Death by medicine

Keisha fidgeted nervously in the packed lobby of an abortion facility in Jacksonville, Fla. The arguments thrown at her by family and friends kept swirling through her mind as the clock ticked past what should have been a 10 a.m. appointment. “You don’t need no baby.” “You already got three kids?” “You need to live your life.” “Nobody’s going to want to watch no baby.” It had all made sense at the time.

But now Keisha began to wish she’d never called the organization that booked her appointment at A Woman’s Choice and paid for her hotel. She wished her friend wasn’t waiting for her in the car outside. “This baby didn’t ask to be here. And I’m only doing this because of what other people think,” she thought. If only she’d come alone. Then she could just pretend she’d gone through with it.

Keisha was about four weeks pregnant. She’d fled Jacksonville and a domestic violence situation for Houston a few weeks earlier. But then, in early March, she found out she was pregnant with her abuser’s child. Texas law forbids all elective abortions. A quick internet search connected her with a group that organizes all-expenses-paid trips to get abortions in other states.

At 1 p.m., the abortionist called Keisha and several others into an exam room. He watched the women put the first drug in the abortion pill regimen, mifepristone, under their tongues. Then he handed them a plastic bag filled with pain meds and four misoprostol pills to take at home. Keisha instantly regretted her decision as the mifepristone dissolved. “I was trying to throw it up and everything,” she said. But it was already gone.

Keisha is one of a growing number of women choosing to end the lives of their unborn children with pills. According to a 2022 study by the pro-abortion Guttmacher Institute, medication abortions accounted for 53 percent of facility-based abortions last year, a jump from 39 percent in 2017. And more women than ever are turning to the pill to get around pro-life state laws passed in the aftermath of Dobbs v. Jackson. As record numbers of women clamor for the abortion pill, pro-lifers are finding new ways to warn them about its dangers while navigating a rapidly changing legal landscape.

A WOMAN WHO ONLY takes the first part of the abortion pill regimen has up to three days to change her mind. It’s too late after they take the ­second drug, misoprostol, that causes the uterus to contract and expel the child.

On the road back to Houston, Keisha’s uneasiness grew. She waited until her friend pulled into a gas station to dial the hotline for the Abortion Pill Rescue Network. She told the nurse who answered that she needed to communicate over text. The nurse connected her with Sandra Ontiveros, director of operations at Fifth Ward Pregnancy Help Center in Houston. It was Saturday evening, several hours after Keisha had taken her first pill.

“It’s always late evening, afternoon because abortion clinics typically will do the abortion pill on Friday so that they have the weekend,” Ontiveros said.

Keisha had 72 hours at best to get the progesterone doses that would reverse the effects of the mifepristone, which starves the baby by blocking progesterone and thinning the uterine lining. That window was closing fast.

French pharmaceutical company Roussel Uclaf developed mifepristone in the 1980s. Former President Bill Clinton urged the company to bring it to U.S. markets in 1994. “And so there were politics injected into the process from the very beginning,” said Katie Glenn, state policy director at Susan B. Anthony Pro-Life America. “Even before the drug was approved in the United States, there have been pro-life doctors speaking out.”

Those concerns are now front and center in the fight to get mifepristone taken off the market. Plaintiffs for Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration, a case that made it all the way to the Supreme Court in April, allege the agency ignored evidence mifepristone endangers women and girls.

“Knowing that Roe v. Wade was going to be overturned, I think the abortion industry really pushed to make it readily available,” said Christa Brown, director of medical impact with Heartbeat International, an organization that partners with the Abortion Pill Rescue Network. “There’s really an aggressive strategy to get these drugs to women very quickly.”

Pro-lifers have watched protections for women and their children erode since the FDA approved mifepristone in 2000. Initially, a doctor would perform an ultrasound to make sure a woman wasn’t too far along in her pregnancy. He would look into her medical background and do Rh testing to make sure the woman’s antibodies didn’t attack future children. A doctor watched her take the medication to ensure she wasn’t coerced. The woman visited again after she finished the process to check for complications. But in 2016, the FDA lengthened the time a woman could use the drug from seven weeks to 10 and cut the number of doctor’s visits to one. In 2021, the agency made permanent COVID-19 pandemic exceptions permitting healthcare workers to prescribe the pill via telehealth and send it through the mail. Local pharmacies and corner drugstores can now dispense the abortion pill thanks to another regulation change early this year.

“So the women are left alone to assess their own symptoms,” said Brown. “This type of abortion can seem very appealing to them … but then when they are alone, and they start to have bleeding and pain, it can be very challenging to know how much is too much.”

William Lile, an obstetrician-gynecologist in Pensacola, Fla., said women often miscalculate the length of their pregnancies. It isn’t unusual for a woman to visit his office thinking she is six weeks pregnant until an ultrasound reveals she is 15 weeks. “That happens every week,” said Lile. Medication abortions are much riskier that far along in pregnancy. Without seeing a doctor, women who take the abortion pill also risk leaving an ectopic pregnancy, the No. 1 cause of maternal mortality in the first trimester, untreated. The warning signs mirror the effects of the pill. “They’re the exact same symptoms: bleeding, cramping, and pain,” Lile said.

Women are four times more likely to have complications after a medication abortion than a surgical abortion, a study in Finland found. Ingrid Skop, a board certified OB-GYN in San Antonio, treated a woman who bled for six weeks because she didn’t realize part of her dead baby was still in her uterus. Doctors also aren’t checking for anemia or sexually transmitted diseases when they prescribe the pill. Coercion is also a concern. “Men can get online and pretend to be women in order to use these pills, sex traffickers, incestuous abusers, coercive boyfriends,” said Skop.

Abortion data is notoriously scant because the government doesn’t track it. Until 2016, the FDA required doctors to report adverse events resulting from mifepristone. Planned Parenthood, which only performs a subset of all abortions in the United States, reported about twice as many adverse events as the FDA. “So clearly, their data was vastly incomplete,” said Tessa Longbons, a senior research associate at the Charlotte Lozier Institute. Researchers at the institute examined state Medicaid data and found women were 50 percent more likely to end up in the emergency room after a medication abortion than after a surgical abortion.

ON A GLOOMY morning in April, a group of Texas pregnancy center directors gathered for their regular Thursday morning Zoom call to discuss trends and challenges at centers around the state. More women are considering the pill and it’s harder to get them to come in for an appointment, so the directors are finding new ways to help women understand the dangers. Jennifer Shelton said staff at Real Options in North Dallas send those women information framed as questions to ask their abortion pill provider.

She said her growing number of South Asian clients bring the abortion pill back from India and give it to their friends. Often they do not even have the packaging. “We have no idea what they’re taking,” Shelton said. Others order the pills online from groups like Aid Access—with no medical consultation or follow-up. The California startup Choix allows women who aren’t pregnant to purchase pills for future use. Although consultations are available by phone, women are only required to fill out a five-minute questionnaire and can communicate with a representative over text.

College students regularly send Texas Right to Life President John Seago pictures of QR codes posted in public bathrooms that direct women to illegal abortion pill websites. The websites mail pills directly to dorm rooms.

And pro-lifers aren’t just concerned about the physical hazards. Abby Johnson, a former Planned Parenthood clinic director whose story is featured in the movie Unplanned, gets emails from women who watched the film and realized they still carry unresolved trauma. “It’s PTSD,” Johnson said. “Reliving the horror of seeing your baby in the toilet, holding your baby in your hands, knowing that you’re the one that made that decision.” It’s cruel to encourage women to take such a drastic step alone in their bathroom, she said.

Pregnancy center staffers experience their own kind of trauma. Executive Director Threesa Sadler and her team at Raffa Clinic in Greenville, Texas, have unwittingly welcomed clients who’ve already taken the pill. The clinic serves the 882-square-mile rural area that is Hunt County, along with several other counties northeast of Dallas. “We started seeing women coming in that were not disclosing they were taking the pill,” said Sadler, who is also a nurse. “That was something we weren’t ready for.”

The first time it happened, the clinic staff didn’t know the woman who came in wanted an ultrasound to see if the pill had worked. “You have a woman who’s relieved and excited that her baby doesn’t have a heartbeat,” she said, adding the encounter “was very, very hard on our staff.”

Sadler and other pregnancy center directors are now turning their attention to post-abortion care. Professional counselors get free office space and in return provide free trauma counseling for their ­clients. A group of women from local churches host Bible studies and weekend retreats for women who want to dive deeper into Scripture.

On April 21, the U.S. Supreme Court intervened in a case challenging the FDA’s approval of mifepristone. U.S. District Judge Matthew Kacsmaryk for the Northern District of Texas had paused FDA approval of the drug, siding with pro-life medical groups who argued the agency rushed it through the approval process. Upon appeal, the 5th U.S. Circuit Court of Appeals ruled too much time had passed to suspend FDA approval but said the agency should adopt several safety requirements requested by pro-life groups. The Supreme Court issued an order that keeps mifepristone widely available for now.

While pro-lifers celebrated Kacsmaryk’s decision, a challenge long in the making, they worry that taking only one of the drugs off the market could further endanger women if abortionists turn to using misoprostol alone. That drug, which causes the uterus to contract, is a common form of chemical abortion in underdeveloped countries. “At less than nine weeks, it’s about 87 percent effective at causing a complete abortion,” said Lile, noting that leaves more women vulnerable to infection.

“It’s going to be more dangerous for women, more complications,” said Jo Markham, executive director of Agape Pregnancy Resource Center in Round Rock, Texas. Markham’s office is currently squeezed into the center’s small prayer chapel that boasts one tiny stained glass window. An influx of clients after Dobbs forced the center to begin remodeling its upstairs to make space for more offices and consultation rooms. The center got ­certified in January to offer abortion pill reversals. “This is abortion now,” Markham said. “And we need to be able to offer them help.”

Sadler says she understands why any effort to take abortion drugs off the market is considered positive. “However, using only the misoprostol is more dangerous, and it takes abortion pill reversal off the table for us,” she said.

And as the number of medication abortions increases, so does the number of women who change their minds. The Abortion Pill Rescue Network hotline is busier than ever. Hotline nurses connect women in the Pensacola area with Lile. He’s delivered about 4,000 babies in his 24-year practice. He remembers some of the triplets and quadruplets, but it’s the women who delivered children they previously tried to abort who are seared into his mind. He’s successfully reversed 13 medication abortions. “When you get to deliver that baby, and see this beautiful little boy or beautiful little girl,” he said, “you realize, months prior to that, there was a chance that we weren’t going to see that baby.”

Fifth Ward Pregnancy Help Center sits off a noisy highway near downtown Houston. Inside, cheerful wall decorations and a patterned area rug welcome women into the bustling lobby. I spoke with Keisha in a room set aside for clients with older children who need a place to play. White ­cotton clouds hang from the ceiling, and nature scenes cover the back wall.

Keisha made it to the pregnancy center on Tuesday, March 14, almost three days after she took the mifepristone in Jacksonville. An ultrasound revealed a heartbeat—frail, but steady. Keisha immediately took her first dose of progesterone. When she started bleeding heavily, she thought it must be too late and stopped the progesterone regimen, ignoring the pregnancy center staff who urged her to go to the hospital to make sure everything was OK.

But two weeks later, Keisha still felt like something wasn’t right. “I finally went to the hospital, and they were like, you’re six weeks and five days pregnant,” she said. “We don’t know how it’s possible.” Keisha was stunned. “I was just hoping and praying,” she said, with a smile.

In spite of the successful reversal, Keisha miscarried about a month after she told me her story in the center’s peaceful childcare room. Ontiveros said the center is walking alongside Keisha in her grief. She told me she worries pro-abortion groups will misconstrue Keisha’s story and others like it to claim abortion pill reversals are ineffective, even impossible. But Keisha chose life for her child, though it ended all too quickly. Stories don’t always end happily, Ontiveros said, but that doesn’t change Fifth Ward’s fight for the unborn or their love for the women who carry them.