How women could access abortions in a post-Roe world

Last week, a leaked first-draft opinion written by Supreme Court Justice Samuel Alito revealed that the nation’s highest court is poised to overturn Roe v. Wade, the 1973 decision that legalized abortion nationwide.

The final opinion is expected to land in late June or early July, and if it aligns with Alito’s initial draft, the federal right to abortion will disappear, and it will be left to individual states to decide how to regulate the procedure.

Many women in America will be impacted by this highly anticipated ruling. The Guttmacher Institute, a research group focused on reproductive health, estimates that as many as 26 states are certain or likely to ban abortion if Roe v. Wade is overturned. Thirteen states have already launched so-called trigger laws, which will make abortion bans go into effect almost immediately if that is the case. Of those, 10 have passed laws that make no exceptions for rape or incest.

So how would women in these states access abortion in a post-Roe world? Abortion access in these states will certainly become more difficult, but experts say the bans won’t stop women from getting an abortion. There are two main ways in which women, in states where it will be illegal, seek to terminate a pregnancy in the post-Roe world. One is traveling to a state where abortion is legal. The other is obtaining a medication abortion, which includes taking two pills, through telemedicine and mail delivery.

Ushma Upadhyay, an associate professor in obstetrics, gynecology and reproductive sciences at the University of California, San Francisco, told Yahoo News that the abortion pill method, which is a way to conduct self-managed abortions, is now the most common type of abortion that exists.

“Our most recent data available is from 2020, and we’ve learned that medication abortion accounts for 54% of all abortions,” Upadhyay said.

What are abortion pills? Abortion pills, Upadhyay explained, involve the use of two types of medications. “The first is mifepristone, which stops a pregnancy from growing. And the second is misoprostol, which allows the uterine to contract and empty the contents of the uterus,” she said.

She also said these types of medications are safe and effective. “Medication abortion is extremely safe. We have analyzed data on 11,000 medication abortions, followed people over time, and we found a complication rate of less than a third of 1%. So it has over a 99% safety rating,” she said.

Where are the abortion pills now? Getting the abortion pill is relatively easy in 22 states where women are allowed to obtain these medications through a telehealth visit with their medical provider. In these states, the doctor and the patient meet online before the doctor sends the pills to the patient through the mail. However, there are 19 states where this isn’t allowed and require a clinician to be physically present when abortion-inducing drugs are administered.

In some states, such as Indiana and Texas, medication abortion after a certain number of weeks of pregnancy is already prohibited. These restrictions, however, have not stopped people from getting abortion pills. Instead, women have turned to international organizations and online pharmacies overseas that sell these medications.

One such place is an organization based in Austria called Aid Access, which offers women in the U.S. online consultations and prescriptions from European doctors. For women who live in states where abortion pill access is limited, the group has become an important resource.

Aid Access told Vox that over the past four years, it has delivered abortion medication to more than 30,000 Americans across all 50 states and that its work will continue in a post-Roe world. The organization also recently said requests for pills and information about them have already tripled since Alito’s draft opinion was leaked.

Even though it isn’t legal for medical providers who aren’t licensed in the U.S. to sell prescription medications to Americans, there’s no effective way of policing these transactions from overseas. Because of this, experts predict these extralegal channels will become more popular if Roe v. Wade is overturned and abortions become harder to access in some states.

“I just don’t see a route for politicians to eliminate access to Aid Access; they just don’t have the jurisdiction to criminalize an international doctor,” Christie Pitney, a midwife who fills prescriptions for Aid Access patients in some U.S. states, told Vox.

David S. Cohen, a law professor at the Drexel Kline School of Law, told Yahoo News that the sale of abortion pills from providers overseas will be difficult to stop because these medications are sent via mail, which can’t be tampered with.

“It’s going to be very difficult because you don’t know what’s in someone’s mail, and so if someone just receives pills by mail, a lot of people are going to be able to do that without any suspicion or without any criminal penalties,” Cohen said.

In the United States, Cohen expects to also see abortion providers wanting to provide pills across state lines. This, he says, will raise legal questions about their licensing and what it allows.

“We’re going to see different, complicated legal issues about actions that are legal in one state but illegal in another,” Cohen said. “It’s going to be a mess. It’s going to be a very complicated situation with some really difficult questions of how states are supposed to work together.”

Should women expect more limits on abortion pills? Cohen said it would be illegal for providers in states where abortion is legal to provide telehealth abortion consultations for patients in states that will ban the procedure. But it is not illegal for doctors in states where abortions are protected to perform in-clinic abortions for those from other states, so for women who can afford to travel, this will continue to be an option. However, Cohen said that if Roe is overturned, anti-abortion states will try different measures to punish those who get and perform abortions.

“I think we’re going to see anti-abortion states really push the limits here and try to ban people traveling to other states, as well as maybe even try to prosecute people who perform abortions on residents of their state,” he said.

Some states have already started to pass laws to criminalize abortion care. Oklahoma Gov. Kevin Stitt recently signed a bill into law making it a felony to perform an abortion. Under this law, anyone convicted of performing the procedure would face up to 10 years in prison and a $100,000 fine. Similarly, a state legislative committee in Louisiana has advanced a bill that would charge women who get an abortion — and those who assist them — with homicide.

What’s happened since the draft leaked? Various states where abortions are legal have also responded with legislation aimed at protecting abortion access and rights.

On Tuesday, New York Gov. Kathy Hochul, a Democrat, announced that her state was launching a $35 million fund for abortion services. Hochul said one of the reasons the fund is necessary is the influx of out-of-state patients who are expected to seek abortions in New York if the Supreme Court draft decision becomes final.

Washington state also recently passed a law that prohibits legal action against people seeking an abortion and those who aid them.

Cohen told Yahoo News that certain states where abortion rights have been protected will become key hubs if nearly half of U.S. states ban abortion. “Illinois, Colorado and New Mexico are going to be very important,” he said. “Illinois is going to become a huge hub because if you look at the map, all the states around Illinois are states where there’s going to be a likely ban.”

Other states such as North Carolina and Florida, which do have some abortion bans in place, could also become go-to places for women in need of an abortion, if the current laws remain as they are now.

Abortion in Florida is currently legal until the 24th week of pregnancy. But last month, Gov. Ron DeSantis signed a bill into law that bans most abortions after 15 weeks of pregnancy. It takes effect July 1. However, if Roe v. Wade is struck down, DeSantis or other Florida legislators could try to pass even stricter limits, or a total ban on abortions.

“If Florida stays the way it is, only banning up to 15 weeks, and doesn’t enact a new complete ban, then yes, Florida’s going to be a place that [pregnant] people under 15 weeks are going to go,” Cohen said.

North Carolina is another state that experts are watching closely. “If people want to travel a little north instead of a little south, they’ll go to North Carolina,” he said.

The state had a pre-Roe abortion ban that was modified in the 1960s allowing for abortions in the first 20 weeks of pregnancy, but it has remained unenforceable. However, if Roe v. Wade is overturned, experts say the 20-week ban could be reinstated.

What else should I know? Finally, people who won’t be able to afford to travel out of state will be able to seek assistance from abortion funds. The National Network of Abortion Funds connects women with organizations that can support them financially and with any logistical needs as they arrange for an abortion.