Abortion Pills Should Be Everywhere

I bought them online. They’re easy to get, and they’ll change everything.

One afternoon about a year ago, just as the Senate began considering Brett Kavanaugh’s nomination to the Supreme Court, I logged on to Day Night Healthcare, an online pharmacy based in India, and ordered a pack of abortion pills. A few hours later, I got a call from a Day Night customer-service agent with a warning. If my credit-card company called to ask about the purchase, “tell them you approve the charge, but don’t say what it’s for,” the man advised. “If they ask, say it’s gym equipment, or something like that.”

In fact, the bank never called, and in a week and a half, a small brown envelope — bearing a postmark not from India but from New Jersey — arrived in the mail. Inside was a foil blister pack stamped with a manufacturer’s logo, dosage information and batch-identification numbers. It contained five pills. One was a 200-milligram dose of mifepristone, better known by its code name during its development in the 1980s, RU-486. The four others were 200 micrograms each of misoprostol, a drug used widely in obstetrics and gynecology, including to induce contractions.

The pills looked unremarkable; tiny, white, round, they did notbetray what some abortion-rights advocates say are their epic possibilities. Mifepristone was approved for use by the Food and Drug Administration nearly 20 years ago. Used in combination with misoprostol for pregnancies of up to 10 weeks, the pills are more than 97 percent effective.

The drugs, which have been used by tens of millions of women around the world, are also some of the safest known to modern medicine — mifepristone has accumulated a record of adverse complications lower than that of Tylenol, Flonase, Xanax and Viagra. In 2017, Canadian regulators lifted most restrictions on the drug, allowing it to be prescribed by any doctor, without requiring an ultrasound, and dispensed in any pharmacy.

Yet thanks to the digital handiwork of an emerging faction within the global reproductive-rights movement, restrictions on abortion pills are becoming increasingly difficult to enforce. Despite the F.D.A.’s restrictions, activists have created a robust online market that makes getting pills surprisingly easy. There are “report cards” on where to find tested drugs, detailed guides on how to use them safely, a help line for consulting with legal experts, and dozens of discussion boards and support groups helping women navigate the fraught decision of whether and how to terminate a pregnancy.

Amid growing restrictions on clinic-based abortions, the online pill market functions as a haven of last resort for desperate women. “The women who come to us don’t have any other alternatives,” said Rebecca Gomperts, a Dutch physician and founder of Aid Access, which offers abortion pills online for about $90, with discounts for patients in financial straits. “They don’t have funds, or they are six hours away from the clinic, or they don’t have transport, they have small kids, they live in cars, there are situations of domestic violence — it’s just really bad situations.” In 2018, Gomperts prescribed the drug online to 2,581 patients.

But the pills aren’t just a way to evade today’s restrictions on abortion. Some activists argue that they can also remake tomorrow’s politics surrounding abortion — that the very presence of the underground market could force the authorities to loosen restrictions on abortion pills, eventually paving the way for an alternative vision for terminating a pregnancy in the United States: the inexpensive, safe, very early, private, at-home, picket-line-free, self-managed medical abortion.

“Did you feel a little rush when your pills arrived?” Elisa Wells, a director of the pill-advocacy group Plan C, asked me during a recent phone call. “It’s like, wow — it’s amazing that this really works.”

She’s right: I did feel a little rush when I got my first pills. I’d expected the whole thing to be onerous. And so, probing for hidden difficulties, I tried again, and again.

In the last year, I’ve ordered abortion pills from four different online pharmacies. The process was sometimes sketchy. There were poorly translated websites and customer-service reps messaging me over Skype with the greeting “yo.” I declined to pursue one order because the site asked me to wire money to a random address in India. After I filled out its consultation form, Aid Access sent me an email asking me if I really am pregnant, as I have a man’s name and “the woman must confirm” that she is ordering the drugs of her own accord; since I’m a man and not pregnant, I didn’t place the order.

But most of my orders came through fine. Each of the three pill packages I got cost me between $200 and $300, including expedited shipping. (The average cost of an abortion in the United States is about $500.)

I spent months looking for a lab that would test my pills; many waved me off, wary of controversy. Finally, I got in touch with Alan Wu, chief of the clinical chemistry laboratory at San Francisco General Hospital, whose lab tested a couple of my mifepristone tablets. The finding: They were authentic. I wasn’t surprised; in a more comprehensive study conducted by Gynuity Health and Plan C, published last year in the journal Contraception, researchers in four states ordered abortion pills from 16 different online pharmacies, and found they were all just what they said they were.

Each time I got a pack of pills in the mail, I was increasingly bowled over: If this is so easy, how will they ever stop this? I’ve been watching digital markets for 20 years, and I’ve learned to spot a simple, powerful dynamic: When something that is difficult to get offline becomes easy to get online, big changes are afoot.

Which is not to say that everyone is on board with the online market for pills. While there’s a growing consensus in the American medical establishment that restrictions on abortion drugs no longer make medical sense, I spoke to several abortion-rights advocates who worried about a parade of horrors that might swamp the movement if the underground online pill market were left to grow unfettered: women getting fake pills, getting ripped off, getting ill, getting slipped pills by men or getting prosecuted.

The activists building the online pill network acknowledge that there are potential dangers in the market — but they insist that the risks are far smaller than many guess. In a study of more than 1,000 Irish women who obtained pills from Women on Web, a pill-dispensing group Gomperts created in 2005, fewer than 1 percent reported adverse effects requiring further medical attention. “Providing abortions this way is as safe as a clinic-based abortion,” Gomperts told me.

For providers and users, legal risk is also relatively low. Regulators have little capacity to enforce restrictions on foreign distributors. In March, the F.D.A. sent a letter to Aid Access demanding that it cease operations immediately. The organization sent a letter back saying, essentially, nope. What happens next is anybody’s guess.

Since 2000, at least 21 people have been arrested in the United States for ending a pregnancy or helping someone do so using pills, according to If/When/How, an organization that provides legal assistance to women who self-manage their abortions. That’s a tiny fraction of the tens of thousands estimated to have purchased pills online in that time.

For some activists, the specter of stepped-up prosecutions against women who buy abortion drugs is closer to a political gift than a cudgel. “The more we do this, and the more they go after women, the more we show how great the risks are, and how badly women are being treated,” Gomperts said.

And the prosecutions might only highlight the compelling evidence that increasing legal access to medical abortion — that is, abortion-by-pill rather than surgically — will allow women to have abortions much earlier in pregnancy, which is far more culturally and politically palatable in the United States.

Daniel Grossman, a professor of gynecology and obstetrics at the University of California, San Francisco, studied the effects of a program in Iowa that allowed women to get abortion pills after consulting with a doctor by video conference. The method proved extremely safe.

What’s more, wider access to abortion pills did not increase Iowa’s overall abortion rate — indeed the rate declined, most likely because of a state program that improved access to contraceptives. But the type of abortions shiftedMore women had first-trimester abortions, and fewer women had second-trimester abortions. Grossman is working on several other clinical studies focused on the pill, and he says he believes the weight of the evidence will soon become irrefutable.

The pill isn’t hard to get now, and it will only get easier.

“It’s just a matter of time,” Grossman told me.