Abortion pills post-Roe: How doctors are helping women have abortions
Linda Prine is a family physician and the co-founder of the Miscarriage and Abortion Hotline, which counsels women who want to use medication to self-manage their abortions. For women who need abortions in the states where the procedure is fully or partially banned, the medication, mifepristone and misoprostol, is often the best chance they have at receiving abortion care, particularly if they are unable to travel.
In 2020, the last year for which full data is available, medication abortions accounted for more than half of all abortions in the United States. While the FDA recently authorized pharmacies to carry the pills, and patients to receive the medication by mail, online pharmacies in the US still won’t sell or ship to states where self-managed abortion is illegal — meaning patients are often relying on overseas providers, which can take weeks.
At the hotline, Prine and other volunteers talk women through the process of self-managing abortions, offer advice about a range of medical and privacy concerns, and help provide resources to women looking to order pills (the hotline does not provide the pills themselves). Prine and physicians like her are on the leading edge of the effort to ensure women retain their right to abortion care — an effort that will have important legal and political implications in the years to come. Vox spoke with Dr. Prine about how her work has changed since the fall of Roe v. Wade (the number of calls to the hotline, she says, have tripled since the Supreme Court’s Dobbs v. Jackson Women’s Health decision last June), and what she thinks will be needed to protect their work providing telemedicine in states with restrictions in the weeks and months ahead.
This interview has been edited for length and clarity.
What made you decide to start the hotline?
We actually started it during the Trump years, when we were just frustrated with all of the piling on of state restrictions, and little did we know how bad it would get. Initially there was only a group of 12 of us, and we staffed it for about 12 hours a day, and we each took a couple of shifts a month. That was plenty in the beginning. And then it got busier.
Do you remember where you were when the Supreme Court decision came down overturning Roe?
I was actually in a car, traveling to go on vacation, and my phone just blew up. It was calls from the practice I was participating in, in New Mexico, because several of the clinics on the Texas side had given out our phone number as they were canceling people’s appointments. I think I spoke to 60 people that day, just nonstop, trying to help them get care wherever we could. It was a really traumatic day for all those people. They were really calling us sobbing and freaked out and upset and incredulous.
What has changed since the fall of Roe? How has it changed your work?
Well, the hotline is getting more calls, and the difference now is that many of our callers are later in their pregnancies, because they’re getting their pills from overseas. They’re ordering pills from online pharmacies, and they come sometimes with no directions. So they call us about that. But also, they’re further along in pregnancy and they’re calling us scared, because they’ve passed a tiny but recognizable fetus, and they are freaked out and they weren’t expecting that. And it’s frankly traumatizing, what people are going through, because they haven’t had any anticipatory guidance that this might be happening, and people who’ve had an abortion before with pills didn’t pass anything that they could see.
The pills are approved by the FDA for up to 10 weeks and by the World Health Organization for up to 12. Most of the time, though, they’ve been used in our country under eight weeks; something like 75 percent to 80 percent of people using pills were using them under eight weeks pre-Dobbs. But now, they’re using them whenever they can get them. And sometimes that is quite a bit later. Sometimes it’s 14 weeks, 18 weeks. And so we get calls from people completely freaked out, crying, sobbing. I think for us, the trauma and the horror of the Dobbs decision is that people are having to go through something that they should not have to be experiencing.
Do you feel like these delays are compounding trauma for people that they wouldn’t otherwise have to go through, if they had access to the pills early on?
Yeah, absolutely. People were not using the pills this late in pregnancy, pre-Dobbs. This is a huge shift. There’s not research to support [that] yet. This is just what we’re seeing on the ground.
You mentioned that your staffing needs at the hotline are different now, post-Dobbs.
We are up to 60 volunteers now. We went from 12 to 20 to 40. And then, yeah, with Dobbs we had to expand our hours and shorten the shifts. You just can’t be on the phone for eight or 12 hours straight. So we do six-hour shifts now, and it’s intense. You’re getting text messages and phone calls at the same time and trying to talk to as many people as need you, and it’s a little bit exhausting by the time the six hours is up.
Are there other kinds of concerns that you’re hearing from patients who are calling in?
People are afraid to go to the emergency room if they think they need it, and most of the time they don’t need it, so we talk them off that ledge and explain what they need to do to take care of themselves. But we also tell them, if they do decide to go, how to protect themselves in terms of how they explain what’s been happening to them. In other words, they’re having a miscarriage, they’re not having an abortion, and that it’s impossible for anyone in the emergency room to figure out that they used pills. There’s no blood test for that. There’s no exam to show that that’s what happened. So letting them know how to preserve their privacy in the medical setting, when it’s become a potentially dangerous place to go, has been really important.
Now, it’s not really true that any medical personnel has any duty to report a patient. In fact, they are not supposed to do that because it would be a HIPAA violation. And it’s not illegal for people to be buying pills off the internet and using them. What’s illegal, in most of these states that have passed laws, is for doctors to provide the pills. So the doctors, if they were providing the pills, would be the ones breaking the law, not the patients. But that doesn’t mean that there’s not an ambiance of fear out there. It hasn’t been made clear to the general public, I don’t think, that people using abortion pills are not breaking any laws.
What are the other challenges patients are facing?
The thing that’s hitting us the hardest is the difficulty accessing care and then accessing the care late. And that’s why so many of us have gotten involved in this movement to get shield laws passed in the blue states so that we can serve people with FDA-approved medications that we can mail quickly through the US Postal Service into those red states, so that people can get what they need in two to three days instead of over a matter of weeks.
How do you think about your personal risk when doing this kind of work? Because it is not a zero risk for you as a provider.
I live in New York City, so I feel very safe there. If it comes to passing the shield laws and we’re mailing pills into the red states and some zealot from Texas or Louisiana or Alabama wants to try to arrest me, I feel confident that the law we’ve passed in New York state, and the lawyers that have surrounded us with pro-bono offers, will take care of me. And really, the optics of arresting doctors for providing humanitarian care in these states that are restricting the care, I don’t think that’s going to win very many votes for the Republicans. So I’m willing to be out there and let them see how that goes over.
Other than the shield laws, are there things that state lawmakers and places that protect abortion rights could be doing to help make your work easier?
Yeah, there’s new legislation being proposed by Assemblywoman Amy Paulin in New York state that would allow standing orders to pharmacies for abortion pills. So that just as you can go into a pharmacy and get a vaccine without having a specific doctor order it for you, you could go into a pharmacy and get your abortion pills without having a specific doctor order it for you. That’s brilliant. And if she needs a doctor to do the standing orders, sign me up.
We’re going to have to continue to get creative like this. And honestly, you don’t need a doctor to get you abortion pills. You’re swallowing them at home, no matter where you get them … It’s really not rocket science. And people are totally competent to decide if that’s what they need at that point in their life. So I’m all in support of all of the initiatives that are making access to these pills easier.
The safety and efficacy of these medicines is what people really need to understand, and especially the legislators, so that they can get more comfortable with easing up the access and making it possible for us to do telemedicine abortion across state lines, making it possible for people to pick them up in the pharmacy, and getting rid of the FDA regulations that make it hard to prescribe this medication.
The other thing that we’re seeing an increase in is people ordering the pills just in case. It’s called advance provision. And those of us who work for Aid Access get a lot of requests for advance provisions — people aren’t pregnant at all, but they want to have these pills in their medicine cabinet just in case. Especially if they live in the red states where it can take three or four weeks to get your pills, having them on hand is a really good idea.
Is that something that you saw a lot of prior to this, people wanting the pills just in case?
No. This has totally gone through the roof since the fall of Dobbs, especially in the first couple of weeks. People were overwhelmed with requests for advance provision.
The bigger problems that I’m hearing, from my OB-GYN colleagues in these red states, with normal maternity care, are terrible. I don’t know what the solutions are for that other than to really have referendums in as many states as possible to make abortion legal.
Would you feel comfortable telling us some of the things that you’re hearing from your own colleagues about maternity care?
I hear them trying to get their own patients to another state for care that they need, which is insane. If you have somebody who has a premature rupture of membranes with a pre-viable fetus, and they need to have that fetus removed for their own well-being and safety, and it’s not ever going to be a living being — to not be able to do that procedure in your own state, but to have to transfer somebody who is at risk of hemorrhage, at risk of infection, is insane. It’s an insane thing that’s happening to health care. People are literally on Signal chats trying to find care for their patients. So, yeah, that’s what I’m hearing. That’s the devastating news out of so many of these states.
What else should we keep in mind?
Now’s the time to get proactive. That November election, the voters told us: We want access to abortion. So we need to get going and see how we can get people access. Enough of being afraid of our shadows, or that we’re going to be criminalized for this, that, or the other thing. Let’s get moving and see what we can do to make abortion available by every creative [method]: legislative, underground, crossing borders, whatever it takes. I think we’ve won. The voters have told us they want abortion access, and the American people want it. So let’s get that for them instead of worrying about our own criminalization.