The first time H* needed an abortion, she drove about two hours to the nearest clinic and back, waited 48 hours—the required waiting period for anyone in Tennessee seeking an abortion—then went back and paid more than $700 for the procedure. That’s not counting gas money for eight hours of driving, or the wages she lost when she took time off from her hourly job for the appointment.
In March, she learned she was pregnant again, and found herself confronting many of the same barriers to getting an abortion: The clinic was still far away, the procedure was still costly, and she would still have to take off a day or two to account for the waiting period and the drives to and from the clinic.
But the coronavirus pandemic had placed a few more obstacles in her way. First, there was the simple fact of quarantine—like everyone else, H, who asked that VICE withhold her name, was supposed to stay inside as much as possible, especially since she is immunocompromised. H had also just lost her second job—a source of income she relied on to cover miscellaneous bills and emergency expenses—to coronavirus-related layoffs. And then the governor of Tennessee joined several other conservative governors in issuing an executive order that categorized abortion as a “non-essential” procedure, telling providers that there was an “expectation” that no abortions would take place amid the pandemic.
Tennessee clinics are still providing abortions, but faced with several layers of restrictions, a compromised immune system, and reduced income, H turned to the internet. She’d heard that the site Aid Access, which is run by the Dutch doctor Rebecca Gomperts, was an inexpensive and trustworthy way to get abortion pills online, so she filled out a form requesting the medication with plans to give herself an abortion. But within a few minutes, she got what appeared to be an email auto-response, telling her that Aid Access was not currently shipping pills to the United States.
What H saw as her best option for getting an abortion during a pandemic had turned into another dead end.
H isn’t alone. Coronavirus is making it harder for people to access abortion services, especially for those who live in one of the states whose government officials have used the pandemic in an attempt to effectively ban the procedure. These extra barriers appear to have created a surge in interest in self-managed abortion, a method that typically involves buying abortion pills online, and administering them on one’s own without medical supervision.
Longstanding Food and Drug Administration regulations make it a federal violation for online services like Aid Access to sell the abortion drug mifepristone, one of two drugs involved in the pill regimen. FDA protocol mandates that it be dispensed by a licensed medical professional in a hospital or clinic. Nonetheless, self-managed abortion has become more common, especially as restrictions on the procedure become more severe—and especially now, when those existing restrictions have been compounded by the coronavirus.
But now the online abortion pill retailers people rely on when they can’t get clinic care are in trouble too, with the pandemic cutting off crucial points in the supply chain that help people get the medication they need. In online forums, people who need abortion care are trying to figure out not a plan B or C, but a plan D.
"The reason we can say that the symbol of self-managed abortion is a pill and not a coat hanger is only because services like Aid Access made that possible,” said Abigail Aiken, an assistant professor at the University of Texas at Austin who studies self-managed abortion. “Without those we are looking at something much more concerning.”
Before serious self-isolation had begun in most of the country, Plan C, a site that provides detailed information about online abortion pill retailers, averaged about 600 visitors a day. By March 23, that number had doubled, an increase that, at the time, Plan C Digital Director Amy Merrill said was likely a “shift in progress”—she suspected that the high traffic to the site could become the new normal during the pandemic. She was right: Plan C’s latest stats show the site has reached 1,800 views per day, three times its usual traffic.
Merrill said that new obstacles to abortion services were likely making self-managed abortion—which can still be highly stigmatized—a more appealing option to those dealing with unintended pregnancies. For others, it became their only option. “It will be very interesting to see how the conversation around self-managed abortion goes in the coming weeks,” Merrill said.
"The reason we can say that the symbol of self-managed abortion is a pill and not a coat hanger is only because services like Aid Access made that possible."
Other sites have registered a shift too. In January, the leftist publication Jewish Currents published an illustrated how-to guide for self-managing an abortion. At the time, the story blew up, with a large portion of the traffic coming from “hate readers,” according to editor Arielle Angel. In the months that followed, the story was consistently one of the most-read articles on the site, but Angel didn’t notice any other spike in readership until a couple of weeks into March, when cities instituted shelter-in-place orders, and people began to social distance more stringently. On March 22, Angel wrote on Twitter that views on the story were “off the charts.”
Most of the traffic, she realized, was coming from Google, which meant that readers were finding the guide by searching for information on self-managed abortion.
“To me, it just speaks to the fact that a lot of people are trying to figure out their contingency plan,” Angel told VICE.
Usually, Aid Access is part of this contingency plan. Though there are several sites that sell abortion pills online, Aid Access is the least expensive—whereas other services charge between $140 and $390 for the medication, Aid Access charges $90, and will reduce or waive the cost for those who can’t afford it. Aid Access is also the only retailer that includes physician oversight: Before writing a prescription for the pills, Gomperts assesses each patient to make sure they’re eligible for medication abortion; she also provides them with instructions for how to administer the regimen and provides assistance if patients have questions while passing the pregnancy. Since its launch in 2018, the site has served tens of thousands of people in the U.S., and reproductive health advocates consider it a vital abortion care provider for the country despite the fact that Gomperts runs the entire operation abroad.
But when India took measures to secure its borders in response to the pandemic, it effectively shuttered the service: After consulting with Gomperts, patients send their prescriptions to an Indian pharmacy she works with, which means the pills ship directly from India. Though India appears to have reopened airports for cargo flights, advocates said they still expect shipment delays. Gomperts did not respond to VICE's request for comment.
The airport closures mean that no pills are shipping out of the country during a time when requests to Aid Access may be reaching a peak. Aiken is currently analyzing data from the site for a forthcoming study on the effect of coronavirus on the service. In the meantime, Plan C cofounder Elisa Wells estimates that Gomperts is seeing at least twice the traffic to Aid Access—similar to the increase Plan C is experiencing—since many people find Gomperts’ service through their site.
“Aid Access was the only safety net we had and, for the moment, it’s not available,” Aiken said. “People are going to have to look to other options.”
In Aid Access’ absence, some people have turned to abortionrx.com, which is the next most affordable abortion pill seller. With shipping, the pills cost around $250—still cheaper than a medication abortion through a clinic, but significantly more expensive than Gomperts’ service, which she operates as a form of humanitarian aid.
On abortionrx.com, patients add a pack of abortion pills to their cart and check out as they would with any other kind of online purchase. “It’s scary to just jump into something and not know if it’s backed up by medical professionals,” said H, who ultimately chose to buy pills through abortionrx.com. “Aid Access has a lot of info on the site, a question and answer tab that tells you who runs it, how to take the pills—it’s very informative. The other sites not so much.”
But abortionrx.com could soon be out of commission too. Online pharmacies like abortionrx.com may be based in the U.S., but they also source their abortion pills from India, which means that if shipments don't arrive before they run out, the sites will have no way of replenishing their stock. And with demand for pills so high, that possibility may not be so far off.
“We know the demand we have is increasing,” Wells said. “We do anticipate that the sites that ship from the U.S. will run out of product at some point.”
A patchwork of access will likely emerge in the coming weeks and months, Wells said. Some people may still be able to get abortion care at a clinic near them, though it will come with increased risk of exposing themselves (as well as providers and clinic staff) to coronavirus. Those who live in one of the 13 states served by TelAbortion—a clinical study that has FDA permission to send abortion medication by mail—will be able to get the care they need, without any increased risk of coronavirus exposure.
Otherwise, Wells expects to see some doctors in the U.S. accept telemedicine abortion as the new norm—in states where it is legal—and ease protocols that sometimes require patients to receive an ultrasound before getting abortion care. According to reproductive health advocates, ultrasounds are often medically unnecessary, and during the pandemic would increase coronavirus risk (three states require them).
"We do anticipate that the sites that ship from the U.S. will run out of product at some point.”
Those doctors could then write patients prescriptions for misoprostol, a drug commonly used alongside mifepristone to end a pregnancy, which can also be used on its own. Since it isn’t subjected to the same restrictions as mifepristone, this may be one of the most obvious solutions, but it comes with a trade-off: Though they’re no less safe, misoprostol-only abortions can be slightly less effective. Still, this regimen may become more common if other abortion access points are foreclosed.
Wells said she hopes these extreme circumstances force government officials to see that the FDA’s restrictions on mifepristone don’t reflect decades of research and investigation, which show that taking the medication is safe and effective, even outside of a traditional clinic setting. (State Attorneys General are urging the FDA to lift the restrictions during the pandemic.)
But in the meantime, some people will simply go without the services they need. When it comes to abortion—which anti-abortion lawmakers and activists would deem “non-essential”—that means carrying a pregnancy to term against one’s will, a condition associated with more health risks than abortion.
H’s pills are supposed to come in the mail in a few days. She anticipates that the $250 she paid to abortionrx.com will set her back a bit, having lost one of her sources of income. Still, she considers herself lucky.
“I’ll have to squeeze by for the next few weeks or even months depending on what continues to happen with COVID-19, [but] thankfully I was able to make it work,” H said. “But I can’t imagine someone who is out of work or who [just] doesn't have the funds having to face this reality.”