lines,” 33.

20 Bazelon, 33.
21 Bazelon, 33.
22 Jenna Jerman, Rachel K. Jones, and Tsuyoshi Onda, “Characteristics of U.S. Abortion Patients in
2014 and Changes since 2008” (New York: Guttmacher Institute, May 10, 2016), https://​www.gut​tmac​her.
org/​rep​ort/​char​acte​rist​ics-​us-​abort​ion-​patie​nts-​2014.
23 Langer, “Philip Corfman, Advocate for Women’s Reproductive Health, Dies at 92.”
24 Cynthia Pearson, interview by Carrie N. Baker, July 5, 2023.
25 Email from Sarah Christopherson, August 9, 2023.
26 Sarah Christopherson, interview by Carrie N. Baker, August 9, 2023.
27 Sarah Christopherson, interview by Carrie N. Baker, August 9, 2023.
28 Ariella Messing, interview by Carrie N. Baker, July 20, 2023.
29 Nina Henry, interview by Carrie N. Baker, August 10, 2023.
30 Nina Henry, interview by Carrie N. Baker, August 10, 2023.
31 Elisa Wells, interview by Carrie N. Baker, May 24, 2023.
32 An MTP kit includes one 200-​milligram mifepristone pill and four 200-​microgram misopros-
tol pills.
33 Plan C, “Websites That Sell Pills,” July 12, 2023, https://​www.pla​ncpi​lls.org/​websi​tes-​that-​sell-​pills.
34 Elisa Wells, interview by Carrie N. Baker, May 31, 2023.
35 “Complaint, Whole Woman’s Health Alliance v. FDA, U.S. District Court for the Western District
of Virginia” (Case 3:23-​cv-​00019-​NKM, May 8, 2023), 3, https://​rep​rodu​ctiv​erig​hts.org/​wp-​cont​ent/​uplo​
ads/​2023/​05/​WWH-​v-​FDA-​Compla​int.pdf.
36 Carrie N. Baker, “Healthcare Providers File Federal Lawsuit to Expand Abortion Pill Access,” Ms.
Magazine, May 9, 2023, https://​msm​agaz​ine.com/​2023/​05/​09/​fda-​laws​uit-​abort​ion-​pill-​mifep​rist​one/​.
37 “Complaint, Whole Woman’s Health Alliance v. FDA, U.S. District Court for the Western District
of Virginia,” 17.
38 “Complaint, Whole Woman’s Health Alliance v. FDA, U.S. District Court for the Western District
of Virginia,” 17–​18.
39 “Complaint, Whole Woman’s Health Alliance v. FDA, U.S. District Court for the Western District
of Virginia,” 18.
40 “Complaint, Whole Woman’s Health Alliance v. FDA, U.S. District Court for the Western District
of Virginia,” 18–​19.
41 “Complaint, Whole Woman’s Health Alliance v. FDA, U.S. District Court for the Western District
of Virginia,” 19.
42 “Complaint, Whole Woman’s Health Alliance v. FDA, U.S. District Court for the Western District
of Virginia,” 21–​22.
43 “Complaint, Whole Woman’s Health Alliance v. FDA, U.S. District Court for the Western District
of Virginia,” 22.
44 Baker, “Healthcare Providers File Federal Lawsuit to Expand Abortion Pill Access.”
45 Memorandum Opinion, Whole Woman’s Health Alliance v. FDA, No. Civil Action No.: 3:23-​cv-​
00019 (U.S. District Court for the Western District of Virginia, August 21, 2023).
46 Biggs et al., “A Cross-​Sectional Survey of U.S. Abortion Patients’ Interest in Obtaining Medication
Abortion over the Counter.”
47 Francine Coeytaux, interview by Carrie N. Baker, May 2, 2023.
48 Plan C. Directed by Tracy Droz Tragos. Dinky Pictures, 2023, at 23:16.
49 Carolyn Westhoff, interview by Carrie N. Baker, August 9, 2023.
50 Francine Coeytaux, interview by Carrie N. Baker, May 2, 2023.
51 Marlene Gerber Fried, interview by Carrie N. Baker, May 18, 2023.
52 Marlene Gerber Fried, interview by Carrie N. Baker, May 18, 2023.
53 Eyal Press, “The Planned Parenthood Problem,” New Yorker, May 15, 2023, 34.
54 Press, 44.
294 • Endnotes

55 Beverly Winikoff, interview by Carrie N. Baker, May 22, 2023.

56 Francine Coeytaux, interview by Carrie N. Baker, May 23, 2023.
57 Pamela Merritt, interview by Carrie N. Baker, June 19, 2023.
58 Reagan, When Abortion Was a Crime, 10.
59 Reagan.
60 Loretta Ross, interview by Carrie N. Baker, June 13, 2023.
61 Carol Mason, “How Trumpism Fostered Anti-​Choice Violence,” Ms. Magazine, February 9, 2021,
https://​msm​agaz​ine.com/​2021/​02/​09/​trump-​capi​tol-​riots-​women-​abort​ion-​anti-​cho​ice-​viole​nce-​anti-​
abort​ion-​ext​remi​sts-​pro​paga​nda/​.
62 Reagan, When Abortion Was a Crime, 10.
63 Reagan, 11.
64 Reagan, 11.
65 Reagan, 13.
66 Mason, “How Trumpism Fostered Anti-​Choice Violence”; Alex DiBranco, “The Long History
of the Anti-​Abortion Movement’s Links to White Supremacists,” February 3, 2020, https://​www.thenat​
ion.com/​arti​cle/​polit​ics/​anti-​abort​ion-​white-​suprem​acy/​; Carol Mason, Killing for Life: The Apocalyptic
Narrative of Pro-​Life Politics.
67 Ari M. Brostoff, “How White Nationalists Aligned Themselves with the Antiabortion Movement,”
The Washington Post, June 22, 2020, https://​www.was​hing​tonp​ost.com/​outl​ook/​2019/​08/​27/​how-​white-​
natio​nali​sts-​alig​ned-​the​msel​ves-​with-​antia​bort​ion-​movem​ent/​; Tom McCarthy, “ ‘He’s So Openly
Racist’: Why Does Iowa Keep Electing Steve King to Congress?,” The Guardian, October 27, 2018, sec. US
news, https://​www.theg​uard​ian.com/​us-​news/​2018/​oct/​26/​hes-​so-​ope​nly-​rac​ist-​why-​does-​iowa-​keep-​elect​
ing-​steve-​king-​to-​congr​ess.
68 Mary Ziegler, Abortion in America: A Legal History from Roe to the Present (New York: Cambridge
University Press, 2020).
69 Rickie Solinger, Pregnancy and Power: A History of Reproductive Politics in the United States, rev.
Ed. (New York: New York University Press, 2019), 3.
70 Solinger, 4.
71 Francine Coeytaux, interview by Carrie N. Baker, May 25, 2023.
72 Francine Coeytaux, interview by Carrie N. Baker, May 25, 2023.
73 Olga Khazan, “The Abortion Backup Plan No One Is Talking About,” The Atlantic, October 12,
2021, https://​www.thea​tlan​tic.com/​polit​ics/​arch​ive/​2021/​10/​plan-​c-​sec​ret-​opt​ion-​mail-​order-​abort​ion/​
620​324/​; Francine Coeytaux, interview by Carrie N. Baker, May 25, 2023.
74 Francine Coeytaux, interview by Carrie N. Baker, May 25, 2023.
75 Francine Coeytaux, interview by Carrie N. Baker, May 25, 2023.
76 Timothy Snyder, On Tyranny: Twenty Lessons from the Twentieth Century (New York: Crown, 2017).
77 A scholar of the Irish decriminalization of abortion, Sydney Calkins, has expressed concerns that
liberalization of abortion laws may in fact decrease access to abortion pills by institutionalizing medical
control of abortion pills. Kath Browne and Sydney Calkin, eds., After Repeal: Rethinking Abortion Politics
(London: Zed Books, 2019), 81, 88.
78 Diana Lugo-​Martinez, interview by Carrie N. Baker, July 24, 2023.
79 Michelle Cohen, interview by Carrie N. Baker, June 8, 2023.
80 Browne and Calkin, After Repeal: Rethinking Abortion Politics, 87.

Appendix B: Glossary
1 Monica Dragoman et al., “Integrating Self-​Managed Medication Abortion with Medical Care,”
Contraception 108 (April 2022): 1–​3, https://​doi.org/​10.1016/​j.contra​cept​ion.2021.12.003.