Open Question is a forum for commentary about social problems and methods of tackling them in the drive for hopeful solutions. The series explores unresolved challenges, fresh perspectives, and new ways of working.
Nearly a year has passed since the U.S. Supreme Court handed down the Dobbs v. Jackson Women’s Health Organization decision, which overturned the guaranteed access to safe, legal abortion established by Roe v. Wade nearly 50 years prior.
The Dobbs decision activated “trigger laws” in some jurisdictions — essentially banning abortion access in more than 10 states, including Texas, Louisiana, and Idaho — and raised concerns nationally that the U.S. might return to a climate of reduced reproductive autonomy akin to the pre-Roe era. Every day since Dobbs was handed down, competing efforts have pushed in both directions on access to abortion care. Tension is high in localities across America.
In terms of lived experience, the concerning risks of that pre-Roe time are considerably lessened in a post-Dobbs world, due in large measure to the development of medication abortion, pills that can be taken privately and safely at home.
How the future of medication abortion in the U.S. will fare remains a bigger question, given the surrounding political and judicial minefield. At the time of this writing, the legality of mifepristone remains intact following a Supreme Court ruling just last month that threw out a previously restrictive decision by a federal judge in Texas. Renewed efforts to limit the pill’s availability are expected. Meanwhile, fears that the drug could disappear from the U.S. market have some states preparing for the worst.
Innovations to abortion regimens (and threats to those regimens) aside, what steadily continues to prove dangerous to pregnant people in America is pregnancy itself — regardless of outcome. At 23.8 deaths per 100,000 live births, the U.S. has the highest maternal mortality rate among high-income nations, and since a significant number of those who are now unable to access safe abortion care are at risk for complicated pregnancies, that figure could worsen.
In 2021, the U.S. Food and Drug Administration (FDA) altered its policies to allow healthcare practitioners to prescribe the drugs necessary for medication abortion in telehealth visits and dispense them by mail. In 2023, the FDA updated this policy to allow pharmacies to dispense the drugs. But laws in at least 19 states are targeted at circumventing the FDA and disallowing telemedicine for abortion or banning mailing of the medications. Meanwhile, California and New York have taken steps to protect clinicians in those two states who work with, and prescribe to, residents of restrictive states.
A ZIP Code Lottery Minefield
As inconsistency rules the day, many people seeking medication abortion are running up against requirements or prohibitions that make access impossible where they live. As a result, they must travel to the nearest state that allows it, order pills online to self-manage their abortion, or source pills from beyond the U.S. or from community-based, non-medical providers.
Abortion access has, for now, become what many are calling a "ZIP code lottery" determined by whether a person lives in one of the country’s “abortion deserts,” large regions where access is limited or impossible. People in these regions must travel long distances at great expense to access care, and in numbers that can overwhelm clinics located closest to these deserts.
Travel costs and requirements for in-clinic visits (sometimes including state-mandated waiting periods or consultation visits prior to the abortion) can be prohibitive for many. The same is true of the price tag attached to traveling a considerable distance, overnight stays, and finding someone to cover work and childcare in their absence. Though costs quickly tip out of reach, some financing arrangements can pose a legal threat in certain states to anyone who helps another exercise reproductive autonomy. Whether abortion funds — nonprofit groups that help pay for the procedure and related expenses — will continue to operate as designed in particularly hostile climates is unclear.
Safe Virtual Pathways
Adjacent to all of this political and ideological noise sits a growing understanding among practitioners that it is possible to flatten barriers and ease access to abortion, particularly if increased attention is paid to streamlining the provision of care.
Could the growing edge of telemedicine more effectively and inclusively serve patients who seek to safely and legally exercise their reproductive autonomy?
Stanford’s Reproductive Equity and Autonomy Lab (REAL), a team of researchers and health clinic and policy experts, believes so and is working with partner Gynuity Health Projects to explore emerging solutions. Innovations like not requiring multiple visits for medication abortion as well as asynchronous ways to screen patients and facilitate access to telemedicine show real promise.
With Stage 2 funding from Stanford Impact Labs, the team conducted an aptly-named MA(medication abortion)-ASAP research study to test how the process of delivering abortion care could proceed without requiring an upfront medical consult, but instead via a carefully designed step-by-step protocol intended to streamline provision of care.
REAL also conducted a nationwide survey of potential users of clinician-administered advance provision. In a paper published in March 2023 about the survey, authors Klaira Lerma and Paul D. Blumenthal write, "As abortion access becomes more constrained, strategies are needed to ensure timely access. Advance provision is of interest to the majority of those surveyed and warrants further policy and logistical exploration."
REAL is committed to testing ways to shift healthcare obstacles out of the way of people seeking abortion care. Being able to consult by email or text, for instance, could loosen up the schedule for a working parent who might otherwise struggle to find time even for a telehealth appointment. Researchers envision uptake by a growing group of medical providers, including pharmacists and nurse practitioners, who could fill in some of the widening gaps in abortion services after Dobbs.
Before any such tools can be rolled out, though, they need to be tested. Through an ongoing pilot study, researchers are assessing the safety, feasibility, and acceptability of this low-obstacle approach to providing medication abortion and patient care. If it works, they hope to gain broad interest from providers so that access and quality of care might be improved, even as political battles rage on.
Emily Willingham is a journalist and science writer. Her work has appeared in The Wall Street Journal, The Washington Post, Scientific American, Aeon, Undark, San Francisco Chronicle, and many other outlets.
Open Question is a forum for commentary about social problems and methods of tackling them in the drive for progress.