By Randall K. O’Bannon, Ph.D., NRL Director of Education & Research
Editor’s note. In Part One, Dr. O’Bannon related the most recent abortion numbers and began his explanation of how and why compiling accurate abortion information is going to be a complex task in the post-Dobbs era.
Today, in conclusion, he will look at one of the major factors that will make it difficult to get exact numbers for the next few years.
Online chemical abortions complicate counts
There is another factor that is going to complicate state abortion counting and may make it difficult to ever measure the impact of Dobbs and new state protections with any precision: abortion pills ordered online and delivered directly to women’s homes by mail.
And that could get worse with the latest actions by the U.S. Food and Drug Administration authorizing pharmacies, under certain conditions, to stock and dispense these deadly drugs.
The evolution of the chemical abortion process
Chemical abortions have been, from the beginning, a dangerous, complicated, multi-drug, multi-step process.
The drugs work only in the earliest stages of pregnancy and are directly associated with pain and bleeding that can easily get out of hand. Women have to be counseled in their use and risks and particularly need to have their baby’s gestational age ascertained and ensure that the child is appropriately located in the uterus ; mifepristone, the drug used most frequently in these abortions, does not work in situations of ectopic pregnancy, where the baby implants outside the womb.
The most responsible course of action is to monitor the woman for several days or weeks after she takes the drugs to make sure the drugs work and do not trigger excessive bleeding, pain, or the development of a potentially deadly infection.
In the earliest years of its use, the U.S. Food and Drug Administration (FDA) required multiple visits and careful monitoring of mifepristone patients with thousands of injuries and more than two dozen deaths showing the wisdom of this course of action.
But under pressure from abortion advocates, sympathetic administrations watered down abortion pill regulations, dropping required visits, and allowing the pills to be virtually prescribed and delivered by mail.
Defying state laws and federal regulations
When this is done through traditional clinics and local abortionists, records of these abortions should exist. But when foreign entities and out-of-state operations who have no regard for state laws or FDA policies get involved, tracking chemical abortions and what happens to the women who get them becomes problematic.
Several new online telabortion “providers” sprang up as soon as the FDA first began adjusting its protocols, ostensibly to help women access abortion pills remotely during the pandemic so they wouldn’t have to visit the clinic. But the official promotion and sale of abortion pills over the internet can be traced back at least as far as 2005, when former Greenpeace activist Rebecca Gomperts started “Women on Web,” where women could order abortion pills after a short online consultation.
Though originally supposed to be for women in countries where such pills were not legally authorized and available, Gomperts brought her pills to the U.S. in 2018 with a group named “Aid Access” when she said she saw “access” threatened here.
While other online abortion groups appear to have tried to comply with state and federal regulations, Aid Access publicly defied them. They shipped pills to women in states which explicitly forbade the prescription of pills without an in person exam or the shipping of abortion pills through the mail.
Difficulties in keeping track
When Texas’ Heartbeat legislation went into effect in September of 2021, abortions officially dropped by nearly half, from about 5,000 a month to 2,251 that September. But Aid Access says that orders for abortion pills jumped to about a 1,100 a month after the law’s implementation, erasing much of its impact.
Of course, this does not necessarily mean that there were 1,100 new chemical abortions every month in Texas from mailed pills from that point forward. Women could have ordered the pills but changed their minds, as many do. Women may have heeded abortion industry warnings and bought pills preemptively to stock their medicine cabinets. The pills may have been bought by resellers or by men intending to slip these drugs into their partners’ drinks. The pills could have been used but failed. The number of orders does not directly translate into the number of abortions.
But some likely do. In the SFP report, they say “This report does not reflect any self-managed abortions, defined as attempting to end one’s own pregnancy without clinical supervision, including use of the Aid Access service.” They caution that “we are unable to estimate the number of abortions that occurred outside the formal healthcare system, such as via Aid Access.”
These are going to be a challenge for both the state and the industry to track. Already, the Guttmacher Institute noted in its latest count (for 2020) that “Our study underestimates the true amount of the increase in abortion since we only measure abortions that occurred in clinical settings. Research documented that more than 55,000 US residents requested abortion drugs from one online provider [Aid Access] during the study period [2018-2020] and many of these requests undoubtedly resulted in self-managed abortions. US residents may also have obtained abortion drugs for self-managed abortion through other websites.”
No word on whether Guttmacher has in mind some way to track these abortions in the future.
Particular state challenges with abortion pills ordered online
States obtain reports from clinics and other abortion “providers” in their states, but generally lack some way of getting such information from out-of-state sources. If these abortions are not legal in the state asking for the information, it seems unlikely that clinics or online providers outside the state will volunteer evidence of their lawbreaking. Even though no state will prosecute the women ordering and using the pills, those women are unlikely to share that information with the state unless they are injured or swindled by the purported pill provider and are seeking compensation.
Tracking, monitoring, or prosecuting these rogue online abortion pill retailers will largely depend on how well the state is able to enforce its prohibitions. Though headquartered in the Netherlands and using pills shipped from India, Aid Access is now relying on a network of American healthcare providers to manage its U.S. cases. And many of those providers are admitting that, in the light of Dobbs and new state legislation protecting unborn children and limiting or proscribing the prescription or sale of abortion drugs, they are fearful of expensive lawsuits, losing their licenses, or even facing jail time (New York Times Magazine, 10/4/22).
Expectations for the future
Heavy promotion of these online chemical abortions by the media and the abortion industry, coupled with the inherent difficulties involved in the prosecution of illegal suppliers, are likely to make the precise counting of these abortions challenging a challenge for years to come.
If considerable numbers of women who use these drugs, many of them foreign knockoffs of untested purity or quality, are injured or worse, and the public becomes aware of the dangers and connects it to these irresponsible suppliers, it could reduce demand for these drugs and threaten the business model of these abortion pill promoters.
In the end, knowledge of the pill’s problems, and awareness of practical, life-affirming alternatives to abortion, may prove the best ways to reduce the count of these abortions, however large or small their actual numbers might be.
Abortions are always hard to accurately count but there are a few things that may make it harder after Dobbs.
The basic delay that has always existed, as states and abortion groups try to collect numbers, we have already talked about, as well as the new challenges posed by abortion pills shipped by rogue suppliers from out of state.
Women traveling to other states, sometimes to a clinic just across the border, has long been an issue. But it will become a bigger issue with differences between state policies becoming starker than ever, with some states providing full protection to the unborn and others actively recruiting out-of-state abortion patients.
For the most part, it appears that abortion clinics in states now fully protecting unborn children have either relocated to other states or closed entirely. A few remain, supposedly offering other non-abortion services or performing only those that qualify as medical emergencies. However, it seems unlikely that they would publicly perform other abortions unless it were part of an industry effort to attempt to overturn the law in state courts.
What they do behind the scenes would not show up in public records, but the risk that these would be discovered and the abortionists prosecuted probably keep most from even from considering performing these, secret or not. Much easier to move to a nearby abortion-friendly state, open a clinic there, and ship pills from there or invite women to cross the border.
One place clandestine abortions might show up in health statistics is in increased visits to the emergency room as women deal with complications from botched surgical abortions or failed chemical abortions show up seeking treatment. Abortion industry advice that women try to pass these off as miscarriages may keep them from being counted as such, but sudden jumps in these numbers will call for some explanation.