WASHINGTON — K.T. Volkova got a positive pregnancy test just days before Texas' controversial law banning most abortions took effect.
The 23-year-old, who identifies as nonbinary and uses they/them pronouns, was nearly six weeks pregnant and immediately knew they wanted an abortion. But Volkova was already on the cusp of the limit set by the new law, which bars in-clinic abortions after the detection of a fetal heartbeat, or as early as six weeks.
The options to get an abortion were limited. Volkova figured it would be impossible to get the procedure done in person at a Texas clinic, flooded by others wanting abortions, before the law took effect Sept. 1. But a busy schedule meant traveling out of state was also out of the question.
Volkova’s solution: ordering abortion pills online to end the pregnancy at home.
“It was almost like an online shopping experience with a customer service representative,” Volkova said. “I personally would say it was maybe even easier than having to go to an actual clinic.”
But Volkova, who used a second last name they don’t use publicly for privacy reasons, has been worried about potential legal ramifications and declined in an interview to give personal information or name the source of the pills.
For many who are seeking abortions, and who tend to be low-income, traveling out of state to get the procedure isn’t feasible, not only because of the cost of the procedure and travel, but also because they are unable to take time off from work or organize child care. Instead, women who live in states that impose restrictions on the procedure are resorting to ordering the pills online to induce abortions at home, for the affordability and convenience, and for some, out of desperation.
They’re circumventing laws that make obtaining abortion pills onerous and complicated, like in Texas, where women must pick up the drugs in person and can’t get them through a telehealth appointment. Another Texas law set to go into effect in December will further tighten restrictions on the pill, narrowing the window for its use from up to the 10th week of pregnancy to the seventh, and prohibiting the drug from being mailed.
Surge in online traffic
Plan C, an organization that provides information about how to order abortion pills online and provides advice about avoiding legal trouble, says traffic on its website has skyrocketed since Texas’ fetal heartbeat law, Senate Bill 8, took effect. The organization, which does not distribute the pills itself, lists providers of the drugs, including some online pharmacies that the organization’s co-founder, Elisa Wells, acknowledged might look questionable at first. But her organization has tested the pills from all of the websites it promotes and has verified their reliability and safety, she said.
“The surge and interest in our website and visits to our abortion pill finder service that we offer is an indication that people really are looking to understand all of their options," Wells said. "So I think there's quite a bit of interest in this."
Aid Access, the only physician-run service in the U.S. that provides those seeking self-managed abortions with pills, is one of the most popular providers. The service doesn’t involve video or phone consultations or require ultrasounds that are otherwise mandated by some states. Instead, it uses electronic forms that ask patients about the first day of their last period and any potential bleeding disorders. If patients live in one of about 20 states where it’s legal to obtain abortion pills through telemedicine services, they receive a prescription from a U.S.-based provider that works for Aid Access that they fill through a mail-order pharmacy.
Those who live in restrictive states like Texas can still get medication from the organization, which is based in the Netherlands. There, the group’s founder, Dr. Rebecca Gomperts, and her team submit prescriptions for those patients to a pharmacy in India, a major pharmaceutical manufacturer, which then ships the pills directly to their home addresses in the U.S. In those cases, pills cost $105 for the patient out of pocket and can take an average of two weeks to arrive. For women who can’t afford the price, Aid Access will accept any donation or cover the cost entirely.
While the Food and Drug Administration during the Trump administration demanded that Aid Access cease and desist its shipments of abortion pills, there is little the government can do to prevent the transactions, experts say. It would be completely impractical for the government to try to seize the packages given that millions of Americans routinely flout the U.S. prohibition on imports of most drugs, they say.
“All of the medications [from Aid Access], whether they're in Texas or another state, are just discreet packages,” said Christie Pitney, a women’s health nurse practitioner who’s a U.S.-based provider of pills for Aid Access. “There's no way that the post office or the mail person would know what's being delivered. There's no way that this could be intercepted in that manner.”
While Plan C and other experts say the pills are safe, the FDA said in a statement to NBC News that it’s concerned about their sale because they haven’t been approved by the agency or properly inspected. Drugs that dodge these regulations “may be contaminated, counterfeit, contain varying amounts of active ingredients, or contain different ingredients altogether,” it said.
While data shows that the pill has become an incredibly popular method of abortion, it's difficult to track exact numbers of self-managed abortions in the U.S.
Abigail Aiken, an associate professor at the University of Texas at Austin who has studied abortions that are self-managed, found that Aid Access, which launched in 2018, received more than 57,500 requests in its first two years of service in the U.S.
When Texas Gov. Greg Abbott imposed a weekslong ban on abortions and other procedures that he deemed "not immediately medically necessary" in March 2020 as a way to conserve medical resources during the Covid-19 pandemic, requests to Aid Access from Texas almost doubled, Aiken found. Her study showed that requests rose in a number of states with “severe and longest-lasting restrictions” amid the pandemic, though Texas showed the largest increase in requests “despite a relatively low burden of Covid-19 during the study time frame.”
Risk of criminalization
Most people seeking an abortion are more focused on trying to end their pregnancies safely and effectively than wary of potential legal repercussions, Aiken, who has studied the issue, said.
“I think those concerns are not top of the list for people who are trying to self-manage,” she said. “I think they're just looking for an affordable and safe way to get the care they need.”
But while studies have shown the vast majority of people who self-manage abortions at home don’t need further medical care, complications, while rare, do arise — and in some cases the patients or otherswere arrested after follow-up care.
The group If/When/How, a network of lawyers focused on abortion rights, found at least two dozen cases in which people were prosecuted for involvement in self-managed abortions since 2000. A woman in Pennsylvania, for example, was sentenced to up to 18 months in prison in 2014 for obtaining abortion pills online and giving them to her teenage daughter, who suffered complications.
Texas’ fetal heartbeat law does not criminalize abortions, but allows anyone, even someone outside Texas, to sue abortion providers or others who help people get abortions after the six-week limit for at least $10,000 per defendant. Abbott also signed Senate Bill 4 earlier this month, which makes it a state felony offense, punishable by jail time, for physicians to provide medication abortions to people who are more than seven weeks pregnant. The bill also seeks to crack down on the mailing of the pills to Texas residents.
But even though Texas, like most states, doesn’t specifically make it a crime for people to self-manage their abortions, there have been criminal investigations in more than 20 states pertaining to such abortions because prosecutors take advantage of laws not directly related to the procedure, If/When/How Executive Director Jill E. Adams said.
Those charges have run the gamut, from practicing medicine and pharmacy without a license to possession of a dangerous substance, and from child abuse to neglect or endangerment of a minor, she said. There have also been charges related to laws on the disposal of fetal remains, abuse of a corpse and concealment of a birth.
Adams warned that Texas’ fetal heartbeat law could “indirectly give rise to more criminalization of people who end their own pregnancies outside the formal medical system” because as more people self-manage their abortions, the potential for complications — and thus the risk of prosecutions under other laws — increases.
After the law took effect, the group received an uptick in calls from people trying to navigate the new environment.
“We want people who are ending their own pregnancies to know that they have the right to do so, but it carries some legal risk, and that they could be unjustly arrested, investigated and jailed, prosecuted and eventually imprisoned,” Adams said.
‘Terrible' environment
The environment for abortion-seekers and providers in Texas since the heartbeat law took effect has been demoralizing, said Amy Hagstrom Miller, founder of Whole Woman’s Health, which operates four abortion clinics in Texas and has been complying with the law.
Her clinics were still providing abortions minutes before the ban took effect. At their Fort Worth location, they faced protesters who illuminated the clinic and parking lot with a spotlight and were shining flashlights into patients’ cars "just to let us know we were under surveillance and they were ready to catch us if we, you know, provided care after midnight," she said. "It's just a terrible environment with this sort of vigilante bounty hunter system."
Her staff is encountering people who come into their clinics and “when we give them the results of their ultrasound and tell them they can't have an abortion in Texas, they just, they're shocked.”
“They're scared, they're numb, they're in anguish,” she said. “Some of them are feeling really desperate.”
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