In Spring 2020, abortion advocates went to war. As COVID-19 spread, some U.S. abortion facilities closed. Others limited in-person procedures. Some governors called abortions nonessential, and the pro-abortion Guttmacher Institute was livid: “Reproductive health care needs and decisions cannot be put on hold.” Its April press release claimed abortion is “as essential to people’s lives as food, shelter and security.”

The abortion industry in recent years has pushed for more telemedicine abortion, which involves sending abortion-inducing chemicals to women by mail after a phone or video consultation. When the Clinton-era Food and Drug Administration in 2000 approved use of abortion pills, it insisted that to keep women safe only physicians could dispense abortion drugs. Doctors needed to check for ectopic pregnancies (when an embryo attaches outside the uterus) and determine the baby’s gestational age. Only a woman at or before seven weeks of pregnancy could take the pills, and two pill-dispensing visits were necessary, along with a follow-up exam.

Abortion advocates said those rules oppressed women, so the Obama-era FDA loosened protections in 2016: It upped the gestation age limit to 10 weeks, scrapped the second required visit, and allowed abortion businesses to conduct the follow-up appointment over the phone instead of in person. In 2020, with many abortion centers closed, proponents shopped for a judge who would further loosen requirements. Many would not. But U.S. District Judge Theodore D. Chuang did, ruling in July that any barrier to accessing abortion pills would cause “irreparable harm.” He lifted the FDA requirements for in-person appointments as long as the coronavirus pandemic persists, but on Jan. 12, the Supreme Court granted the Trump administration’s request to continue enforcing FDA restrictions. But Chuang’s six-month injunction gave a possible preview of the abortion pill’s new frontier, especially if the Biden administration removes FDA requirements.

ABORTION ENTREPRENEURS saw the opening and rushed through, throwing off restraint and creating an abortion Wild West. Julie Amaon, formerly a Planned Parenthood facility manager in Austin, Texas, was one of them. She started medical school in 2012 with the goal of becoming an abortionist, and by the end of her Minnesota residency program was a pill proponent. In a September 2020 issue of Bustle, Amaon said, “In a perfect world, you could see a family medicine doctor for a sinus infection, for birth control, and for a medication abortion. That doctor could call the medicine in to your pharmacy or have it mailed to your home—whatever is best for you.”

Amaon last year launched Just the Pill, a startup company with an online platform that allows women to order abortion drugs directly to their Minnesota addresses and take them at home. Similar startups launched as existing abortion facilities began providing telemedicine and as U.S.-based online pharmacies like Honeybee Health started fulfilling abortion pill prescriptions.

Choix, a California startup, seems particularly lax in pill distribution. While other telemedicine abortion providers require a video call or at least a phone call with a provider, Choix allows “visits” to take place via text only, although phone calls are an option. The patient provides her medical details through an online form that includes questions about her history with ectopic pregnancies, her Rh blood type, and a place for her to fill out the date of her last menstrual cycle.

The provider uses the patient’s answers to determine if the woman is eligible for the abortion pill. The simple questionnaire is a risky way to assess a woman’s fitness for a drug that could threaten her life in ectopic pregnancies or pregnancies beyond seven weeks. A lack of knowledge or lack of honesty could yield false answers. When I emailed Choix customer support about safety concerns, the agent responded, “It is as safe and quicker than going to your doctor’s office or visiting a clinic.”

Although fully virtual, the sites can’t send pills to every state. When I inquired via email in November, the support staff at Honeybee said the drug required a prescription and that it wasn’t licensed to dispense the drug in Ohio, where I live. Just the Pill says it can “only serve people within Minnesota,” and Choix says it’s “a fully virtual telehealth company,” has no clinic, and is only available in California. The Choix agent said its drugs kill and remove the unborn baby more than 96 percent of the time, with complications “highly unlikely.”

State-by-state restrictions on the pill still stand, according to Judge Chuang’s ruling, so online abortion pill providers will have a harder time operating in the 19 states with existing laws against telemedicine abortions. But at street level this doesn’t mean only state residents can get abortion pills. Brief email exchanges with both Just the Pill and Choix revealed that providers require not an in-state ID but only an in-state mailing address.

The Choix representative told me, “Our providers must be licensed to practice within any state that we wish to provide care. … You should see Choix expanding into more states next year.” Noting my Ohio location, the Honeybee staffer recommended I visit Plan C, a U.S. website that acts as a database for online abortion pill distributors, or order pills from AidAccess, a Dutch website that illegally sold the abortion pill to U.S. women long before the pandemic. Now, thanks to the partnership of licensed U.S. doctors and Chuang’s ruling, ordering from AidAccess is legal in some states.

One group starting in 2016 found a different loophole. Gynuity Health Projects, a group with connections to the pro-abortion Population Council, started a TelAbortion “clinical trial” to push the limits even further. Now in 13 states, the program allows women to receive pills by mail after a video call from their homes. Before the pandemic, the trial required ultrasounds to confirm the pregnancy, but new protocols released at the start of COVID-19’s spread recommended skipping the tests to reduce doctor-patient contact. Now, due to Judge Chuang’s ruling, operations like TelAbortion no longer need to disguise themselves as clinical trials.

DEVELOPMENTS IN GREAT BRITIAN, which approved its pandemic-era “pills by post program” in late March, may show what the United States has in store as access to abortion pills expands. In May, leaked internal emails from the National Health Service suggested that the new system isn’t safe for women. Among the 13 incidents described: Severe bleeding from ectopic pregnancies. Delivery of infants whose mothers had attempted to abort using the pill, even though they were past the legal 10-week limit. Two dead women. Police investigated the alleged murder of one 28-week infant reportedly born alive after the mother self-administered the pill.

The new regime has its critics. Kevin Duffy spent six years in Africa and Asia as a director and consultant with MSI Reproductive Choices (formerly Marie Stopes International). He saw what self-managed abortions look like. MSI distributed pills over the counter at local pharmacies, and no one assessed women to make sure they were eligible for a chemically induced abortion. Duffy saw more and more women with incomplete abortions needing emergency treatments for infections or severe bleeding.

Duffy sent a dozen volunteers in Tanzania to buy abortion pills in local drug shops. He discovered stores weren’t giving women the full dosage: To have a complete abortion they needed 12 misoprostol tablets, but the drug shops only sold them six. No one checked how far along the women were in their pregnancies.

In April, Duffy contacted pro-life organizations in Great Britain and proposed a survey of Great Britain’s “do it yourself” abortion protocols. With sponsorship from Christian Concern, Duffy and a volunteer recruited a team of women to spend six weeks calling the three primary abortion pill providers: MSI, the British Pregnancy Advisory Service (BPAS), and the National Unplanned Pregnancy Advisory Service (NUPAS).

Each pill order required two to three calls with the provider. The first conversation was usually with call center staffers, who took the caller’s general information and the date of her last period. Follow-up calls with a nurse or health adviser usually involved a flurry of yes-or-no questions about the woman’s health history and a quick overview of what to expect during the chemically induced abortion.

The volunteers adopted fake personas and gave false dates of their last menstrual periods during the calls. One volunteer intentionally switched the date of her last menstrual period between the initial calls and the follow-up calls, saying she had remembered incorrectly the first time. Providers accepted the new date and sent her pills, even though the first date she provided would have put her past the legal limit for chemical abortions.

For each persona, volunteers prepared responses to the question of why they wanted an abortion, starting with common reasons: the timing was bad, or money was tight. The call operators asked so they could check a box on the patient’s form: A patient’s reason for obtaining the abortion had to fit within the law. Usually they shoehorned the answers into the broad category of “unable to cope emotionally,” which meant the pregnancy posed a risk to the woman’s mental health.

Some of Duffy’s volunteers tried daring scenarios. When asked for the reason for her abortion, one volunteer told the midwife on the phone that she had just booked a holiday to the beach and didn’t want to look pregnant. The midwife said that was fine, but she had to fit it within a legal category: “I don’t want to put words in your mouth. … Any reason other than the sex of the baby is a valid reason to us, but to attach it to a legal reason, it sounds like emotionally it’s not the right time.”

The staff showed little concern for the emotional effects of expelling a dead baby in the bathroom at home. When the volunteer callers sounded worried, staff members told them they could expect to see “blood clots.” One MSI nurse told a volunteer to “sit on the toilet seat, and let everything just fall in to the toilet … rather than you having that in your pad” to make it more “pleasant.” The nurse told the caller the bleeding could last up to two or three weeks, that there was a 1 percent chance of “complications or failure,” and that the chance of “tissue” remaining in the uterus was more than 3 in 100.

Duffy’s team successfully obtained pills 26 times. The life-ending drugs arrived at volunteers’ homes in unassuming paper or cardboard packages with instructions and phone numbers to call in case of emergency. Christian Concern used the NHS emails and Duffy’s findings in a legal challenge against the health secretary’s decision to allow at-home abortions, but the judge dismissed the evidence. Christian Concern appealed the decision to the U.K. Supreme Court and is awaiting an outcome.

Meanwhile, the British government is moving forward with plans to make at-home abortions permanently available. Politicians expect that the law will change before the temporary pandemic measure expires at the end of its allotted two years. The Biden administration will be watching.

The pill’s history

Pro-life and pro-abortion groups have fought over chemical abortions since a French pharmaceutical company first invented RU-486 in the 1980s. Also known as mifepristone, the abortive drug received approval from the French government in 1988. Early studies found that mifepristone combined with a second drug, misoprostol, was 95 percent effective at killing and expelling an unborn baby. Mifepristone cut off nutrients to the baby and misoprostol induced uterine contractions, which pushed out the baby’s remains. In 1991, Great Britain became the second country to approve RU-486.

A stalwart pro-life movement in the United States kept mifepris­tone out of the country for some time, but the drug eventually received an FDA-style thumbs-up after a rushed approval process in 2000. The explicit goal of all the rules: preserve maternal health. An undiagnosed ectopic pregnancy can kill a mother. If done too late in the pregnancy, a chemically induced abortion can cause severe infection. If no one checks with her afterward, no one can confirm the procedure worked. The implicit result of removing the rules: endangering women’s lives in the name of women’s health. —L.H.