Medication abortion has become the most common method of abortion since the 2022 Dobbs decision ended the federal right to abortion. (Getty Images)

Researchers whose anti-abortion-funded studies were used to argue for restrictions on medication abortion — and then were retracted on methodological grounds — are now taking legal action against academic publisher Sage, which pulled their papers in February.

Represented by conservative law firms Consovoy McCarthy and Alliance Defending Freedom, the latter of which sued the Food and Drug Administration over abortion drugs in 2022, the researchers claim Sage’s retractions were unjustified and politically motivated and have led to “enormous and incalculable harm” to their reputations. They asked the Ventura County Superior Court in California to compel Sage to arbitrate with the researchers.

“Sage punished these highly respected and credentialed scientists simply because they believe in preserving life from conception to natural death. These actions have caused irreparable harm to the authors of these articles, and we are urging Sage to come to the arbitration table — as it is legally bound to do — rescind the retractions and remedy the reputational damage the researchers have suffered at the hands of abortion lobbyists,” said ADF senior counsel Phil Sechler in the recent announcement.

A representative for Sage declined to comment on the pending litigation.

A representative for the anti-abortion think tank Charlotte Lozier Institute, which employs the petitioning researchers, declined to comment. The nonprofit serves as the research arm of the influential Susan B. Anthony Pro-Life America, which works to elect federal and state anti-abortion lawmakers.

The three studies at the center of the dispute were published in the journal “Health Services Research and Managerial Epidemiology,” between 2019 and 2022. Two of them featured prominently in a federal lawsuit aimed at restricting abortion pills, which the U.S. Supreme Court rejected this summer but continues to make its way through the lower courts.

States Newsroom was the first to report last year that Sage had opened an investigation after pharmaceutical sciences professor Chris Adkins contacted the journal with concerns that the researchers had misrepresented their findings. In the 2021 paper, the researchers looked at Medicaid data in 17 states between 1999 and 2015 and tracked patients who had had a procedural or a medication abortion and counted each time they went to an emergency department in the 30 days following those abortions. Their finding that emergency room visits within 30 days following a medication abortion increased 500% from 2002 to 2015 was frequently cited by plaintiffs and judges in the FDA case and used to conclude that the abortion-inducing drug mifepristone is dangerous. But Adkins and other public health experts told States Newsroom that the researchers inflated their findings, and appeared to conflate all emergency department visits with adverse events.

These concerns prompted Sage to re-examine the peer review process and to identify that one of the initial peer reviewers was an associate scholar with the Charlotte Lozier Institute. The publisher then enlisted a statistician and two reproductive health experts to newly peer review all three articles.

“Following Committee on Publication Ethics (COPE) guidelines, we made this decision with the journal’s editor because of undeclared conflicts of interest and after expert reviewers found that the studies demonstrate a lack of scientific rigor that invalidates or renders unreliable the authors’ conclusions,” Sage said announcing the retractions, which notes that the experts found that the papers had “fundamental problems with the study design and methodology,” “unjustified or incorrect factual assumptions,” “material errors in the authors’ analysis of the data,” and “misleading presentations of the data.”

In a petition to compel arbitration filed late last week, the studies’ lead author James Studnicki and nine co-authors argue that Sage has delayed arbitration in violation of California contract law. They say they’ve had difficulty publishing new research since the retractions. As examples, the petition notes that in March a free online archive and distribution server for unpublished, non-peer-reviewed manuscripts refused to post one of the petitioners’ manuscripts and that in April a journal rejected the same manuscript, “citing similar pretextual reasons that HSRME used in its retraction.”

“These rejections are just the tip of the iceberg but reveal the enormous and incalculable harm that Sage’s retraction has inflicted on the Authors’ reputations and their ability to publish research and scholarship,” reads the court petition. “As scientists, the Authors’ credibility is their lifeblood, but Sage has destroyed the Authors’ hard-earned professional reputations.”

Studnicki, Charlotte Lozier’s vice president and director of data analytics, was on the editorial board of “Health Services Research and Managerial Epidemiology” until last fall, but the journal’s editor-in-chief dismissed him after the journal and Sage decided to retract the papers. The blog Retraction Watch reports that the journal is no longer accepting new submissions.

Medication abortion has become the most common method since the 2022 Dobbs decision ended the federal right to abortion.

Despite claims by the Charlotte Lozier Institute that medication abortion is unsafe, when administered at 9 weeks gestation or less, the FDA-approved regimen has a more than 99% completion rate, a 0.4% risk of major complications, and around 30 reported associated deaths over 22 years. Common symptoms include heavy bleeding and cramping, diarrhea, and nausea, and sometimes medical intervention is necessary to avoid infection. ProPublica recently reported on two women in Georgia who suffered rare complications of medication abortion, but whose deaths were ruled preventable and were attributed to the state’s near-total abortion ban.

The U.S. Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization in June 2022 ended federal abortion rights. (Sofia Resnick/States Newsroom)

Editor’s note: This five-day series explores the priorities of voters in Arizona, Georgia, Michigan, Nevada, North Carolina, Pennsylvania and Wisconsin as they consider the upcoming presidential election. With the outcome expected to be close, these “swing states” may decide the future of the country.

Dr. Kristin Lyerly’s placenta detached from her uterus when she was 17 weeks pregnant with her fourth son in 2007. Her doctor in Madison, Wisconsin, gave the devastated recent medical school graduate one option: to deliver and bury her dead child. But she requested a dilation and evacuation abortion procedure, knowing it would be less invasive and risky than being induced. And she couldn’t fathom the agony of holding her tiny dead baby.

But Lyerly’s doctor declined, giving her a direct window into the many ways Americans lack real choice when it comes to their reproductive health decisions. At the time of this miscarriage, Lyerly was getting a master’s degree in public health before beginning her residency. She was able to get a D&E at the same hospital by a different doctor. As an OB-GYN, she soon would learn how much abortion is stigmatized and limited throughout the country, but also regularly sought after and sometimes medically necessary, including among her many conservative Catholic patients in northeastern Wisconsin.

And then, on June 24, 2022, the U.S. Supreme Court ended federal abortion rights, prompting states such as Wisconsin to resurrect dormant abortion bans from the 19th and 20th centuries. Lyerly’s job changed overnight. She stopped working as an OB-GYN in Sheboygan and moved her practice to Minnesota. She became a plaintiff in a lawsuit over an 1849 Wisconsin feticide law being interpreted as an abortion ban, which has since been blocked.

When a congressional seat opened up in a competitive Wisconsin district this year, the 54-year-old mother of four joined the post-Dobbs wave of women running for office to restore reproductive rights, which this election cycle includes another OB-GYN and a patient denied abortion care. Lyerly’s decision to run is emblematic of the nationwide backlash against the Dobbs decision, which altered the reproductive health care landscape, with providers, patients and advocates turning to the ballot box to change the laws to restore and broaden access.

Wisconsin is among seven swing states expected to determine the country’s next president and federal leaders. And in many ways they’re being viewed as referendums on how much the right to have an abortion can move the needle in a tight presidential election.

“What we’ve seen in every election since the Dobbs decision is that abortion is at top of mind for voters — and it’s not just helping voters decide who or what to vote for. It’s actually a turnout driver,” said Ryan Stitzlein, vice president of political and government relations at national lobbying group Reproductive Freedom for All. The group is investing in down-ballot races in conservative districts such as Lyerly’s, buoyed by cash and momentum from Democratic presidential nominee Kamala Harris’ reproductive-rights-focused campaign.

Anti-abortion money is also flowing through the swing states, led by lobbying groups Susan B. Anthony Pro-Life America and Women Speak Out PAC. Some of their messaging, adopted by Republican presidential nominee Donald Trump and many GOP candidates, often paints Democrats as champions of infanticide, focusing on the rarest and most controversial type of abortions, those performed in the third trimester.

But aside from that rhetoric, many Republican candidates have been quiet on an issue that for years motivated their staunchest supporters.

SBA Pro-Life America declined an interview for this story but shared a press release outlining the organization’s strategy trying to reach 10 million voters in Montana, Ohio and all of the battleground states except for Nevada. The group endorsed 28 House candidates total this cycle, and a fifth of them are in North Carolina. One of North Carolina’s endorsed candidates in a toss-up race is Republican GOP challenger Laurie Buckhout, who does not mention her abortion stance on her campaign website, and did not return a request for comment.

“Our field team is talking to persuadable and low propensity pro-life voters to urge them to cast their votes against the party that endorses abortion in the seventh, eighth and ninth months,” said SBA’s national field team director Patricia Miles in the press statement.

But throughout this election cycle, polls in the swing states have shown bipartisan support for abortion rights, especially when voters are educated about what abortion bans do. Voters in more than half of the states expected to determine the presidential winner have, to varying degrees, lost access to abortion. And abortion-rights activists across these states told States Newsroom they are determined to protect that access, or to get it back.

Arizona sees backlash after GOP upholds Civil War-era abortion ban

In Arizona, the Dobbs decision resurrected a Civil War-era ban that allowed abortions only to save a pregnant patient’s life.

Legislators repealed the law, but abortion-rights supporters fought for more certainty. This fall, Arizonans will vote on a proposed ballot measure that would protect access until fetal viability, around 24 weeks of pregnancy.

Now, two of the judges who upheld the abortion ban — Justices Clint Bolick and Kathryn King — are up for reelection, in races infused with national cash by groups such as RFA and Planned Parenthood. Also on the ballot is Proposition 137, which would give lifetime appointments to state judges. The Republican-initiated measure has garnered controversy in part because it is retroactive to this year’s election, so if approved, any retention bids would be nullified even if the majority votes to unseat the judge.

Ballot organizers turned in more than 800,000 signatures, double the required number, and overcame opponents’ legal challenges to qualify the abortion-rights ballot measure, Proposition 139. Abortion is legal up to 15 weeks of pregnancy, but there are many state restrictions that the Arizona Abortion Access Act would eliminate, such as a ban on any abortions sought for fetal genetic abnormalities and a blocked law from 2021 granting personhood status to fertilized eggs.

Recent deaths reignite controversy over Georgia’s abortion ban

This month, ProPublica reported on the deaths in 2022 of two Georgia women who suffered rare complications after they obtained mifepristone and misoprostol for early-term medication abortions. Both were trying to navigate a new state law that banned abortions at about six weeks of pregnancy and threatened medical providers with up to a decade in prison.

In one case, doctors at an Atlanta-area hospital refused for 20 hours to perform a routine dilation and curettage, a D&C, to clear the patient’s uterus when her body hadn’t expelled all the fetal tissue. In the other, a woman who had ordered the pills online suffered days of pain at home, fearful of seeking medical care. Both women left children behind.

As abortion bans delay emergency medical care, this Georgia mother’s death was preventable

Georgia’s law permits abortion if the patient’s life is at risk, but medical providers have said the law’s language is unclear, tying their hands and threatening the health of patients who have high-risk pregnancies.

Their cases, which a state medical review committee found to be “preventable,” have galvanized activists in the state.

Harris spoke at length about the women, Amber Nicole Thurman and Candi Miller, at a recent campaign event in Atlanta. She blamed their deaths on Georgia’s law, calling it “the Trump abortion ban,” because the former president appointed three justices he’d promised would overturn Roe v. Wade.

“This is a health care crisis, and Donald Trump is the architect of this crisis,” Harris said. “Understand what a law like this means: Doctors have to wait until the patient is at death’s door before they take action. … You’re saying that good policy, logical policy, moral policy, humane policy is about saying that a health care provider will only start providing that care when you’re about to die?”

Trump has not commented on the deaths. He has repeatedly said this year that abortion access should be left to the states. He has dismissed the idea of a federal abortion ban, but during the presidential debate, he refused to say whether he would veto such legislation.

At a recent rally in North Carolina, Trump addressed “our great women” (a demographic he’s trailing among), saying, “you will no longer be thinking about abortion, because it is now where it always had to be, with the states, and with the vote of the people.”

Abortion was a driving concern in this spring’s qualifying process for Georgia’s 2024 legislative elections —?the first opportunity for aspiring state lawmakers to jump on the ballot in response to their state’s severe abortion restrictions.

Melita Easters, the executive director and founding chair of Georgia WIN List, which endorses Democratic women who support abortion rights, was already calling this year’s general election “Roevember” back when President Joe Biden was still the party’s nominee.

But Easters told States Newsroom that having Harris on the ticket instead has elevated the issue of reproductive freedom even more and “has breathed new life into down-ballot campaigns.” Easters said she is especially encouraged after a Democratic state House candidate in Alabama who ran on abortion rights flipped a Huntsville seat during a special election in March.

Michigan Democrats continue betting on abortion after 2022 successes

Michigan was one of the earliest states post-Dobbs to show that abortion rights could be a strong election-winning issue.

Months after the Supreme Court’s ruling, Michiganders overwhelmingly approved a ballot measure to protect abortion rights in the state constitution; reelected Democratic Gov. Gretchen Whitmer, who vowed to prioritize reproductive freedom; and voted for Democratic majorities in both chambers, giving the party a legislative trifecta for the first time in 40 years. In 2023, the legislature repealed a 1931 abortion ban that was still on the books and passed the Reproductive Health Act, expanding abortion access in the state.

This year, state and national abortion-rights groups have campaigned in toss-up congressional districts across Michigan, warning that a federal ban would supersede the state’s protections.

State judicial races, meanwhile, have attracted millions of dollars, as they could determine partisan control of the Michigan Supreme Court. Democrats secured a slim 4-3 majority on the state Supreme Court in 2020 after Republican-nominated justices controlled the court for most of the last few decades.

Nevada reproductive rights activists hope ballot initiative improves turnout

In Nevada, abortion remains legal through 24 weeks and beyond for specific health reasons. In 2023, the state’s Democratic-led legislature passed a law shielding patients and providers from out-of-state investigations related to abortion care; it was signed by Republican Gov. Joe Lombardo.

Seeking to cement these rights in the state constitution, reproductive health advocates mobilized a ballot initiative campaign, which they hope will drive voter turnout that would affect the presidential and down-ballot races. Constitutional amendments proposed through an initiative petition must be passed by voters twice, so if voters approve Question 6 in November, they will have to approve it again in 2026.

In the state’s closely watched U.S. Senate race, Democratic Sen. Jacky Rosen currently edges Republican Sam Brown, who has had inconsistent positions on abortion and reproductive rights but opposes the abortion-rights measure.

National anti-abortion groups Susan B. Anthony Pro-Life America and Students for Life of America have notably not focused on Nevada in their campaign strategies.

Growing Latinx voting bloc in North Carolina?

In North Carolina many Democrats are campaigning in opposition to a 12-week abortion ban that the Republican-majority legislature passed last year after overriding Democratic Gov. Roy Cooper’s veto.

In a high-profile race for governor, Democratic Attorney General Josh Stein faces Republican opponent Lt. Gov. Mark Robinson, who has previously said he believes “there is no compromise on abortion,” according to NC Newsline. The lieutenant governor is now facing calls to withdraw from the race over comments made on a pornography website years ago, and Stein has started racking up endorsements from prominent state Republicans.

Iliana Santillan, a political organizer who supports abortion rights, has focused on mobilizing Latinos, a growing voting bloc in the state. The executive director of progressive nonprofit El Pueblo and its political sister group La Fuerza NC told States Newsroom she’s talked to many young women motivated to secure their own reproductive rights, including her college-age daughter. She said the Latinx community faces additional reproductive care barriers such as language and transportation, with undocumented immigrants scared to cross state lines without a driver’s license.

Santillan also said there’s a misconception that all Latinos are against abortion because they’re Catholic, when in reality opposition to abortion skews among older voters.

“With older folks, the messaging that we’ve tested that has worked is: ‘We don’t want politicians to have a say in what we do with our bodies,’” Santillan said.

Motivated voters in Pennsylvania

Pennsylvania, with its 19 electoral votes, is the largest swing state and considered essential to win the White House.

In a poll conducted this month by Spotlight PA and MassINC Polling Group, abortion ranked as the fifth most-important concern in the presidential race for likely voters, with 49% naming it as among their top issues.

The issue is far more important to Democrats, however, with 85% calling it a top issue compared with 17% of Republicans. Among those who aren’t registered with either major party, 49% called it a top issue.

In 2022, voters surprised pundits by sending enough Democrats to the state House to flip it blue. Voters were responding to the Dobbs decision, Democratic Gov. Josh Shapiro told Pennsylvania Capital-Star at a recent Harris campaign event.

Shapiro also won in 2022, and so far his administration has supported over-the-counter birth control pills and ended the state’s contract with a network of anti-abortion counseling centers. He said his administration would not defend a current state law that prohibits state Medicaid funding from being used for abortions.

Abortion isn’t protected under Pennsylvania’s state constitution, but it remains legal up to 24 weeks’ gestation, and clinics there have seen an influx of out-of-state patients.

Wisconsin abortion services resume

After more than a year without abortion access, reproductive health clinics in Wisconsin resumed abortion services in September 2023, shortly after a judge ruled that the 1849 state law that had widely been interpreted as an abortion ban, applied to feticide and not abortion. A state Supreme Court race a few months earlier saw Justice Janet Protasiewicz win in a landslide after campaigning on reproductive freedom.

Seven months later when Republican U.S. Rep. Mike Gallagher announced his resignation, Lyerly threw her hat in the ring, running as the only Democrat in the 8th District. She now faces businessman Tony Wied. Although in the past it was considered a swing district, it has leaned conservative in recent election cycles. With the redrawn maps and national support, Lyerly said it’s a competitive race.

“We have the potential to really fix, not just reproductive health care, but health care,” Lyerly told States Newsroom. “Bring the stories of our patients forward and help our colleagues understand, build those coalitions and help to gain consensus that’s going to drive forward health care reform in this country.”

Wied’s campaign website does not mention abortion or his policy proposals related to health care, though the words “Trump-endorsed” appear prominently and abundantly throughout the site. Wied hasn’t said much about the issue beyond it should be a state issue, but the two are scheduled to debate this Friday night. His campaign declined an interview.

Currently the only OB-GYNs who serve in Congress oppose abortion. If Lyerly wins in November, she would not only change that (potentially alongside Minnesota Sen. Kelly Morrison) but also could help flip party control in the U.S. House of Representatives.

Most Wisconsin voters oppose criminalizing abortion before fetal viability, according to a poll this year by the University of Maryland’s Program for Public Consultation.

Patricia McFarland, 76, knows what it’s like to live without abortion access. For more than 50 years, the retired college teacher kept her pre-Roe abortion a secret, having grown up in a conservative Irish Catholic family like many of her suburban Milwaukee neighbors.

McFarland told States Newsroom she has been politically active most of her life, but the Dobbs ruling dredged up the physical and emotional trauma from the illegal procedure she had alone in Mexico City. Now, McFarland rarely leaves home without her “Roe Roe Roe Your Vote” button, engaging anyone who will talk to her about the dangers of criminalizing pregnancy.

The mother and grandmother said she’s been canvassing and doing informational sessions with her activist group the PERSISTers, as well as the League of Women Voters. As she has warned fellow Wisconsities about the federal power over their reproductive freedom, she said the enthusiasm for abortion rights in her state is palpable.

“For women my age,” McFarland said, “we don’t want our grandchildren to lose their ability to decide when to become a mother.”

Georgia Recorder’s Jill Nolin contributed to this report.

Doctors are dealing with 'moral distress' as they try to determine care for pregnant patients in states with abortion ban, particularly those facing medical emergencies, according to the Care Post Roe study led by Dr. Daniel Grossman at the University of California San Francisco. (Kieferpix/Getty Images)

In the two years since the U.S. Supreme Court started allowing states — what has become almost half of the country — to ban all or most abortions, doctors continue to report that these laws have detrimentally changed their jobs and the quality of care they can provide pregnant patients.

A research team led by Dr. Daniel Grossman at the University of California San Francisco has been studying the impacts on medical care of the Dobbs v. Jackson Women’s Health Organization decision that overturned the federal right to abortion under Roe v. Wade. On Monday they released their latest Care Post Roe findings. Having grown from 50 to 86 submissions since the preliminary findings were released in May 2023, the survey details medical situations gone wrong because of legal concerns over a state’s abortion ban.

When Grossman — a clinical and public health researcher who specializes in abortion and contraception — talked to States Newsroom last year about the early findings, he emphasized the patient fear palpable in the narratives of their doctors. They told stories about women traveling outside their ban states just to check if they could be pregnant, or during a medical emergency. But as more submissions continue to flow in, Grossman recently said he’s struck by the distress coming from the medical community.

“One thing that was notable in some of these more recent submissions,” Grossman told States Newsroom, “is how moral distress is being incorporated into medical education, like medical students and residents are essentially now learning about the moral distress as part of their medical education, as they’re learning about the care that they can’t provide.”

The Care Post Roe study details 86 submissions received between September 2022 and August 2024 from health professionals recounting cases involving patients from 19 states that, during the study’s time frame, fully or partly banned abortion. Participants described cases that “deviated from the usual standard” of care because of a state abortion ban, some that resulted in preventable complications like severe infections or the placenta growing too deep into the patient’s uterine wall. The participants were directed not to give details that could identify themselves or their patients.

Grossman said the study was designed this way to protect the identity of health providers and patients, many of whom currently fear prosecution for their medical decisions. Researchers also conducted optional in-depth interviews with more than 30 of the participants, but those findings were not included in Monday’s report.

The majority of submissions so far have come from Texas, Grossman said, the largest of the states and where abortion has been illegal the longest. According to the study, the narratives represent a range of different ages, income levels and racial and ethnic backgrounds, though a high proportion are Black and Latinx. Submissions were also reviewed by two physicians and were rejected if they did not contain information about a specific case or did not relate to a change in care since the Dobbs ruling.

Grossman said the study is limited in size and scope and doesn’t say how common these medical situations are or how they will trend over time. But he said the stories are consistent with ongoing news reports and lawsuits wherein doctors and patients describe denying and being denied care because of abortion bans. He said the study, which includes excerpts from health providers’ narratives, serves as a qualitative representation of the types of medical emergencies that doctors all over the country have been reporting.

The submissions were organized into several categories, including:

Second-trimester obstetric complications

The most common type of reported scenario involving second-trimester complications is the preterm prelabor rupture of membranes (PPROM). A doctor described treating a patient who had ruptured membranes at 16-18 weeks’ gestation but instead of being offered an abortion procedure or an induction termination, she had been sent home, where she had developed a severe infection.

“I meet her 2 days later in the ICU. She was admitted from the ER with severe sepsis…and bacteremia. Her fetus delivers; she is able to hold [the fetus]. We try every medical protocol we can find to help her placenta deliver; none are successful,” the physician writes. “The anesthesiologist cries on the phone when discussing the case with me — if the patient needs to be intubated, no one thinks she will make it out of the OR. I do a D&C.”

Ectopic pregnancies

Ectopic pregnancies occur when a fertilized egg implants outside the uterus. They are medical emergencies, but study participants reported cases of ectopic pregnancy requiring extra steps, such as consulting multiple physicians, as well as patients delaying care because they were too scared to be seen in their home states where abortion is banned.

“If [the patient] had seen [a] provider in [her home state] when bleeding started,” one doctor wrote, “she would have had the ectopic diagnosed about 6 weeks earlier, potentially eligible for [methotrexate] and therefore potentially avoided surgery, and even if [she] needed surgery [it] would have been at home with her family and support. Instead [she] had to… recover alone in a hotel room in a random state she had never been to before.”

Underlying medical conditions?

Some physicians described cases where patients had underlying medical conditions that complicated their pregnancies. In some cases, patients were delayed or denied treatment, worsening their conditions.

“She was mid-second trimester [16-18 weeks] when she presented. She has [more than 5] children at home and had severe postpartum cardiomyopathy when she gave birth a year ago, which has persisted,” a doctor wrote. “The risk of her dying from childbirth would have been extremely high — but she was unable to find anyone in her state willing to do the procedure.”

Miscarriage

Respondents also reported challenges with miscarriage management in states with abortion bans.

“The pharmacy refused to fill the medication until they had confirmation of its use but was unable to list what that confirmation needed to include,” one clinician wrote. “The back and forth delayed the care and ultimately the client could no longer face attempting to pick up the medication and decided to utilize expectant management [i.e. waiting for the tissue to pass naturally] due to the trauma of being refused her prescribed treatment.”

Fetal anomalies

Several submitted narratives involved patients whose pregnancies were complicated by fetal anomalies, many of which were described as being incompatible with neonatal life, though termination was not possible in their state.

“Due to the anencephaly, as soon as the umbilical cord was cut, the pink skin of the baby rapidly progressed to navy, only for the baby to be completely dark navy by the time they were wrapped in a blanket and handed to the mom,” a medical student physician wrote. “The patient was letting out a loud scream throughout the labor due to the sheer pain of giving birth, but the scream and wailing she let out once she saw the baby was soul-crushing.”

Denied other types of medical care?

One of the more shocking examples for Grossman involved a patient with a postpartum hemorrhage who needed a common procedure known as dilation and curettage, or D&C, which is used for abortions, miscarriages and sometimes to empty the uterus after the baby has been born. But according to the narrative submitted, a patient had been told by the labor and delivery staff that “D&Cs were now illegal for any reason.”

In another case, an abortion ban allegedly led to the cancellation of a patient’s liver transplant.

“Patient with… [an intrauterine device (IUD)] in place came in for liver transplant after there was a donor match found,” the physician wrote. “On routine pre-surgical testing she had a positive urine pregnancy test, and her bHCG quant was in the 1000s. Her transplant was cancelled because of her positive pregnancy test despite it being an undesired, very early pregnancy.”

Carceral system

Three submissions highlighted how patients in detention, awaiting trial, or on parole faced additional obstacles obtaining an abortion in states with bans.

“Asked for permission to leave her county (and state) to receive abortion care and was told NO,” a physician wrote. “Patient left the state for abortion care anyway. Given 24-hour waiting period in [state with legal abortion] and need for a 2-day procedure, was away for 3 days (2 separate trips). She also refused any sedation because she needed to be drug tested and couldn’t admit to leaving the state for a procedure.”

Researchers predict more poor-quality care if EMTALA ruled to exclude abortion care

“It is notable that the narratives reported here describing delayed and denied care have occurred with EMTALA still intact and hospitals required to provide emergency abortion care,” the study’s authors write, referring to the federal Emergency Medical Treatment and Labor Act, which the federal government has stipulated includes emergency abortion care, and which states with abortion bans have sued over. The U.S. Supreme Court this summer declined to rule on Idaho’s lawsuit challenging the federal requirements, allowing doctors to provide emergency abortions while litigation continues.

“Although it is difficult to assess from the narratives, some … may have been EMTALA violations since stabilizing care was not provided,” the researchers write. “Other cases, such as those where the patient was admitted to a hospital for observation or those involving a patient pregnant with a fetus with an anomaly incompatible with life, are likely not EMTALA violations. Regardless, we anticipate these cases of poor-quality care would become even more common if the Supreme Court were to rule that EMTALA does not apply to emergency abortion care.”

Overall, participants reported that their patients suffered emotionally and financially, sometimes even insured patients having to pay out of pocket for medical care because it was in another state. Grossman also noted that affected patients could face long-term physical and mental-health consequences because of the medical care they did or did not receive.

“When we came out with our first report, maybe I was a little bit more optimistic and thought that perhaps this information could be used to help streamline care, reduce these delays, and identify workarounds,” Grossman said. “And perhaps that has happened in some places, but I think it’s really clear now, more than two years out, that those kinds of fixes or Band-Aids on a bad policy just aren’t going to work, and that really it’s not possible to provide evidence-based care in these states. These bans need to be repealed.”

Abortion fund directors nationwide have been raising the alarm for months about declining donations and their struggles to meet the needs of those seeking help with the financial burdens of finding abortion care, especially those who live in one of?22 states?with near-total bans or severely restrictive abortion laws. (Photo by Scott Olson/Getty Images)

Advocates for abortion access say compounding crises of abortion bans, rising economic costs and systemic health care issues are beginning to cause significant funding challenges and potential disruptions to reproductive care of all kinds.

Several people described it as a “perfect storm” of problems with the U.S. health care system, particularly post-pandemic, and the rise of abortion bans and other reproductive care restrictions in the wake of the Dobbs v. Jackson Women’s Health Organization decision in June 2022. Many individuals must now travel hundreds or thousands of miles to seek abortion care, and the consolidation of demand at a smaller number of clinics is increasing wait times, which means pregnancies progress to a more advanced stage and the costs balloon further. According to leaders of Planned Parenthood affiliates and abortion funds, there simply aren’t enough dollars right now to support the need at any level. A recent report from #WeCount showed the number of abortions nationwide started to increase in 2017 and has continued to increase post-Dobbs, with more than 102,000 abortions in January alone.

Abortion fund directors nationwide have been raising the alarm for months about declining donation revenue and their struggles to meet the needs of those seeking help with the financial burdens of finding abortion care, especially those who live in one of 22 states with near-total bans or severely restrictive abortion laws. That includes every state in the Southeast.

Planned Parenthood of Northern New England announced at the beginning of the month a projected funding shortfall of about $8.6 million over the next three years, and Planned Parenthood of Greater New York announced just a few days later that it would pause abortion care at or beyond 20 weeks because of financial struggles that began earlier this year. The National Abortion Federation runs America’s largest financial assistance program for abortion patients and said that just in the first half of this year it has partially funded more than 60,000 people’s abortions — a total of around $6 million per month — but has now had to reduce patient grants from 50% of the cost of care to 30%.

Even in areas with new abortion restrictions, such as Florida, donations have declined significantly. Stephanie Loraine Pi?eiro, executive director of Florida Access Network, said during a June press conference that the month after the Dobbs decision ended federal abortion rights, the fund received $200,000 in individual donations — but after the state supreme court decision in April 2024 reduced the state’s abortion ban from 15 gestational weeks to six weeks, the fund received just $40,000 in donations.

“That is a stark difference, and it has everything to do with donors feeling burnt out,” Loraine Pi?eiro said.

States with abortion access face hostile political winds?

Planned Parenthood Federation of America told States Newsroom it is meeting its fundraising goals, but the organization’s local health centers and regional affiliates are struggling to provide care in the current climate.

Nicole Clegg, interim CEO of Planned Parenthood of Northern New England, told States Newsroom the affiliate has always been under-resourced and under-reimbursed for the care it provides, which includes birth control, testing for sexually transmitted diseases and routine gynecological care in addition to abortion services. But now that the region, which includes Maine, Vermont and New Hampshire, is taking on more patients from states with abortion bans, it is reaching a tipping point.

“The services we provide are just not valued by the insurance industry, or Medicaid and Medicare — they have always been poorly reimbursed,” Clegg said. “Once costs really started to skyrocket, the margin we were operating with disappeared.”

According to an analysis of health care spending and costs by KFF, health spending tripled between the year 2000 and 2022, from $1.4 trillion to $4.5 trillion. The pandemic accelerated that spending, but the analysis also said the aging population of the U.S., rising rates of chronic conditions, inflation, and expansions of insurance coverage have also driven up costs.

A bill that would have provided nearly $3.4 million to Maine’s family planning centers got caught in legislative wrangling that affected many appropriations bills at the end of the session.

In New Hampshire, which allows abortions until 24 weeks of pregnancy, the affiliate had nearly secured a multi-year grant of more than $2 million total, with the support of Republican Gov. Chris Sununu. However, Clegg said that when the grant went before an executive council for final approval in 2023, the members struck it down, saying they didn’t want taxpayer dollars to fund abortions. Both led to the projected $8.6 million shortfall over the next three years.

“The executive council has become increasingly hostile to Planned Parenthood,” Clegg said.

Planned Parenthood Great Northwest, which includes northwestern states as well as Hawaii, Alaska, Indiana and Kentucky, also said it is facing financial challenges that put access to care at risk. Lisa Humes-Schulz, vice president of policy and communications for Planned Parenthood Alliance Advocates, said in a statement that the affiliate is facing the same health care cost challenges, an underfunded federal family planning program, workforce shortages and rising labor costs. Great Northwest includes Idaho, where there is a near-total abortion ban and which was at the center of a recent U.S. Supreme Court case over whether emergency room physicians could be prosecuted under the state law for providing an abortion in the case of a medical emergency. The affiliate’s clinics in Washington have seen an influx of patients from Idaho as a result of the abortion ban over the past two years, including some emergency patients that were airlifted out of Idaho.

“Unlike other safety net providers, we are trying to navigate these business challenges on top of the unprecedented political attacks focused on providers of abortion care and gender-affirming care,” Humes-Schulz said.

For Planned Parenthood of Greater New York, financial struggles have already prompted a change in care. After the state legislature failed to increase Medicaid reimbursement rates for medication abortion, the affiliate said it implemented executive pay cuts, consolidated job functions and closed small health centers to make up deficits. More than half of the patients that visit Planned Parenthood centers rely on Medicaid.

But it took another step in temporarily stopping abortions at 20 or more weeks starting Sept. 3 because it can’t afford to cover the vendor costs for anesthesia. Only one Planned Parenthood location in New York City will offer deep sedation and abortions at 20 or more weeks for now.

‘Unprecedented is not even the word anymore’

The struggles also extend to organizations that provide more basic infrastructure for abortion clinics, such as the Abortion Care Network, which started a campaign called Keep Our Clinics to raise funds for independent abortion clinics. Independent clinics make up 55% of abortion providers, according to the network, while Planned Parenthood comprises 41%, and the remaining 4% occur at physicians’ offices and hospitals. The vast majority of clinics offering abortion care after 22 weeks — about 86% — are also independent.

Erin Grant, co-executive director of the Abortion Care Network, told States Newsroom the organization’s mission is to provide grant funding for independent clinics to support infrastructure needs — such as supplies, equipment, building repair, security, and litigation support — rather than patient care. The network has supported 32 clinics, and gave out $700,000 to providers in recent months.

But for the network too, donations are down by one-third. The full amount of donations to the Keep Our Clinics campaign goes to clinic members, and the organization granted nearly $5 million to clinics in 2022, but only $3.4 million in 2023. The requests for support did not go down during that time, but donations did.

Grant said it’s important to support the infrastructure of independent abortion clinics because once they close, it is extremely difficult to work through the bureaucratic process again to reopen them. In areas with newly instituted six-week abortion bans, such as Florida, Iowa and South Carolina, more clinics have closed their doors.

“We are in times where ‘unprecedented’ is not even the word anymore, and there is so much happening that calls for our attention. … There’s a need in this moment for us to hold multiple crises across communities,” Grant said. “… This isn’t something we get to say we did as an immediate need, because there’s decades of work ahead to build the actual infrastructure to have health care access, let alone abortion access in this country.”

During a June press call, several leaders of state abortion funds discussed funding struggles. Oriaku Njoku, executive director of the National Network of Abortion Funds, said the funds provided more than $36 million in abortion funding and $10 million in logistical support in 2023.

“This is not the same movement that it was five years ago, let alone 50 years ago, and yet we’re still operating and funding as if it were the same issue as it was before,” Njoku said.

There are nine clinics in Ohio, where voters affirmed their desire to keep access to abortion in 2023, but it is surrounded by three states with near-total bans — Indiana, Kentucky and West Virginia. Lexis Dotson-Dufault, executive director of the Abortion Fund of Ohio, said during the press conference that her organization averaged about 100 patients per month in 2022, but now it averages more than 500.

“While abortion funds have a huge increase in need, we are not seeing a huge increase in money coming in to support this need,” Dotson-Dufault said.

National Abortion Federation: Without cutbacks, funding would run out by fall?

Planned Parenthood Federation of America, the national organization, did not directly address whether it would provide more support to the affiliates facing significant financial troubles.

“While issues around funding are a concern, it is important to note that the reproductive health care ecosystem is straining under the weight of the post-Dobbs crisis,” a Planned Parenthood spokesperson said in a statement. “PPFA is working to support affiliates as they take action to adapt and continue to provide care.”

The organization’s comments came a few days after 41 abortion funds from around the country signed on to an op-ed in The Nation saying there is a disconnect between the most visible national reproductive rights organizations, like Planned Parenthood and the National Abortion Federation, and grassroots groups working to directly support those who need care. The op-ed called out the National Abortion Federation for cutting back its financial assistance program in July, from 50% of the cost of seeking care to 30%. Signers included the Abortion Fund of Ohio and the Florida Access Network.

Brittany Fonteno, CEO and president of the National Abortion Federation, called the change an “incredibly heartbreaking and difficult” decision that had to be made despite an “incredible and generous budget” that is the largest it has ever been. She said that in the first half of this year, NAF was funding at $6 million per month for abortion care, and then upwards of $200,000 per month in patient assistance funds to help with associated travel costs. These patient assistance funds are completely funded by foundation and individual donors, Fonteno said, noting that individual donations dropped nearly 40% in 2023 from the previous year after the Dobbs decision leaked.

In 2023, NAF said it funded 106,865 people with an average amount of $519 per patient. So far in 2024, the hotline has funded 66,330 people at an average of $541 per patient.

“We’re truly in a public health emergency right now, and unfortunately, we just can’t keep pace with the patient need,” Fonteno told States Newsroom. “We had to make this decision in order to make sure that we could stretch our funds and make sure that we could help as many people as possible for the rest of this year. If we hadn’t made this decision, then we would have run out of funding in the fall.”

The changes include no longer making exceptions for those in later stages of pregnancy who face higher costs — sometimes as much as $10,000, Fonteno said — because the procedure costs more or they have to travel further to find a clinic that can provide it. That “exception budget,” which was also used for patients facing extreme circumstances like intimate partner violence, will not exist for the remainder of the year, according to Fonteno.

“Of course, we’re working incredibly hard to try to fundraise, to try to get the word out and bring awareness to this issue. And if we’re able to fundraise, we may be able to consider increasing the funding that we’re able to do,” she said.

Presidential election matters, director says?

Clegg, interim CEO of Planned Parenthood of Northern New England, said the problems will only get exponentially worse if the presidential election in November breaks for Republicans over Democrats. Project 2025, the blueprint document produced by the Heritage Foundation for the next Republican presidential administration to follow, calls for the federal government to prohibit Planned Parenthood from receiving any Medicaid funds (for non-abortion reproductive health services; federal funding of abortion is currently prohibited) and issue guidance to states that says they are free to defund Planned Parenthood in their state Medicaid plans as well.

Instead, it calls for the funding to be redirected to “health centers that provide real health care for women.” The anti-abortion organizations involved in crafting the document, such as Susan B. Anthony Pro-Life America, often promote funding for crisis pregnancy centers, which counsel pregnant patients against abortion and are known to spread misinformation about the procedure. A recent analysis from reproductive rights advocacy group Equity Forward showed nearly $490 million was allocated in 23 state budgets over the past two years for crisis pregnancy centers, most of which were in the same states that restrict abortion access.

“It’s not just making sure the public understands that we need them to engage and partner with us to make sure we can keep providing the care; it’s also having them connect the dots to the November election and understand that who they vote for, who they put in office is going to determine our future,” Clegg said.

Medication abortion has been the most common way to terminate a pregnancy since 2020, when pills accounted for 53% of all pregnancy terminations, according to the Guttmacher Institute. (Getty Images)

Reproductive rights has taken center stage in the first post-Roe presidential election that presently features a longtime advocate for reproductive rights in possible Democratic nominee Vice President Kamala Harris, opposite former Republican President Donald Trump, whose three appointed U.S. Supreme Court justices helped overturn federal abortion rights.

Although Trump’s former health staffers have co-authored the Heritage Foundation’s conservative anti-abortion policy blueprint for a future Republican administration, called Project 2025, Trump, his outspoken anti-abortion running mate Ohio U.S. Sen. J.D. Vance, and many GOP candidates have attempted to soften their abortion stances while also adopting the longtime movement narrative that abortion is dangerous to women and equivalent to infanticide.

As the first presidential election season since the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision heats up, here are the facts behind the most commonly touted myths about abortion.

1. Abortion is safe.

The National Academies of Sciences, Engineering, and Medicine (NASEM) concluded in a comprehensive review of the safety and quality of abortion care in the U.S. in 2018 that complications from abortion are rare, especially when compared to the complications of pregnancy and childbirth. The anti-abortion movement falsely claims abortions are more dangerous than childbirth, and tried unsuccessfully to legally force the U.S. Food and Drug Administration to revoke its approval of the abortion medication mifepristone. Meanwhile, a new Louisiana law will, starting this fall, classify mifepristone as “dangerous,” despite opposition from state doctors.

Medication abortion has been the most common way to terminate a pregnancy since 2020, when pills accounted for 53% of all pregnancy terminations, according to the Guttmacher Institute. When administered at 9 weeks gestation or less, the FDA-approved regimen has a more than 99% completion rate, a 0.4% risk of major complications, and a reported 32 associated deaths over 22 years. Common symptoms include heavy bleeding and cramping, diarrhea, and nausea.

2. Abortion can reduce health risks and infertility and save lives.

There are many conditions that can develop during pregnancy — such as ectopic and molar pregnancies, severe preeclampsia, and preterm premature rupture of membranes — that can put the pregnant person at risk of death, serious health complications, and future infertility, as well as make it unlikely the fetus would survive even if the pregnancy continued. Though anti-abortion activists do recognize this reality, they use the political term “separation of a mother and her unborn child” to obfuscate that abortion is sometimes necessary. And even in emergency cases, they advocate for riskier procedures like C-sections to avoid performing less invasive abortion procedures. Meanwhile, the future legality of emergency abortions in states like Idaho remains uncertain.

3. Abortion is not infanticide.?

Candidates have been campaigning on rhetoric that abortion is infanticide and happens “post birth,” “up until the moment of birth,” or “after birth,” as Trump alleged in the June debate with President Joe Biden. However, abortion does not happen “after birth.” That would be categorized as murder, as it was in the case of former Philadelphia abortion doctor and convicted murderer Kermit Gosnell.

4. “Late-term” and “partial-birth” abortions are political terms not grounded in science.

According to the Centers for Disease Control and Prevention, more than 93% of abortions occur within the first trimester, and less than 1% after 21 weeks’ gestation. Still, anti-abortion groups and candidates emphasize the idea of “late-term” abortions, which is not a medical term. Susan B. Anthony Pro-Life America, which helps elect anti-abortion candidates, has begun calling the vice president an “abortion czar,” with president Marjorie Dannenfelser claiming Harris wants to “impose on all 50 states all-trimester abortion without any limits, even painful late-term abortions in the 7th, 8th, and 9th month of pregnancy.” Though abortions do occur later in pregnancy, they are rare and typically involve nuanced and heartbreaking circumstances. The GOP’s national platform opposes “late term abortion.”

Sometimes anti-abortion activists also refer to “partial-birth” abortions, a non-medical term for a procedure known as dilation and extraction (D&X), which is already banned under federal law.

5. Abortion exceptions for rape, incest, fetal anomalies, and health risks do not exist in most states where abortion is totally banned.

Despite Republicans’ oft-touted support for rape and incest exceptions in abortion bans, many currently on the books don’t include them. Of the 14 states with near-total abortion bans, only Idaho, Indiana, and North Dakota’s maintain some exceptions for survivors of rape and incest. Indiana also allows for abortion if there is a fatal fetal anomaly. Reproductive health experts say abortion exceptions are rarely granted even when they exist.

6. The terms “heartbeat bill” and “six-week abortion bans” are misleading.?

Currently Florida, Georgia, South Carolina, and soon Iowa will ban abortion at the moment embryonic cardiac activity can be detected on an ultrasound, which typically occurs around six weeks’ gestation. This type of law is often referred to as a “heartbeat bill,” but reproductive health experts say the term is misleading because the heart is not fully developed at that stage. These laws are also referred to as six-week bans, which is also misleading, given how gestational age is calculated: by counting from the first day of one’s last menstrual cycle. This is an approximate estimate and varies depending on when conception officially occurs. For many, a six-week ban is closer to four weeks or less of pregnancy, before many people realize they’re pregnant.

7. The GOP platform contradicts promises to leave abortion to the states and to protect IVF.

The Republican Party’s recently unveiled “Make America Great Again!” policy platform does not explicitly call for a federal ban on abortion and expresses support for birth control and in vitro fertilization. But it simultaneously supports states establishing “fetal personhood” under the U.S. Constitution’s 14th Amendment, which legal experts warn could lead to the criminalization of pregnancy and implicate abortion, contraception, and IVF.

A nationwide concern about Americans’ access to IVF kicked off this winter after the Alabama Supreme Court ruled that embryos are “children,” leading IVF clinics in Alabama to shutter temporarily. In the aftermath, some states, including Alabama, have taken steps to ensure access to the fertility treatment, but future access remains largely uncertain, especially as congressional bills to protect IVF nationally have failed to advance.

8. Emergency contraceptives are not abortifacients but could be impacted by personhood laws.

Emergency contraceptives like Plan B and ella are designed to be taken shortly after sex, to delay or prevent ovulation. They are not abortifacients, according to the American College of Obstetricians and Gynecologists, and they don’t work on someone who is already pregnant. Anti-abortion activists largely oppose emergency birth control (and many other contraceptives), based on outdated drug labeling that Plan B might work by preventing the implantation of a fertilized egg, which many in the movement say should be treated in law as a person. The FDA revised the label in December 2022, following additional scientific evidence concluding Plan B works before fertilization.

Research on ella also indicates it likely does not prevent implantation, but Project 2025 includes a proposal to exclude ella from contraceptives currently covered under the Affordable Care Act, referring to it as “a potential abortifacient.”

A new paper from researchers whose abortion-pill studies were retracted touts C-sections and induced labor as alternatives for pregnant patients in medical emergencies as a federal appellate court revisits a pivotal case in Idaho. (Getty Images)

The day the U.S. Supreme Court overturned Roe v. Wade in 2022, the medical board that certifies OB-GYNs in America released a statement calling legal pregnancy termination and knowledge of abortion procedures “essential to reproductive health care.”

But a small number of influential anti-abortion doctors have spent the last two years trying to change the reproductive health care standards in state and federal health policy, in a way that is potentially dangerous, doctors representing major medical institutions say.

The question of when abortion is essential health care that states can’t ban is central to several ongoing lawsuits, including Moyle v. United States, a case about whether emergency rooms receiving federal funding have to treat pregnant patients with stabilizing care if it might result in the end of the pregnancy. The U.S. Supreme Court recently kicked the case back to the appellate court, a move that newly allows doctors in Idaho to perform emergency abortions. But the issues remain unresolved, with doctors in Idaho (as in other states) still seeking clarity about whether what they’ve long considered necessary care is legal.

Now as the case returns to the U.S. 9th Circuit of Appeals, researchers behind retracted studies claiming abortion drugs are dangerous are out with new policy recommendations that say when pregnancy termination is necessary, doctors should opt for procedures considered by the wider reproductive health community to carry bigger health risks, such as cesarean sections, rather than less invasive abortion procedures.

“[M]any physicians argue that it is almost never necessary to end the life of a child directly and intentionally by an abortion procedure,” public health researcher James Studnicki and OB-GYN Dr. Ingrid Skop, of the Charlotte Lozier Institute, wrote in a paper published this summer in Medical Research Archives, a journal of the European Society of Medicine. “[W]hen a pregnancy endangering the life of the mother requires termination, a direct ‘dismemberment’ dilation and evacuation (D&E) abortion may be unnecessary, as delivery can usually be performed with a standard obstetric intervention such as labor induction or cesarean section (if indicated).”

Experts told States Newsroom that Charlotte Lozier’s claims contradict national standards of care. And they come at a time when states with strict abortion bans like Texas and Louisiana are seeing a rise in surgical incisions like C-sections and hysterotomies to end pregnancies, even though they carry higher risk, delay future pregnancies, and can affect fertility.

“The end goal of doing a medical intervention to end a pregnancy and save a patient’s life is the same as when we do an abortion. They are just calling for more complicated, sometimes invasive procedures to get to that same end goal,” said Atlanta-based OB-GYN and complex family planning specialist Dr. Nisha Verma. “I think this is really dangerous — it creates confusion. It prevents the public from understanding that abortion is a necessary life-saving procedure.”

The Charlotte Lozier Institute has for more than a decade worked to build the anti-abortion movement’s credibility, by providing research and data to defend anti-abortion laws in the legislature and in the courts. Their claims frequently contradict major American medical institutions on abortion science and safety, and their research methods have faced academic scrutiny — while continuing to wield influence.

Between 2019 and 2022, Studnicki and Skop co-authored three papers in the journal “Health Services Research and Managerial Epidemiology,” two of which were used by anti-abortion plaintiffs and judges to argue for the restriction of abortion pills in a lawsuit against the U.S. Food and Drug Administration, which the Supreme Court rejected this term for lack of standing. But earlier this year, Sage Journals retracted these studies following a reader-prompted investigation, in part for methodological flaws and data misrepresentation. The Charlotte Lozier researchers have insisted the retractions were meritless and politically motivated.

Skop, an OB-GYN from San Antonio, Texas, and Charlotte Lozier’s director of medical affairs, now has even more influence, after her controversial appointment to Texas’s maternal mortality review committee. Skop has made unfounded claims, including that abortion bans will improve maternal mortality rates and that rape or incest victims as young as 9 can “safely give birth to a baby.” But experts say minors are at increased risk for serious complications like preeclampsia and likelier to give birth to low-birth-weight babies.

Last year the San Antonio-based OB-GYN served as a state expert witness when Kate Cox from Dallas asked a Texas judge to grant her an abortion for a nonviable pregnancy. Skop’s sworn affidavit alleged Cox was not at risk of death or “substantial impairment of a major bodily function,” though Cox’s doctor recommended an abortion to preserve her health and future fertility. Denied the abortion in her home state, Cox aborted in New Mexico, and is newly pregnant again.

As a fellow for the American College of Obstetricians and Gynecologists, which has more than 60,000 members, Verma said she has regularly testified before Congress alongside OB-GYNs with minority-held positions on reproductive health policy like Skop and Dr. Christina Francis, the CEO of the anti-abortion American Association of Pro-Life Obstetricians and Gynecologists, which comparatively has approximately 7,500 members.

“It can be really deceptive and confusing for the public who just hear different things coming from two OB-GYNs,” Verma said.

Studnicki and Skop argue that abortion is “not evidence-based” because many people do not seek abortions for physical health reasons, and because much of the existing abortion-safety and efficacy data does not involve randomized controls, i.e., comparing groups of people receiving abortion procedures with those delivering unwanted or nonviable pregnancies to term.

“Based upon the research standard of the Cochrane guidelines, our study shows the science required to consider abortion ‘evidence-based’, alone or in comparison to other interventions, does not exist,” said Studnicki in an written statement, referring to guidelines for systematic reviews, named after British medical researcher Archie Cochrane. “All of us who want the best for women should desire better quality data, including comparison of abortion to other pregnancy outcomes like childbirth, so we can best address the needs of women in heartbreaking circumstances.”

They do not mention the longitudinal Turnaway Study, produced at the University of California San Francisco, which found short- and long-term improved health and socioeconomic outcomes for women who received versus were denied wanted abortions. (Editor’s note: Reporter Sofia Resnick contributed proofreading and editing to UCSF professor Diana Greene Foster’s 2020 book about the study she led.) Anti-abortion activists have criticized that study, including in a published critique that was retracted following concerns about its peer review.

Studnicki and Skop did not agree to an interview but provided a fact sheet for their claims, which notes that OB-GYNs should adhere to guidelines set by ACOG when it comes to life-threatening situations, but also asserts that existing abortion bans do not preclude necessary care.

Claim: “Almost all induced abortions demonstrate no therapeutic intent or medical necessity.”

That abortion is not legitimate health care is a similar argument that a coalition of anti-abortion doctor groups including AAPLOG (of which Skop is a member) made in the abortion-pill case. It’s an argument Charlotte Lozier advanced in an amicus brief submitted to the Supreme Court in Moyle v. United States.

And it’s an argument featured in Project 2025, the Heritage Foundation’s blueprint for a potential future GOP presidency, which says that the federal Emergency Medical Treatment and Labor Act? should not be interpreted to cover abortions. Republican presidential nominee former President Donald Trump has attempted to distance himself from Project 2025’s proposed federal abortion restrictions, though they were authored by officials from his previous administration.

But decades of research have established the high safety record and medical benefits of termination.

“Data from the Centers for Disease Control and Prevention (CDC) clearly shows that pregnancy is a condition that can kill you,” said Dr. Sarah Horvath, an OB-GYN and complex family planning subspecialist and researcher at Penn State University’s Hershey Medical Center, in an email. “As a mother, I can tell you that the benefits of a wanted child often, but not always, outweigh the risks of pregnancy complications and death.”

According to the CDC, the U.S. has the highest maternal mortality rate in the developed world at 22.3 deaths per 100,000 live births as of 2022, with rates for Black women more than double, at 49.5 deaths per 100,000 live births. Research in the journal Obstetrics & Gynecology shows that by contrast the risks from an induced abortion are smaller than the continuing a pregnancy: In the first trimester (more than 90% of all abortions), the rate of maternal death is less than 1 per 100,000, and for abortions at 18 weeks gestation or higher, the risk of death is 6.7 per 100,000.

In the two years since the Dobbs decision overturned federal abortion protections, OB-GYNs in states with near or total abortion bans have reported denying critical care because of these new laws. Many have become politically active, trying to impress upon lawmakers and the public that pregnancy is highly variable and vague exceptions to prevent death are impossible to interpret medically, especially as complications are not always immediately deadly but could become so if not treated promptly.

Claim: When the ‘separation of a mother and her baby’ is necessary, C-sections and inductions should be prioritized over induced abortion to allow parents to ‘express appropriate grief.’?

Referring to a medically indicated abortion as the “separation of a mother and her baby,” which is not a medical term, Studnicki and Skop pose labor induction or cesarean section as the ethical choice.

“Beyond 22 weeks’ gestation, the baby will often survive separation from the mother if given active medical intervention, and even if too young or sick to survive, the family can show the child love and express appropriate grief with the assistance of supportive palliative care,” Studnicki and Skop write. “No study has compared the well-being of a woman and family who end their child’s life in these tragic circumstances to those who continue to allow their child to live until a natural death.”

Verma said depending on the situation and especially before 20 weeks, induction or a C-section could introduce unnecessary risks and delays of care. And the patient would have to wait longer to try to get pregnant again.

“I have a hard time even understanding this claim that a C-section is equally invasive and morbid to abortion procedure,” Verma said. “That’s a major abdominal surgery. We are making a large incision in the abdomen, making incisions in the tissue below the skin, pulling apart the muscles, going into the abdominal cavity, the peritoneal cavity, cutting open the uterus and removing a pregnancy. … If the patient wants to get pregnant again, after a D&E procedure, they can start trying a month later, whereas after a C-section, you have to wait months to be able to safely start trying again without as much risk of your uterus rupturing in the next pregnancy.”

Verma said that sometimes C-sections do make sense in these cases, and that many of her patients do opt for labor and delivery to hold their dead or dying child, but she doesn’t believe these options should be forced on patients.

Claim: Rape and incest victims — who are often adolescents and children – don’t need abortions.

“The emotionally provocative scenario of a young adolescent girl seeking to abort a pregnancy conceived in rape or incest is repeated in the media at a rate which is grotesquely disproportionate to the rarity of its occurrence,” Studnicki and Skop write. “The question of importance is whether an abortion in this circumstance improves the mental or physical health status of the victimized girl. Understandably, there have been no clinical trials addressing this question, so even an abortion in this tragic circumstance cannot be characterized as an evidence-based medical intervention.”

But there is evidence that children and teens face greater physical health risks from pregnancy and childbirth than adults. And Verma noted that the incidence of young children getting pregnant, often by rape or incest, is small but real.

“I have treated young kids in, like the 10-, 11-year-old range,” Verma said. “It’s not something that’s happening every day, but there are many reasons why people need abortions, and that is something that we see and it is terrible.”

Lauren Ralph, an epidemiologist and associate professor at UCSF who specializes in the impact of abortion policies on young people, told States Newsroom that initial research out of Texas is showing fewer young people able to access abortions. According to a national 2021-2022 patient survey, about 10% of abortion seekers were 19 and younger, and about 2% were 17 and younger. Ralph noted that many rape and incest cases among young people are likely underreported.

“The rarity of it, I don’t think diminishes its importance in conversations around the reasons why people seek abortion, for young people in particular, who are victims of sexual assault,” Ralph said. “We know that they’ve had their autonomy violated once, and then if you deny them access to a wanted abortion and force them to continue a pregnancy and give birth, that violates their autonomy yet again.”

Mark Lee Dickson (far right), director of Right to Life East Texas, prays in front of the U.S. Supreme Court on April 21, 2023 in Washington, DC. (Chip Somodevilla/Getty Images)

Mark Lee Dickson says he’s been home maybe once in the two years since the U.S. Supreme Court vanished federal abortion rights in Dobbs v. Jackson Women’s Health Organization.

The 38-year-old director of Right to Life of East Texas in Longview has been on an endless road trip trying to set legal traps for people who are driving someone out of state to get an abortion. The native Texan said he drives from town to town attending pregnancy-center banquets, men’s prayer breakfasts, Republican women’s club meetings, Catholic fish fries and the rodeo, trying to convince local lawmakers and potential citizen petitioners to make their cities and counties so-called “sanctuaries for the unborn,” stretching local law to restrict abortion in as many ways as possible — such as restricting travel and medical waste disposal — to potentially provoke an eventual lawsuit.

“I find myself in a variety of different places, wherever the Lord takes me,” Dickson told States Newsroom.

Many of the pregnant residents in the rural areas Dickson goes to struggle with lack of access to maternal care, but Dickson likens himself to Batman on a vigilante quest to save embryos and fetuses from abortion. Reproductive justice organizers and attorneys who’ve spent the last two years fighting to restore reproductive health care access throughout the U.S. liken Dickson to a reincarnated version of 19th century anti-vice crusader Anthony Comstock, whose eponymous anti-obscenity law Dickson has been wielding as one of many tools to fast-track a national abortion ban.

Two years since Roe v. Wade was overturned and four months away from a presidential election, one of the biggest threats to abortion rights is a federal administration willing to enforce and reinterpret the dormant Comstock Act to criminalize the mailing of abortion-related drugs, medical equipment and information. But abortion providers and advocates say that even without Comstock, monitoring and policing of pregnant women and information is already here, thanks to activists like Dickson, whose proposed city ordinances allow residents to sue anyone suspected of helping someone get an abortion.

“I have a whole lot of friends that spend time on the sidewalks of abortion facilities throughout America,” Dickson said. “And I’ve told these friends, if you ever meet someone from Abilene, Texas, that is seeking out an abortion in New Mexico, use the sanctuary city ordinance as a deterrent as much as you can.”

Rising Comstocks?

Dickson’s partner in the endeavor to broadly criminalize abortion in every state, one city at a time, is Jonathan F. Mitchell, the onetime solicitor general of Texas, who is also counsel for former President Donald Trump. Along with these sanctuary cities ordinances, together they helped draft Senate Bill 8, a blueprint for largely banning abortion in Texas in 2021 by authorizing citizens to sue those suspected of providing or assisting with an abortion.

And since Roe fell, they have been pushing a version of the Comstock Act that historians and legal scholars say never existed.

Legal scholars Reva Siegel and Mary Ziegler in their forthcoming article about the old law write that Anthony Comstock was focused on preventing illicit sex and pornography, not on preserving fetal life. The religious zealot was known for bringing dildos, contraceptives, and pornography to testify before state and local lawmakers about the need for anti-obscenity laws.

“The statute is a ban on obscenity, not criminalization of health care,” Siegel, a professor at Yale Law School, told States Newsroom. “And when you listen to the revivalists, they just talk about Comstock as an absolute ban as if it has no exceptions. That’s just not true — in light of the text or the history.”

But that doesn’t really matter to Dickson and Mitchell.

Through their Sanctuary Cities for the Unborn project, Dickson and Mitchell have helped pass approximately 80 ordinances in cities and counties in seven states, mostly in Texas, but also in strategically located cities in abortion-access states, like New Mexico, where a challenge to ordinances that cite the Comstock Act currently awaits a ruling from the state supreme court and could eventually make its way to the U.S. Supreme Court.

Where Anthony Comstock had the financial backing of the YMCA and was elevated to power as a special agent of the U.S. Post Office, the influential conservative think tank Heritage Foundation is pushing Mitchell and Dickson’s version of Comstock in its plan for a potential future Trump administration to go after providers and distributors of abortion pills. Mitchell has received some financial support in 2023 and 2022 from the Christian right law firm Alliance Defending Freedom, which brought the recent abortion pill case before the Supreme Court.

Dickson said he wants these ordinances to go even further, such as opening up lawsuits to rideshare companies. But immediately on the agenda, he said, is to try to use Comstock to challenge state abortion-rights ballot initiatives.

“There are many ways the Comstock Act can be used to help inoculate pro-abortion ballot initiatives in states like Arizona and Nebraska,” Dickson said. “A lot is planned between now and November, I can say that.”

Mitchell, who did not respond to an interview request, is currently defending the right of Texas professors to penalize students who miss class to obtain an abortion. That new lawsuit will be heard by U.S. District Judge Matthew Kacsmaryk, whose opinion last year advanced a challenge to an abortion pill and cited Comstock as a valid argument. Though the U.S. Supreme Court recently rejected the mifepristone case, new challenges to the abortion pill continue, as does increased support for anti-abortion Comstock arguments from federal judges like 5th Circuit Court of Appeals Judge James Ho and Supreme Court Justices Samuel Alito and Clarence Thomas.

Meanwhile, longtime anti-abortion groups like Operation Rescue, which led clinic blockades in the 1980s and 1990s, continue to apply old-school surveillance and monitoring tactics. Based in Wichita, Kansas, president Troy Newman said his group maintains a sidewalk presence at abortion clinics in Wichita, and regularly files public records requests for 911 calls, which they post online. They also publish detailed reports on thousands of abortion providers in the U.S., referring to them as “the abortion cartel.”

Newman told States Newsroom that the goal is not to target women getting abortions, but to report potential abortion-clinic violations in order to shut down clinics that since Dobbs have relocated to states without abortion bans.

“I don’t think we can keep track of them all, but we have people feeding us information on a daily basis,” Newman said.

Siegel and Ziegler argue “comstockery’’ is a threat to democracy, as it depends on suppressing freedom and promoting government censorship. Comstock famously helped imprison women who disseminated information about birth control and abortion, some who later died by suicide.

“Revivalists hope to chill the exercise of rights already recognized in positive law, including state constitutional protections and the right to travel,” Siegel and Ziegler write. “Further, by disparaging reproductive rights and intimidating those who seek to exercise them, Comstock revivalists seek to short circuit an ongoing process of popular constitutional meaning-making that has unfolded in state ballot initiatives, state courts, and grassroots movements.”

Resisting Comstocks

Many legal experts argue that Comstock would be a difficult law to defend even with a partially willing U.S. Supreme Court; however, the effects of even temporary enforcement could rock reproductive health care throughout the U.S. even more than it has since Dobbs. After initial discouragement from national reproductive rights groups, Democrats in Congress this month finally introduced a bill to repeal Comstock, though it is unlikely to advance before the election.

New Republic staff writer Melissa Gira Grant and Harvard Law lecturer Kendra Albert last month coalesced historians, attorneys, organizers, and journalists at a one-day summit at Harvard Law School called ComstockCon to unite against modern-day Comstocks from further constricting abortion rights. Grant said the criminalization of sex and pregnancy has long been borne by more marginalized groups, including people of color, sex workers and people who are trans or living in poverty. She said that the reproductive justice movement now more than ever needs solidarity.

“We know that those eager rising modern-day Comstocks, the Jonathan Mitchells of the world and others, they’re in this fight for the long term,” Grant said. “We know that they regard so many of us as obscene for who we are, how we are, and how we want to be. … If they see the suppression of all of us as one fight, then that should be a point of solidarity for us.”

And many called for resistance to the dead letter and legally dubious anti-abortion deterrent laws.

“You have to keep pushing now,” said one of the panelists, Renee Bracey Sherman, founder of We Testify, which lifts up people’s abortion stories. “There will always be another ban. It’s not going to stop us from talking, from sending pills.”

Ban by deterrence

To date, no civil lawsuit has been filed under SB 8 or a sanctuary city ordinance, Dickson said.? But, as the Texas Tribune has reported, Mitchell has filed petitions (under a little-known state rule) to depose abortion funds, providers, researchers and — despite assurances that these laws won’t punish women having abortions — women who left the state to get an abortion.

These past few months, Dickson has been in Amarillo mobilizing anti-abortion activists to make their high-trafficked roads illegal for the purposes of interstate abortion-related travel. Embedded in the Amarillo ordinance is a reference to the Comstock Act. Petitioners gathered enough signatures to force the city council to vote on the measure, but abortion-rights advocates fiercely campaigned against the ordinance. After the council rejected the proposal earlier this month, Amarillo Mayor Cole Stanley said the city doesn’t have the authority to enforce the ordinance — a point with which Dickson vehemently agrees and said he spent hours explaining to the mayor.

The whole point of these ordinances, Dickson said, is that they allow for citizen lawsuits, not government enforcement. He admits that they function largely as deterrents, to chill abortion-related activity even in states where it’s legal. And it’s working, he said, noting that in the year before Dobbs, most doctors stopped providing abortions in Texas after the 2021 so-called vigilante law. One who didn’t was Dr. Alan Braid, and though he was sued, those lawsuits were dismissed.

After Dobbs, however, Braid relocated his abortion practice to New Mexico and told NPR earlier this year that his Albuquerque clinic had higher no-show rates, which he partially attributed to people scared to drive through Lubbock because of its abortion-travel ban.

“These ordinances are doing exactly what they’re intended to do,” Dickson said. “I liken it to an armed security officer at the bank who serves as a deterrent. He doesn’t have to fire his gun in order for him to be viewed as an effective method of protecting the interest of the bank.”

But there’s another purpose to these ordinances, too, particularly Amarillo’s, which anti-abortion petitioners are still trying to get on the November ballot.

Amarillo is the home of Kacsmaryk’s court, where anti-abortion attorneys have been filing their strategic lawsuits since Dobbs. Dickson said he and Mitchell are eager to make it a so-called sanctuary city as a way of arguing for legal standing in the cases to come.

Lindsay London, a nurse who co-founded the Amarillo Reproductive Freedom Alliance, which has been fighting the ordinance, said she resents having her native city used as a “strategic chess piece.” She said her coalition includes Amarillo Republicans skeptical of government overreach and is confident that, if given the opportunity, her fellow residents will vote down this law, which she said would be harmful to the community.

“It creates a culture of fear and mistrust,” London said. “The last thing that people need to be concerned about when they’re moving through a difficult situation is, is someone that they trust or a neighbor or anything like that going to use that vulnerable situation to try and sue them? Positing neighbor upon neighbor is not how we create healthy communities.”

Elisha Brown contributed to this report.

Mifepristone, FDA-approved for pregnancy termination up to 10 weeks gestation, is used in about 63% of U.S. abortions. (Photo by Chris Coduto/Getty Images)

In the aftermath of the U.S. Supreme Court’s unanimous ruling Thursday to maintain current access to the abortion medication mifepristone, abortion-rights advocates and opponents vowed to continue their respective battles over the drug.

Mifepristone is one of two drugs used to treat miscarriages and terminate a pregnancy during the first trimester, and is the most common method of abortion in the U.S. Anti-abortion groups, in conjunction with conservative religious law firm Alliance Defending Freedom, sought to revert the FDA guidelines to 2016, when the prescribed gestational time frame was three weeks shorter and there were more requirements around who could prescribe it and where and when provider visits had to take place. The case made its way to the nation’s highest court after outspoken anti-abortion U.S. District Judge Matthew Kacsmaryk in Texas ruled that mifepristone’s approval should be revoked, followed by a Fifth Circuit Court of Appeals opinion that agreed in part, saying the restrictions should revert to pre-2016 rules.

In a unanimous decision rejecting the anti-abortion groups’ challenge to the U.S. Food and Drug Administration’s regulation of the drug, justices agreed that the case lacked standing, saying there was no clear injury to the plaintiffs to warrant reinstating the restrictions.

“The plaintiffs do not prescribe or use mifepristone. And FDA is not requiring them to do or refrain from doing anything. Rather, the plaintiffs want FDA to make mifepristone more difficult for other doctors to prescribe and for pregnant women to obtain,” Justice Brett Kavanaugh wrote in the opinion. “Under Article III of the Constitution, a plaintiff’s desire to make a drug less available for others does not establish standing to sue.”

Wendy Heipt, attorney for advocacy organization Legal Voice, said the fact that the unanimous ruling is focused on standing is helpful, because that’s an area of law that has been in question in many reproductive rights-related cases since the Dobbs decision in 2022.

“I’m not relaxing; it’s not over. But the fact that this one rogue judge in Texas opened the courthouse doors to people who had no right to be there was a real challenge to the way our judicial system works, so I am reassured that there are still rules,” Heipt told States Newsroom.

Many reproductive rights and medical organizations issued statements following the ruling, including the Guttmacher Institute, a reproductive rights research organization that has closely tracked abortion pill use in the two years since the Dobbs decision.

“We are relieved by this outcome, but we are not celebrating,” said Destiny Lopez, acting co-CEO of the Institute, in a statement. “From the start, this case was rooted in bad faith and lacking any basis in facts or science. This case never should have reached our nation’s top court in the first place and the Supreme Court made the only reasonable decision by leaving access to medication abortion using mifepristone unchanged.”

Nikki Madsen, co-executive director of the Abortion Care Network, said she wasn’t surprised by the ruling, but noted it only preserves the status quo.

“It’s just not enough,” Madsen told States Newsroom. “We know that the anti-abortion extremists are relentless, and their goal is to truly chip away at any abortion access. So today’s decision just preserves access, but it’s really not enough for the people across the country who are truly navigating a human rights crisis right now.”

Three intervenor states expected to continue fight at district court level

Alliance Defending Freedom, the conservative law firm that argued the case, is the same organization that argued in favor of the Dobbs decision that returned abortion regulation to the states. In a statement, ADF attorney Erin Hawley said the ruling was disappointing, but that they will continue to “advocate for women’s health.”

“The FDA recklessly leaves women and girls to take these high-risk drugs all alone in their homes or dorm rooms, without requiring the ongoing, in-person care of a doctor,” Hawley said, adding that ADF is grateful to attorneys general in Idaho, Kansas and Missouri who successfully intervened in the case at the district court level with Kacsmaryk’s approval, because they intend to keep litigating the case there.

In a statement posted on X on Thursday, Missouri Attorney General Andrew Bailey wrote, “Today’s ruling only applies to standing; the court did not reach the merits. My case is still alive at the district court. We are moving forward undeterred with our litigation to protect both women and their unborn children.”

Bailey’s spokesperson did not give any further details about what that case would look like, and Idaho Attorney General Raúl Labrador’s office did not respond to a request for comment.

According to Susan B. Anthony Pro-Life America, a national anti-abortion organization, those attorneys general will move forward with the case “based on harms suffered by women in their states.”

Abortion opponents target abortion drugs from multiple angles?

Anti-abortion opponents have been fighting against the expansion of access to medication abortion since the FDA first approved the regimen in 2000, and they say they are not deterred by Thursday’s ruling.

“The Justices simply discussed the issue of legal standing and did not reach the merits of the case,” Carolyn McDonnell, litigation counsel at national anti-abortion policy shop Americans United for Life, told States Newsroom in a statement. “It’s still an open question whether the FDA unlawfully deregulated mifepristone.”

Longtime anti-abortion activist Rev. Pat Mahoney, chief strategy officer for the Stanton Public Policy Center, said the Supreme Court’s decision in this case was instructive, if not what abortion opponents wanted.

“There’s, I think, a misconception that a loss is a loss, and that isn’t always the case,” Mahoney told States Newsroom. “Sometimes a loss helps define the parameters for bringing the next case and next case, and believe me, there are going to be next cases on medical and chemical abortions. So now we know this isn’t a route to go.”

Mahoney said that like past legal defeats for the anti-abortion movement, this ruling offers at least a partial road map, such as the one abortion opponents followed after the Supreme Court ruled in 1992’s Planned Parenthood v. Casey that abortion until fetal viability was a federal right but that states could pass regulations that didn’t create an “undue burden” for people seeking abortions.

That ruling led to hundreds of restrictions and regulations around the country that kept nudging the viability and undue burden lines — limiting abortion access even before Roe v. Wade was overturned. Mahoney said his organization and others are pursuing various legislative proposals, such as regulating the disposal of embryonic and fetal remains following a medication abortion, which most people have at home or in private settings.

Americans United for Life said in a statement following the ruling that it “will continue to offer legal prescriptions for the strengthening of protections for unborn children from abortion pills through action on the federal and state levels in both executive and legislative branches of government, including through executive enforcement of the Comstock Act and RICO Act.”

Ever since Roe v. Wade was overturned, resurrecting the long-dormant Comstock Act to ban the mailing of abortion drugs and equipment (something legal scholars and historians say is an inaccurate interpretation of the law and how it was applied) has been the long-term focus of East Texas pastor Mark Lee Dickson and his partner Texas attorney Jonathan Mitchell.

They have been pushing various legal and legislative strategies to prevent people from obtaining abortions in states where it’s still legal. They have helped pass dozens of local ordinances in Texas and other states with restrictions that challenge current federal law, such as banning interstate travel to obtain an abortion. In New Mexico, where abortion is legal and largely unrestricted, a challenge to two local ordinances based on the Comstock Act await a ruling from the New Mexico Supreme Court.

The U.S. Supreme Court did not address the Comstock Act in its opinion, but Kascmaryk cited the old law in his initial ruling last year. Major conservative groups are pushing former President Donald Trump, if reelected this fall, to enforce the Comstock Act along with other federal abortion regulations. Trump has stayed silent about what he will do.

In the meantime, anti-abortion groups have not stopped pursuing other cases.

“I can confirm that there are several attorneys in the pro-life movement that are planning on bringing a number of different lawsuits relating to abortion-inducing drugs and the harm that they cause to mothers and their unborn children,” Dickson told States Newsroom.

Mahoney also said groups like his are working with attorneys on a potential class-action lawsuit against abortion-pill manufacturers. He said they are “actively gathering testimony and information from women who have been hurt through medical chemical abortions.”

“We’re working on it,” said Mahoney, adding, “It took us 50 years to overturn Roe.”

Proposals from the 14 Wisconsin residents, brought together to come up with consensus solutions on abortion, arrived at proposals?designed to address the economic, health, and education disparities that can lead to people choose abortion. (Baylor Spears/Wisconsin Examiner)

Editor’s note: This story is the third in a series about a group of people from Wisconsin trying to come up with policies to address abortion and its root causes that could be applied nationwide. Their larger goal is to find common ground on one of the most divisive issues in America.?

MADISON, Wis. — The Starts With Us civic experiment on abortion began with a hypothesis that was reflected in the session’s first working title: Abortion Access & Limits.

And the experiment’s results, following heated discussions among 14 Wisconsin residents with divergent abortion beliefs, are reflected in the session’s final title: Abortion & Family Well-Being, whose just-released five proposed consensus solutions are designed to address the economic, health, and education disparities that can lead people to choose abortion. The group ultimately could not come to any consensus about abortion itself.

But they came very close.

Shortly before Starts With Us went live with its public feedback period on Wednesday, participant Dr. Kristin Lyerly experienced what facilitator Mariah Levison had throughout this session described as heartburn.

The OB-GYN and abortion provider told States Newsroom she couldn’t sign off on the final language of what would have been a sixth proposal titled, “Keep abortion available when a woman is experiencing a life-threatening medical risk.” She said she took issue with some of the non-medical terms like “unborn child,” but her bigger concern was that the proposal used Wisconsin’s definition of a life-threatening medical risk, which she said is poorly defined and does not explicitly include mental health emergencies.

“As a physician … I do this in practice, and everybody else is just talking about the theory of it,” said Lyerly, who has since stepped away from the Starts With Us project because her recently launched congressional campaign conflicts with its nonprofit status. “When I’m taking care of my patients, I’m focused on, what does my patient need medically right now? Not, hey, can you Google what current Wisconsin law says about when a mother’s life is in danger?”

Starts With Us communications manager Tori Larned told States Newsroom that despite high-level consensus on this issue, several participants — both who support and oppose abortion access — disagreed with this proposal’s final language, so they’ve scrapped it for now with the potential to revisit in the near future.

“For some, the language is still too permissive and for others it’s too restrictive,” Larned said in an email. “Citizen Solutions is about bringing more nuance to what is often a binary, overly simplistic conversation.”

Lyerly said she is excited about the proposals the group did achieve consensus on and the connections she made with people who disagree with her. But she remains firm in her view that a medical procedure shouldn’t be narrowly regulated.

“I think we made some important headway, and I think that the fact that we were not able to address the pressing issue of abortion itself really emphasizes how complicated this problem is, and how it belongs in the realm of medical practice, not politics,” Lyerly said. “It’s really hard to find that middle ground because there isn’t necessarily middle ground that applies universally. It’s a personal issue for you that affects your personal self and your personal family.”

Several of the participants on either side of the abortion access divide told States Newsroom that this civic experiment motivated them to keep engaging in discussions about abortion with people they disagree with. A couple said they were disappointed with the ultimate results. And some expressed improved understanding in the other’s point of view, but no major shifts in thinking.

“Initially, I just felt that, how could you want to kill a baby inside your womb? How could you ever come to that conclusion?” said participant Jeff Davis, 76, who has worked with crisis pregnancy centers for women who are contemplating abortion. “From just some of the experiences of people who were there who viewed things differently than I do, I could see why a person could come to those conclusions. And so even though I didn’t change my view, it’s like, okay, now how can these concerns be addressed so that a person would want to choose life?”

Davis also told States Newsroom that he was among those abortion opponents who initially agreed that pregnancy termination should be allowed to preserve the life of the woman but could not agree to include mental distress as part of that definition. The semi-retired bovine veterinarian said his reasoning revolves around the qualitative nature of mental distress.

“It seems to me that those who are pro-abortion want to set the bar very low,” Davis said. “As a result, almost every woman could claim mental distress as a reason for being able to have an abortion.”

Participant Ali Muldrow, the executive director of the abortion fund WMF Wisconsin, said she ultimately thinks theirs is a progressive set of policy proposals in what it doesn’t include: abortion-ban exceptions for rape and incest.

“The fact that we actually didn’t agree on an exception for rape and incest I think is a win,” Muldrow said. “We’re not oversimplifying hugely traumatic experiences as if they can be easily identified, proven, and used to access health care. We didn’t take the bait of compassion with a condition of extreme brutality. That’s something you’re seeing around the country right now and it’s really dangerous.”

She said that for her the group’s dynamics reflect what she sees in the U.S., that there is a majority broadly on the side of abortion access despite their diverse personal views, and a minority (in this case five white Christians) advocating for limits because of deeply held religious beliefs.

“When you pair people who represent 80% of the population with people who represent kind of a specific religious perspective and pretend that those sides are equal, while also failing to kind of acknowledge that one of those groups of people has had historically more power than the other group of people, it creates a pretty complex dynamic,” Muldrow said.

Abortion opponents also expressed disappointment at what they saw as an imbalance of abortion perspectives. Kateri Klingele said that ahead of the final session held in April she acted as spokesperson for the five abortion opponents, and said they would refuse to consider an abortion exception related to fetal health diagnoses. Lyerly noted that three of the nine abortion-access supporters were absent for the final in-person debate. Heather Martell and Ramona Williams were absent because of personal issues, and Monique Minkens started feeling sick and had to leave.

Proposed consensus solutions on abortion and family well-being

This group of 14 Wisconsinites live all across the state, including Milwaukee, Rock, Chippewa, Door, Brown, Grant, and Dane counties. But now residents from the entire state – and the nation – can vote and comment on the group’s proposals for state lawmakers to potentially consider. The proposals were evaluated by 14 health, legal, and policy experts with divergent views on abortion access, three of whom (a “Catholic marriage and family expert,” “pro-life OB/GYN,” and “professor of educational policy studies”) chose to remain anonymous.

In brief, they would:

• Require human development education in schools (and ensure that it’s medically accurate, developmentally appropriate, and state-funded);

• Require all options information at pregnancy centers, abortion clinics, and prenatal care providers (and to make sure it is standardized, medically accurate, and required for dissemination at centers that oppose abortion the same way it is at abortion clinics);

• Extend Medicaid 12 months postpartum (something that failed to pass in Wisconsin’s most recent legislative session);

• Provide a refundable state child tax credit (“While Wisconsin recently expanded its state-level child and dependent care tax credit, the state has no state-level child tax credit. Fifteen states do provide these additional state-level child tax credits, many of which come in at or above $1,000 per qualifying child.”); and

• Enact paid family leave, including foster and adoptive parents.

“We envision a world where Wisconsinites have greater support for planning and sustaining their families,” the participants write in their joint vision statement. “Unintended pregnancies and poor fetal and maternal health outcomes are experienced disproportionately by women of color and lower-income women. … Better community and social supports — including for children and families, as well as during pregnancy, childbirth, and the postpartum period — help those who become pregnant feel like they have options for continuing their pregnancy.”

Starts With Us head of programs Ashley Phillips said that after the public feedback period concludes on May 31, the participants will find out which proposals got the most support and then evaluate potential next steps, including bringing them to state lawmakers. She noted that for their first session, on gun rights and safety launched last year in Tennessee, more than 30,000 Tennesseans weighed in on eight proposals and five majority-supported proposals were ultimately brought to the state legislature.

Phillips said Starts With Us absorbed a lot of participants’ feedback (including hiring a mental-health counselor to help guide the final session in April) as they continue to iterate their Citizen Solutions sessions throughout the country. She said the results of this particular experiment, on abortion in Wisconsin, make her optimistic.

“If you look at the five [proposals], they’re much more about root causes of abortion,” Phillips said. “That’s the conversation that this group is trying to have. How can we expand the conversation on abortion, so it’s not just about weeks, and it’s not just about exceptions and carve-outs and bans and not bans and morality or not?”

Many of the participants said this experience was hard, but for most it was worthwhile.

“I think it’s important to hear where people are,” Muldrow said. “As important as the areas where we agree, I think the areas where we disagree are deeply important. If you want there to be this kind of happy Kumbaya ending to a conversation about abortion with people with very different beliefs, it’s a little disappointing that one of the more pronounced elements of that conversation is where people disagree, but people were able to disagree and stay in that space together. I think there’s a lot to learn from that.”

Milly Gonzales, 31, who works with?domestic violence, sexual assault, and human trafficking survivors, supports abortion rights. She said the repeal of Roe v. Wade in 2022 was “devastating.”?(Baylor Spears/Wisconsin Examiner)

Editor’s note: This story is the second in a series about a group of people from Wisconsin trying to come up with policies to address abortion and its root causes that could be applied nationwide. Their larger goal is to find common ground on one of the most divisive issues in America.

MADISON, Wis. — For the 14 abortion-rights opponents and supporters recently recruited to find consensus solutions on abortion and family well-being, their first major agreement was that Wisconsin has some of the best cheese in the nation.

Their second was that even where abortion is outlawed (currently in Wisconsin that’s after 20 weeks gestation), life-saving treatment for the pregnant person should not be.

“If the mother’s having to make a choice between do I live or does my child live, she gets to make that choice,” said Bria Halama, a 31-year-old white, Catholic clinical mental health counselor in Milwaukee. In the past, she said she struggled with her stance on bodily autonomy and faith, but now opposes abortion and seeks to honor both the mother and child.

Five of the participants in the Wisconsin Citizen Solutions on Abortion & Family Well-Being defend the concept of “consistent life ethic,” which opposes the intentional ending of human life from conception until natural death. One exception they account for is called the doctrine of double effect, a principle that says that sometimes doing something morally good (for example, saving a pregnant woman’s life) will have a morally bad side effect (ending the unborn’s life, for example), and that this is morally permissible as long as the bad effect was not intended.

All 14 Wisconsinites agreed that situations like ectopic pregnancies are medical emergencies that need to be treated regardless of any abortion ban. But there’s an ultimately unresolvable dispute over how to determine “life-threatening,” something that OB-GYN Dr. Kristin Lyerly told the group is rarely black and white and always unique to a particular pregnancy. (Lyerly has since stepped away from the Starts With Us project because her recently launched congressional campaign conflicts with its nonprofit status.)

However, there is a slight shift in some of the abortion opponents’ thinking on medical interventions to save the fetus when a pregnancy is terminated to preserve maternal life. When Halama suggested that within the exception for maternal health emergencies they include a caveat that all efforts should be made to save the baby, Lyerly pushed back.

“I really struggle with that, because there are babies that are born as a result of an abortion that are alive but are not likely to live,” Lyerly said. “And the parents … will wrap their babies and hold them until they die instead of taking them away and poking them with needles and putting a breathing tube down their throats and making them suffer and experience pain until they die. And I think that some people would choose one and other people would choose the other, and I can’t make that decision for my patients.”

Halama agreed with Lyerly that efforts to save fetal life may not always be the best option in all circumstances. And so did Thomas Lang, a Catholic from Janesville who opposes abortion.

“I really appreciate that,” Lang said. “Because we can bring that to end-of-life-care, too, where you know, the breaking of the ribcage, enough already. You’re prolonging death, you’re not prolonging life here.”

Another place of early agreement in the same realm involved miscarriage management. Stories of women being turned away from hospitals with non-viable pregnancies persist around the country and are the subject of the second major U.S. Supreme Court case since Roe v. Wade was overturned, which justices heard Wednesday. But there’s also a story around this table.

Participant Heather Martell shared with the group that her first pregnancy, at 19, ended in a miscarriage. She alleged that her doctor would not evacuate the pregnancy because of the doctor’s anti-abortion beliefs and that she bled for months before seeking treatment at a Planned Parenthood clinic.

“I almost died because of a pro-life agenda,” Martell told the group.

The participants initially agree on a proposal that says that receiving medical care for miscarriages should not be subject to a state’s abortion laws.

Dispute resolution on steroids

Facilitating these sessions were Mariah Levison and Kelly Wilder from Convergence Center for Policy Resolution, a Washington, D.C.-based nonprofit that for about a decade and a half has helped opposing groups in the public and private sectors find consensus on a range of policy issues like education, poverty, and health care. But what typically takes Convergence at least a year for each project, Starts With Us has asked them to do in three days (they will eventually add a fourth day in early April).

“This is the same methodology like on steroids,” Levison, Convergence’s CEO and president, told States Newsroom. The Minnesotan said she has worked in dispute resolution her whole career, but abortion is a new topic for both her and Convergence, which facilitated Starts With Us’s inaugural session, about gun rights and safety in Tennessee; a third session on immigration is being planned for later this year.

Beyond agreements on policy proposals, Levison said the larger goal is to help people build trust and understand each other.

And it’s the role of Starts With Us as a civic engagement nonprofit to elevate these examples of understanding and agreement and try to change the narrative that issues like abortion and guns and immigration are intractable. For the first three days of the session last December, camera operators filmed the participants, while the rest of the team watched in a makeshift video village in a drafty hallway space. In the months since, they’ve used the footage to help tell the group’s story and to give Wisconsin residents (and those in other states) a different option on abortion policy that isn’t just relegated to ban vs. no ban. They invited States Newsroom to observe the December sessions, though everything said was initially off the record unless participants gave permission to be quoted.

Levison told the participants they must find OPTIONS: Only proposals that include others’ needs succeed. She had them consider the example of a neighbor complaining about the other’s constantly barking dog. A real consensus solution, she explained, goes beyond keeping vs. getting rid of the dog. And she instructed them not to compromise; if a proposal would cause anyone “heartburn,” it didn’t go on the final list. As in a jury, even one dissenting vote can tank a proposal.

In the group, the biggest sticking points are: fetal health; maternal health that might not be immediately life-threatening; and sexual and domestic violence and whether someone should be forced to procreate with an abuser.

The teams are broken into two groups to facilitate better discussion. By the end, participants will raise their voices, burst into tears, slam a folder. Kai Gardner Mishlove, the executive director at Jewish Social Services, quickly becomes the group’s emotional stabilizer, guiding them through deep breathing during tense moments. But they keep showing up, and listening.

Walls coming down

Heading into the cold December night after the second day of heavy discussions, Thomas Lang told States Newsroom that his wife knows the very night their eldest of three was conceived. The 61-year-old property manager grinned as he remembered her reciting a prayer before being intimate on their honeymoon.

“There is a purpose and meaning of sexual intimacy,” said Lang, who supports the teaching of natural family planning as opposed to “artificial” birth control. He’s very much in love with Amy, who’s 11 years younger and whom he met on the dating site Ave Maria Singles 15 years after a divorce and annulment from a relationship with which he shares three adult children. “One of the basic principles behind the proper use of NFP is that married couples should always have an openness to life.”

Of the 14, Lang is among those on the most restrictive end of the spectrum, a stance informed by his deep Catholic faith, his mother’s abortion regret, his six living children, as well as two miscarriages and a stillbirth. To support his position, he repeatedly cites the 1968 papal encyclical “Humanae Vitae” and the legislative director of Pro-Life Wisconsin.

And unlike some of the other abortion opponents in the group, Lang is comfortable using the word murder to describe what Lyerly does for a living. He doesn’t expect to connect with her.

Throughout the initial three-day session, the OB-GYN from Green Bay patiently answered medical questions, described abortion procedures, and explained how she views abortion morally.

“My obligation to my patients is to make sure that I’m helping them with the right thing for them,” Lyerly said. “If I’m taking care of a woman from the Jewish faith, they have a very different perspective than my Catholic patients than my agnostic or atheist patients. So my job is to understand where they’re coming from and to make sure that they feel fulfilled and well taken care of and have what they need to be able to live their lives according to their morals.”

At one point Lyerly obliged Lang when he asked her to switch from clinical language (fertilization, products of conception) to his preferred terms (conception, baby), a move that frustrated several of the abortion-access participants but endeared her to him.

“I would have been repulsed to have met an abortionist before this meeting,” Lang told Lyerly on the second day of the session, “but I can’t tell you how much you enamor me with regards to the way you put yourself in your patients’ shoes. I would love you to be my wife’s doctor.” (He later acknowledged to States Newsroom that this could never happen because Lyerly’s “compassion is incoherent without principled procreative and life ethics.”)

With Lang and Lyerly at opposite ends of the spectrum, the 14 were able to come to only small agreements about when abortion should be legal and accessible, but found more common ground on how to mitigate some of abortion’s root causes, which many of the participants have experienced.

Kateri Klingele, 25, a white mental health professional and co-founder of Wisconsin Student Parents Organization at the University of Wisconsin-Madison, has two children. Not only was Klingele navigating poverty and school during her two unplanned pregnancies, but she was also incredibly sick. She was diagnosed with hyperemesis gravidarum, which resulted in her being fed intravenously during both pregnancies and delivering both her children early due to malnutrition. She said she also experienced partner abuse and was on every social support available, living in constant terror of falling off the so-called benefits cliff.

But she’s firm that abortion should rarely ever be an option because she believes that ending the life of a child is wrong and does not end other issues, like abuse and poverty.

“I am deeply troubled by this idea that providing an abortion and ending the life of a child is a way to stop domestic violence,” Klingele told the group. “As someone who’s experienced that, what’s harmful is the treatment of being abused. What’s harmful is that there’s insane wait lists for domestic abuse survivors’ housing. But my sons were not the problem here.”

Her life experience has brought her to the opposite conclusion to other participants who work with domestic and sexual violence survivors, like Monique Minkens and Milly Gonzales.

“In 2022 I could see both perspectives, especially as a person of faith,” Gonzales told the group. “But it scared me when Roe v. Wade was repealed. It was devastating, especially in my work, seeing how it affected women and all persons that are able to have children. Sometimes we don’t think through decisions that people have to make and how those decisions impact the babies that are being born.”

Meanwhile, Halama, who said she has counseled patients facing crisis pregnancies, began to grapple with the idea that maybe the hardline anti-abortion stance doesn’t reduce the most amount of harm.

“Am I coming from a place of pride? Am I coming from a place of rigidity and not loving compassion?” Halama told the group on the third day. “This is just like to challenge maybe us pro-lifers, but I don’t know, are we working so hard to eliminate this harm, and harming women who are in these positions of domestic violence, and in these positions of discrimination, when we know that we have a merciful God?? … I don’t know what to do with that because it’s so hard for me to concede on something that in my mind is harming, [but] I don’t know if having this harsh black-and-white stance on [abortion] is the right way to do it.”

Back in video village, the sometimes chatty or snacking Starts With Us staff are rapt looking at the screens. Someone whispers: “Wow.”

There’s also an understanding reached between Klingele and Ali Muldrow, a Black abortion fund director, where Muldrow agrees with Klingele about treating people with disabilities with compassion and not suggesting that they should not be born. “I want you to know with my whole heart and soul that I don’t think we should be universally killing people with Down syndrome,” Muldrow told Klingele.

“A variety of health factors inform why people terminate pregnancies, and to suggest that people simply don’t want children with disabilities is insensitive to the complexity of information people obtain about the health and quality of life that factor into people’s decisions around pregnancy,” Muldrow later clarified to States Newsroom. “I think folks who are anti-abortion access take disability into consideration when you’re talking about the fetus, but they don’t seem as willing to acknowledge disability as a factor for the pregnant person.”

Unlikely partnership

On the second day, during breakouts, Klingele smiles kindly at Lyerly and explains that the “intentional ending of a pregnancy” should not be legal.

“I think there should be no criminal charges on women for seeking that,” Klingele said. “But with regard to providers, I think there should be penalties. So, I want to look at you when I say this because I value you and I care about you and I know you care about your patients and about their children. But poisoning them and pulling them out of the womb and vacuuming, whatever terms you want to use, destroys their dignity.”

“I appreciate your perspective,” Lyerly replied. The next day she addressed some of the participants’ notions of her work. “I sit here with people who might be shouting at me as a doctor entering an abortion clinic. Someone who yesterday essentially said I should be in jail. I’m a murderer, right? But every time that I trust women and understand that they know what’s best for them, every time I perform an abortion for someone, we acknowledge that there’s a life there. And we honor that life. And I know that that sounds crazy. But we do the best that we can under every circumstance. And these are hard, hard decisions and everybody is different. But I would offer to you that we do love them both.”

And that’s the next point of common ground: Klingele clarifies that she doesn’t believe abortion providers should be incarcerated, which as Lyerly points out, they could have been under Wisconsin’s temporary abortion ban that went into effect after the Dobbs decision. Klingele ultimately can’t answer what it means for abortion providers if termination is illegal; she said she’s more concerned about making it easier for people to give birth and parent safely.

“I don’t have all the laws or regulations,” she told Lyerly. “But I see ending a life as wrong and there are consequences for doing something that’s wrong.”

But the two found that they agree on a lot more outside of abortion. Lyerly told States Newsroom that the two have agreed to work together in some capacity.

Starts With Us head of programs Ashley Phillips told States Newsroom she was heartened but not surprised to see participants agree and connect.

“It’s hard to hate up close,” Phillips said. “And when you have the opportunity to sit for three days across the table from one another and have nuanced discussions about both your lived experience and the issue at hand, it’s not surprising that you’re able to humanize and learn and grow. And it’s still beautiful to see.”

Tomorrow: A doctor gets heartburn.?

The Wisconsin Social Session on Abortion and Family Well Being has brought together 14 residents from a diversity of backgrounds and viewpoints to create proposals for state lawmakers on abortion. (Baylor Spears/Wisconsin Examiner)

Editor’s note: This is the first in a series about a group of Wisconsin residents trying to come up with policies to address abortion and its root causes that could be applied nationwide.

MADISON, Wis. — Thomas Lang, 61, is white, deeply Catholic and opposes abortion.

“Each one of us has a beginning, and that unique beginning … is conception,” Lang said. “And I would go back to the lack of personhood in slavery and how that personhood can be manipulated. … And I’m saying, no, that child has rights. … And yet we are going to allow for the killing, murder, because of this, this and this.”

Anti-abortion activists and legal scholars in the U.S. increasingly argue that denying the “personhood” of all unborn life is akin to slavery. It’s a comment that doesn’t sit well with the women of color in this room of people with different beliefs about abortion, including some with their own traumatic pregnancy experiences. The women repeatedly point out that white supremacy and racism are well rooted in every aspect of American life, including reproductive health care.

Ali Muldrow, who is Black, a mother of three girls, and runs an abortion fund in Wisconsin, told the group that the so-called father of gynecology, J. Marion Sims, invented tools like the speculum and surgical techniques after torturing enslaved women in horse stables. As someone who faced painful and medically complex pregnancies, Muldrow, 36, pointed out repeatedly that Black women are more likely to die in childbirth than white women, and more likely to experience criminalization because of their pregnancies. She said she was temporarily jailed while pregnant with one of her daughters after being beaten by an abusive boyfriend.

Muldrow’s first pregnancy was at 16, and she hired a lawyer to be able to have an abortion as a minor. She said she doesn’t regret that abortion or the one she had at 18, or her subsequent decisions to parent despite the varying medical, social, and economic perils she sometimes faced. But she’s firm that these were her decisions to make, and rejected Lang’s personhood argument.

“Our personhood is invalidated every day,” Muldrow said. “My health matters, and it’s a factor throughout the entirety of a pregnancy. My body as a tool for breeding, like a cattle animal that can be bred and forced to have kids, is something I’m really against, because I’m against slavery.”

In this room at a historic space in Wisconsin’s capital city, 14 people from around the state have been recruited to find common ground on abortion amid their deeply divergent stances. The Wisconsin Citizen Solutions on Abortion and Family Well Being is an experiment designed by Starts With Us, a nonprofit civic organization whose mission is to try to effect change through citizen solutions and show that people on opposite sides of controversial issues can come to a mutual understanding when they engage in guided mediation.

Founded in 2021, Starts With Us launched its first project last year on gun rights and safety in Tennessee, following a deadly school shooting in Nashville. KIND Snacks founder and “Shark Tank” entrepreneur Daniel Lubetzky has said that, as the son of a Holocaust survivor, he was motivated to co-found this nonprofit to address toxic polarization and extremist thinking. Other founding partners include renowned chef José Andrés, civil rights activist Bernice King, and hip-hop artist will.i.am.

For its second session, held for three days in Madison in December 2023 and for a final day this month, Starts With Us invited 14 Wisconsinites to tackle what has become a galvanizing political issue ever since the U.S. Supreme Court overturned federal abortion rights nearly two years ago.

“To us, the opportunity to build and to actually create solutions is the brass ring,” Starts With Us CEO Tom Fishman told States Newsroom. “But at minimum to have transformative experiences for 14 people in a room and then tell that story is such that it gives people hope and confidence … that at minimum we don’t have to … reduce each other as a caricature list of talking points on two sides of an issue that’s sold to us by algorithms and cable news.”

After months of processing the discussions from the sessions with health, legal and policy experts, Starts With Us on Wednesday unveiled what the group achieved consensus on. Wisconsin residents can now rank and comment on the proposals online. At the end of a monthlong public feedback period, the participants will see which proposals have majority support and evaluate next steps, including bringing some or all of the proposals to state lawmakers for consideration.

Why Wisconsin

The team chose Wisconsin because of its dynamic politics — a swing state with a Democratic governor, a GOP-controlled legislature, and a liberal-leaning state supreme court — and because it’s one of more than a dozen states that banned abortion in the wake of the historic Dobbs v. Jackson Women’s Health Organization decision. Abortion services resumed in Wisconsin last year, after a Dane County judge ruled that an 1849 feticide law does not apply to abortion, but litigation continues, as do further attempts to restrict abortion. Earlier this year the Wisconsin State Assembly passed a 14-week abortion ban that failed to advance in the Senate. As of now, abortion can be performed until 20 weeks post-fertilization.

The 1973 Roe v. Wade decision attempted to reconcile biological complexities and diverse moral worldviews regarding pregnancy, developing life, and reproductive autonomy. Dobbs changed that by letting states make their own abortion laws. And in many states that has meant conservative lawmakers pursuing hardline restrictions and even resurrecting laws from the 1800s, as in Arizona. These policy changes have broadly impacted maternal health care throughout the U.S.

A majority of voters post-Dobbs are showing they don’t want strict abortion bans. Already in six blue, purple, and red states voters have preserved abortion rights directly on the ballot, and about a dozen more are trying to do the same in November. Spurred by the fall of Roe, some have gotten into politics, like Wisconsin participants Heather Martell, now a Chippewa Falls alderman, and Dr. Kristin Lyerly, who this month launched a bid for Congress as a Democrat in Wisconsin’s 8th Congressional District (she has since stepped away from Starts With Us because her campaign conflicts with its nonprofit status). Lyerly is among several OB-GYNS around the U.S. who have sued their states for criminalizing pregnancy termination, which they believe cannot be divorced from standard medical care.

Starts With Us head of programs Ashley Phillips said they recruited individuals based on their nuanced public views on abortion and their willingness to come to the table with opponents on this issue. She said hundreds of Wisconsinites were contacted but many never responded. The selected participants were each paid travel expenses and a $900 honorarium for four days of their time and effort.

The chosen 14 consist of 11 women and three men. Five (three women, two men) mostly oppose abortion; they are white, range in age from 25 to 76, and identify as Catholic or Protestant. The remaining nine include four Black women, one Hispanic woman, and range in age from mid-30s to mid-70s, and identify as Unitarian, Jewish, and atheist. There’s a lot of overlap in the whole group. Several have experienced domestic violence, sexual abuse, and poverty. Most are parents.

How abortion views are born

From day one there is resounding agreement around the table that the current health, economic, and legal systems do not work for many families in Wisconsin or the country at large. Roe and Dobbs flipped the overall legality of abortion, but neither federal court decision addressed the underlying economic and social factors that, according to reproductive-health researchers at the University of California San Francisco, lead many to choose abortion — nor did they address the limited reproductive, prenatal and maternal care access around the U.S.

But the larger debate in the room, and outside of it, is who gets to make decisions in a given pregnancy: the person who is pregnant or the state? And at what point should the developing life be protected from termination?

Though life-of-the-mother exceptions exist in most of the current abortion bans, stories about women being denied health care pervade around the country. Patients who have been able to travel and survive their experiences have sued. On Wednesday morning, the U.S. Supreme Court heard arguments about whether doctors should be protected from prosecution under federal law if they provide abortion care to a patient in an emergency, even in a state with an abortion ban.

Also becoming more pervasive are stories about women denied abortions despite a fetus’s fatal anomalies. The same weekend the group met in Madison, the Texas Supreme Court overturned a court order that would have allowed Texan Kate Cox to terminate a non-viable pregnancy, forcing Cox to travel out of state. It’s a story that 37-year-old alderman and legal assistant Heather Martell is unfortunately familiar with.

As Martell explained to the other participants, in 2021, she went to her 19th week anatomy scan excited to see what would have been her second living child. But the ultrasound and subsequent detailed scans uncovered a rare disorder known as VACTERL association, which can affect multiple body systems and cause abnormalities in the vertebrae, anus, heart, trachea, esophagus, kidneys, and limbs. The disorder carries varying degrees of severity depending on how many systems are affected, according to the Cleveland Clinic. Martell said her baby’s case was incredibly rare in that it impacted nearly every part of his body. It was the worst possible prognosis: “incompatible with life.”

“This child would have needed open heart surgery before he was a year old, but wouldn’t have been able to have the surgery, because he would have been in late stages of kidney failure, having only one undersized kidney,” Martell told States Newsroom in an email after the sessions had concluded.

After a second opinion, Martell and her husband, who is Catholic and was at that time against abortion, sought a termination to spare the suffering of the baby they would name Oliver, which she learned was imminent if he continued to develop. They had to leave the state, because Wisconsin restricts abortion after 20 weeks.

“I Googled it, and I found studies that said the fetal nervous system develops fully by 24 to 26 weeks,” she told the group during their first day introductory discussions. “It gave me 14 days to get an abortion, or kill myself.”

Martell traveled to a Minnesota clinic, where she faced anti-abortion protesters telling her she had other options and where the type of abortion procedure she wanted — an induced stillbirth — was unavailable. That meant she couldn’t hold and bury Oliver, which remains a traumatic memory.

Her pregnancy and life experiences solidified Martell’s belief that reproductive health decisions should be left to patients and their families.

But it’s all about the child for Laura Brown, a 61-year-old chief financial officer for a nonprofit in West Allis, who’s on the board of an anti-abortion crisis pregnancy center.

“A concern I have is that in almost every discussion I don’t hear any mention of the child,’’ said Brown on the second day of the session.

“When I talk about abortion, I am talking about the child,” Martell said. “I’m talking about my child.”

Martell’s two previous pregnancies, when she was 19 and then 21, were marked first by a life-threatening miscarriage, and then by intimate partner abuse and extreme pressure to have an abortion, which she resisted. She told States Newsroom it was difficult to hear some of the statements from the abortion opponents at the sessions, including the implication that she didn’t consider the life of the child in her abortion decision.

“We would have had to pay millions of dollars out of pocket for Oliver to suffer and die. And in the meantime, our living child, Jack, would have become a glass child,” Martell said. “It isn’t easy to watch someone die. It’s even harder when it is your own child and sibling. I was not going to allow that to happen to my family. To be accused of not taking the child into consideration when I discuss abortion is a slap in the face, because I did.”

Brown’s view on abortion is also shaped by trauma.

At 20, her affair with a married man culminated in an unplanned pregnancy that she said she felt pressured to end. The man didn’t offer any support, she said, and though she didn’t want to end the pregnancy, she didn’t see other options. Brown alleges that a counselor at the Planned Parenthood sensed she was not sure about her decision and tricked her into believing she had an ectopic pregnancy that was not viable.

After the procedure began, Brown said she asked the doctor to stop and recalled him telling her, “You should have thought of that before.’’ The experience made her feel violated and eventually suicidal and informed her unbending view that “abortion is not health care,” she said.

Like Martell, Brown still mourns the baby that would never be born.

Brown said she turned to God and is now a regional coordinator for Silent No More Awareness Campaign, which shares stories of those who say they were harmed by abortion, and is affiliated with the national anti-abortion-rights group Priests for Life. She told States Newsroom that years ago, her daughter went into labor at 26 weeks and the medical care she received allowed her baby to be born very small but healthy. These life experiences have made it difficult for Brown to approve any reason for abortion, including if there’s a health risk, fetal anomaly, or the pregnant person is a child or victim of sexual abuse.

“Because abortion is traumatic, it’s also physically traumatic to force a young person to go through that. And then what happens is that the young person is a victim, and then they actually turn into a perpetrator,” Brown told States Newsroom in an interview. “Giving birth is less traumatic than having an abortion and later realizing what you did.”

The majority of those who oppose abortion in this group believe in the concept of “personhood” for all unborn children, starting at the early stages of fertilization. It is the principle behind banning some forms of contraception that can prevent implantation, as well as in vitro fertilization, which since the Alabama Supreme Court’s controversial ruling that frozen embryos are equivalent to human children, has proven to be very politically unpopular.

Martell told States Newsroom that hearing Brown’s story helped her understand how someone becomes an abortion-rights opponent.

“For me it was very interesting to see someone who regretted it, and how easily my life view could have been shaped by that one choice,” Martell said. “Had I not experienced that [pregnancy] loss in 2006, in 2008, I might have succumbed to that kind of peer pressure [to have an abortion], and who knows, I could have ended up like Laura, living with that shame and that regret. And if Laura had had a situation where she had put her foot down and said …? I’m having this kid, maybe she would have been pro-choice now.”

Brown said she agrees with “separation” of the embryo or fetus in life-threatening cases such as ectopic pregnancies, but she believes abortion is over-recommended and not always necessary to save maternal life. “With our medical advancements, high risk pregnancies can definitely be mitigated and cared for.”

But in this group, no one understands the medical nuance of pregnancy better than Dr. Kristin Lyerly, a white, 54-year-old OB-GYN and mother of four who has provided abortions throughout her career. When she herself needed a second-trimester abortion procedure after miscarrying years ago, she told the group she couldn’t find a doctor in Madison qualified to perform what she described as a complex and politicized procedure. Lyerly now commutes to Minnesota for work; she stopped performing abortions in her home state in 2023 while Wisconsin’s abortion ban was briefly in effect.

When gestational limits or narrow health exceptions are proposed, Lyerly consistently pointed out that things happen progressively in pregnancy and that each case is different. “We’re philosophizing. We’re not in the middle of it like my patients are,” she said. “When in the middle of it, you sometimes do things you wouldn’t expect.”

The only other doctor in the room is Jeff Davis, a white, semi-retired bovine veterinarian from southwest Wisconsin who has been involved with crisis pregnancy centers. He said his earliest defining moment on this issue happened on his family’s farm in Illinois.

“My whole pro-life view on life began when I was like 12 years old, and my hand was small enough to get inside the vagina of a ewe to pull out some twin baby lambs,” Davis told States Newsroom. “It was so exhilarating to be able to do that because if not, she might have had dead lambs.”

Davis believes that terminating pregnancies at any stage is wrong because it ends life. His belief was solidified by the birth of his children, the viewing of his first grandchild on an ultrasound, and his Catholic faith.

‘No magic solutions’

But when given the hypothetical, the majority of Americans take a middle position, explained Charles Franklin, a professor of law and public policy at Marquette University in Milwaukee, one of three subject-matter experts to address the group that weekend. The Marquette Law School Poll director has been polling Wisconsinites on abortion for years, and he said the overall numbers haven’t changed much.

Marquette’s most recent poll, from June 2023, finds that 32% of those polled believe abortion should be legal in all cases, 34% in most, 25% illegal in most, and 6% illegal in all.

A few in the group take that middle view, like Jacob VandenPlas, a white veteran and farmer who runs a rehabilitation farm for other veterans in Sturgeon Bay and has run for Congress (the same district as Lyerly, but as a Libertarian). The father of two said he thinks abortion should be allowed until approximately 15 weeks gestation and then qualified with exceptions for fetal and maternal health, rape and incest.

“I don’t believe the government has a place to dictate what someone can and can’t do,” VandenPlas said. “It doesn’t mean I have a disregard for life. I’m not happy about abortions and want to solve the root cause.”

“Morality is so personal; I struggle with assigning it,” said domestic violence advocate Monique Minkens. The 55-year-old Black mother and executive director of End Domestic Abuse Wisconsin told the group that she personally opposes abortion later in pregnancy, but that she doesn’t believe in imposing limits. She noted that she has worked with people trying to avoid being tethered to an abuser for life.

“Late-term abortion, that’s hard,” Minkens said. “I can’t see someone carrying a child, feeling it kicking, and then being given an abortion. And yet I know that there are times when someone says, your child is dead, you’re going to have to push out this child, or your child is going to die as soon as they’re born, or whatever it is, and your life is in danger. I’m not going to pull out my morality on them.”

Abortion polling numbers vary widely, Franklin explained to the group, depending on where people live throughout the state, their politics, their race, their religion, and when presented with real-life circumstances, like Martell’s husband.

“There’s no magic solutions here,” Franklin said. “I’m not trying to present you with solutions. But what I am trying to do is say we need to understand what the broad public is thinking when they think about these things and get a little bit away from the common impression that we have two monolithic, adamantly opposed groups. … We’re divided, though a majority in almost every measure say they favor legal abortion in at least some circumstances.”

As predicted, the solutions this group ends up with months later are not magical, though they are, the participants will eventually agree, positive steps toward improving reproductive health access and family well being in Wisconsin. They include standardizing and ensuring accuracy in pregnancy options information, and expanding health insurance coverage. The group is almost but ultimately unable to come up with abortion-specific policy agreements.

But while these participants were still in the thick of debating and trying to see past their own trauma-laced biases and experiences, consensus on this issue seemed far away.

“I think that we’ll go round and round and round, and I don’t know how we reach an understanding,” Minkens said at the end of the second day; on the third they would be expected to agree to a list of proposals. “I’m just thinking about … the history of harm that has happened over the years; it’s always been the Catholic Church or it’s always been a Christian state that has done the harm, and that is where I’m struggling. Your cold dead hands, my cold dead hands, I don’t know where we go from here.”

Tomorrow: The group struggles to find common ground.

Sidebar

Wisconsin Citizen Solutions on Abortion and Family Well Being participants

• Laura Brown — A 61-year-old white, Protestant nonprofit chief financial officer from West Allis, who opposes abortion rights.

• Jeff Davis — A 76-year-old white, Catholic semi-retired bovine veterinarian and widower with three daughters and eight grandchildren from southwest Wisconsin, who opposes abortion rights.

• Milly Gonzales — A Hispanic domestic violence, sexual assault, and human trafficking professional in Door County, who supports abortion rights.

• Bria Halama — A white, Catholic clinical mental health counselor in Milwaukee, who opposes abortion rights.

• Kateri Klingele — A 25-year-old white, Catholic clinical mental health professional and mother in Madison, who opposes abortion rights.

• Thomas Lang — A 61-year-old white, Catholic property manager from Janesville, who opposes abortion rights.

• Dr. Kristin Lyerly — A 54-year-old white OB-GYN, mother of four, and abortion provider from Green Bay. (She has since stepped away from Starts With Us because her campaign conflicts with their nonprofit status.)

• Heather Martell — A 37-year-old white mother, legal assistant, and Chippewa Falls alderman, who supports abortion rights.

• Kai Gardner Mishlove — A Black grief doula and the director of Jewish Social Services of Madison, who supports abortion rights.

• Patricia McFarland — A 75-year-old white abortion-rights activist, mother, grandmother, and retired college teacher.

• Monique Minkens — A 55-year-old Black executive director of End Domestic Abuse Wisconsin, who believes abortion should be available to everyone.

• Ali Muldrow — A 36-year-old Black mother of three daughters and the executive director of the abortion fund WMF Wisconsin in Madison.

• Jacob VandenPlas — A 39-year-old white veteran and farmer from Sturgeon Bay, who used to oppose abortion but now believes it should be available with limits later in pregnancy.

• Ramona Williams — A Black mother and regional nonprofit coordinator who supports abortion rights.

Protesters take to the streets outside the U.S. Supreme Court on Tuesday, March 26, 2024, where justices questioned attorneys about broad changes in access to mifepristone. (Sofia Resnick/States Newsroom)

WASHINGTON—As the enormous yellow banner unfurled in front of the steps of the U.S. Supreme Court Tuesday morning, Laura Clime-Coates turned to her 9-year-old daughter and said, “Those are the names of people who agree with us.”

On the sign, titled “We the People Support Medication Abortion,” were what activists estimated to be half-a-million signatures from people across the U.S. asking the Supreme Court not to restrict mifepristone, a commonly used drug for abortions and miscarriage management. And for Clime-Coates, who said she signed several petitions in support of medication abortion, mifepristone is the reason her oldest child was standing beside her, and the reason she has a little sister at home in Baltimore.

Back in 2009, Clime-Coates said she experienced what she referred to as a missed miscarriage.

“There was no heartbeat, and it was risking my future ability to have children, and I really wanted children,” she told States Newsroom. “The tissue was not developing and threatening my uterus. My choice was to wait around and damage my body or take mifepristone.”

Clime-Coates and her daughter were among hundreds of abortion rights supporters holding signs and chanting, while inside, the justices heard oral arguments in U.S. Food and Drug Administration v. Alliance for Hippocratic Medicine, their first major reproductive rights case since overturning Roe v. Wade almost two years ago.

In the absence of a legal precedent protecting the right to terminate a pregnancy, the implications for abortion access in this case are as high as they have ever been. More than a dozen states have banned or heavily restricted abortion since 2022’s Dobbs v. Jackson Women’s Health Organization decision, but abortion rates have risen rather than fallen. The Guttmacher Institute recently published data estimating more than 1 million abortions in 2023, of which about 63% were via medication, and that only includes abortions in the formal medical system. Many reproductive rights researchers and providers credit the rise in part to the FDA lifting certain restrictions on abortion medication after more than two decades of consistent safety and efficacy data. Beginning in 2016, the FDA increased the gestational window women could terminate pregnancies using medication, adjusted the dosages, removed in-clinic requirements, and made medication abortion available via telemedicine and directly at pharmacies.

Initially filed in 2022 by anti-abortion doctors and medical groups a few months after Roe was overturned, the case has incurred criticism from throughout the medical and scientific community because of its flawed scientific claims that mifepristone is dangerous and should not have been approved by the FDA. At issue now in the FDA’s appeal to the Supreme Court is whether to uphold the 5th U.S. Circuit Court of Appeals’ opinion that the FDA must reapply older restrictions against the agency’s own scientific determination. The coalition of anti-abortion medical groups?have largely relied on anecdotes from longtime anti-abortion activists, as well as a handful of studies produced by some of the main medical groups connected to the lawsuits, two of which were recently retracted by academic publisher Sage for methodological flaws and undisclosed conflicts of interest.

In anticipation of the oral arguments in this case, those in the pharmaceutical industry have expressed anxiety that a ruling against the FDA could stifle future drug development, by allowing anyone with an ideological opposition to a medication to try to force a drug-policy change.

“This case isn’t about mifepristone,” said Elizabeth Jeffords, the CEO of a small biotech company called Iolyx Therapeutics, on a webinar organized by reproductive health researchers last week. “This is about whether or not the FDA is allowed to be the scientific arbiter of what is good and safe for patients. …. It’s critical for our ecosystem that we continue to have investors, and investors will only come to our ecosystem if they have some certainty. If I had to believe that I would have to stand up to multiple litigations from parties without standing over the course of any drug that we’re working on developing, I wouldn’t have enough money to exist, and all of the little biotech companies would be out of existence as well.”

Pharmaceutical sciences professor Chris Adkins – who sparked the investigation into those studies and has co-authored a new academic paper in the journal Contraception breaking down what he says are significant methodological flaws – said it has been difficult to watch this case advance all the way to the Supreme Court.

“I just hope moving forward that we’ve got more public awareness that our federal courts have not always been the best evaluators of scientific evidence,” Adkins told States Newsroom. “I really hope that the public can really put some pressure on the courts to do a better job at evaluating the scientific and the medical literature, because I think this all impacts each one of us, our families, our futures. … This type of case could threaten regulatory approval or the processes they’re involved with, not just for mifepristone, but for others.”

But for both abortion opponents and supporters outside the Supreme Court Tuesday, the issue is personal.

“I was really glad I had that choice,” Clime-Coates said. “It’s health care! And I would hate for any of my children or any woman or anyone who’s capable of reproduction to not have that choice in the future.”

Alethea Shapiro, a protester from Florida, told States Newsroom she needed mifepristone years ago to terminate a pregnancy for medical reasons. “Hands off our mifepristone!” she yelled in a small circle of activists organized by the Women’s March and the Center for Popular Democracy. Some of the activists had prepared for arrests, but they eventually dispersed while law enforcement officers surveilled the crowd.

Robin Ross, an anti-abortion activist from Amarillo, Texas — home of the conservative federal district court where the case was originally filed, told States Newsroom she had secretly attended abortion rights demonstrators’ planning session the night before but said she learned little beyond logistics. The 57-year-old Navy veteran said she recently became an activist after learning that her teenage mother had attempted to abort her in the 1960s, before abortion was legal throughout the country. Ross said that she has had many health problems, including the inability to have children, because of the abortion attempt (she did not give specifics, but she said it was not the medication abortion method authorized by the FDA, at issue in this lawsuit). She is currently working to make Amarillo a so-called sanctuary city for the unborn.

“As soon as I heard about the ability to put my faith into action and me as an abortion survivor, I instantly wanted to start [anti-abortion activism].

Some anti-abortion activists proudly displayed their pregnant bellies in protest of medication abortion.

“I’m here because I’m 34 weeks’ pregnant. I’m advocating for the rights of my child, my baby in the womb,” said Savannah Evans from Tampa, Florida, who does marketing for the national anti-abortion group Live Action. “ I don’t want her to grow up in a world that sees an abortion as an acceptable option for women.”

At 22, Evans said her pregnancy was unplanned and that she was initially “terrified,” but she and her now-husband chose to parent.

Among the speakers in the largely outnumbered anti-abortion crowd, messages focused heavily on alleged high risks of medication abortion and called on the Supreme Court to order the FDA to reapply the since-lifted restrictions that have made it possible for women to have medication abortions via telemedicine and in their homes.

“FDA, do your job!” shouted Marjorie Dannefelser, the president of Susan B. Anthony Pro Life America. “We certainly do not have complete agreement upon the fact that there are two patients in every pregnancy, but we can at least pledge ourselves to one patient: the woman receiving abortion drugs in the mail in her home alone. … She has become her own abortionist in an unsafe home abortion.”

Recent research on telemedicine abortions, co-authored by University of California San Francisco epidemiologist Ushma Upadhyay, finds a low rate of serious adverse risks. And reproductive rights activists working to expand medication access around the nation said in interviews that abortion drugs are here to stay, even if the Supreme Court sides with the anti-abortion activists, which as States Newsroom reported Tuesday, is far from a sure thing.

“We know that people, no matter what happens with this case, are going to continue to access pills outside of the formal health care system,” said Bethany Van Kampen Saravia, senior legal and policy advisor at Ipas, which for decades has worked in countries with restrictive laws to train providers and help expand access to abortion care. Since the overturning of Roe, she said Ipas has refocused their efforts throughout the U.S., where at least half the states have near-total bans or heavy restrictions. As States Newsroom recently reported, new data shows a rise in self-managed abortions since the Dobbs decision.

“People will continue to get medication abortion through online access, through telehealth service, through online pharmacies, through your community network,” Van Kampen Saravia said. “Self-managed abortion is a WHO-recommended method of care. What Ipas knows from decades of working outside of the U.S. is that abortion with medication is safe and effective. And that’s not going to stop no matter what happens.”

Abortion providers who work in and outside of the formal medical system told States Newsroom they should be able to prescribe the current medication abortion regimen off label, if the FDA is ordered to change its protocol.

“We’re continuing to work because the pills are still on the market, they’re still registered, so they will be available and the doctors have the freedom to prescribe them off label,” said Dutch physician Dr. Rebecca Gomperts, founder of the online clinic Aid Access, which she said has been working with states with shield laws to ship abortion drugs to women in states with abortion bans. She was in front of the court handing out, for free, a small amount of boxes of the abortion-medication regimen. She said Aid Access will continue helping women self-manage their abortions.

“No matter what the Supreme Court is going to do, we’ll be there,” Gomperts said.

Retired Arizona nurse Mary Cross volunteers as an abortion doula for Planned Parenthood Arizona. (Jerod MacDonald-Evoy/Arizona Mirror)

A 39-year-old single mother of two got up extra early on a recent Wednesday morning, hoping to be one of the first outside the Planned Parenthood clinic near Phoenix, Arizona.

The upside of not telling anyone about her abortion was that she wasn’t going to have to explain herself. The downside was that she couldn’t receive any pain medication, since she’d have to drive herself home. After scraping together $770 to pay for the procedure — $250 of which she said came from an abortion fund — she couldn’t afford an Uber for the 80-minute round trip. So she was overcome with relief when not only did the busy clinic not turn her away, but a retired nurse named Mary Cross offered to be her abortion doula, free of charge.

“I was very, very happy that she was in the room,” said the patient, who asked not to be named, given the stigma and legal uncertainty around abortion in the U.S. (Abortion is currently mostly legal in Arizona through 15 weeks’ gestation, amid ongoing litigation over an 1864 law banning abortion.) “I wanted to keep [the abortion] as private as possible, but it still isn’t something that you want to go through alone without sedation.”

The overturning of Roe v. Wade in June 2022 was a turning point for the reproductive health community, and the public at large. A longtime operating room nurse, Cross now had free time and an urge to get involved.

“I’ve always had a choice of what I wanted to do with myself, with my career, with my body,” said the 70-year-old from Tempe. “And now here I was a retired nurse, and the law changed. That really was the trigger that sent me to be more involved in a hands-on kind of way.”

Cross started attending regular conference calls hosted by Planned Parenthood to learn about ways to get involved. At one of those meetings, Planned Parenthood Arizona nurse Kischea Talbert talked about a program she was developing to offer free doula services to patients at their clinics.

“My ears perked up immediately,” Cross said. “I started thinking, ‘That’s something I could do. That’s something I have a skill set for.’ So I texted her right away.”

Doulas are trained, non-medical patient advocates, typically associated with pregnancy and childbirth and end-of-life care. But there’s a growing movement in the U.S. to have advocates provide physical and emotional support to other potentially high-anxiety reproductive health services, such as abortion and miscarriage management, as well as for Pap smears and birth control insertion, which Talbert said can be challenging for patients with past sexual trauma.

In addition to her nursing duties, Talbert became a patient navigator in April 2022, when it was anticipated the U.S. Supreme Court was going to overturn Roe v. Wade. In this role, she helps connect patients with financial and transportation services to access legal abortions. In the early days before the high court’s ruling, Talbert said she attended a presentation by Planned Parenthood Global, in case she might have to start navigating patients to Mexico if abortion became illegal or inaccessible in Arizona, which still has the Civil War-era abortion ban on the books.

Mexico decriminalized abortion in 2023, but even before, abortion drugs had been widely available. Talbert said Planned Parenthood Global has a relationship with several clinics in Mexico that were using doulas to help patients manage the symptoms of medication abortion, which is essentially an induced miscarriage. She said the presenters reported better patient outcomes and less need for medical intervention, which they attributed to the doula program. As a former labor and delivery nurse who worked with postpartum patients and in the neonatal intensive care unit, Talbert was very familiar with doulas.

“I immediately said to myself, ‘Oh, that would be great if we had that program here at Planned Parenthood Arizona,’” Talbert told States Newsroom. “Because in my mind, I’m thinking from a nurse’s perspective how beneficial this would be to have our patients have something like this, and especially at the time, because we didn’t know what the future of abortion care was going to be. So I wouldn’t really let it go.”

With the help of Ohio’s Southwest affiliate, which was the first national Planned Parenthood affiliate to start a doula program, Talbert said Planned Parenthood Arizona launched theirs in October 2022.

The Arizona affiliate currently has approximately 20 active doulas, a mix of nursing and pre-med students, retired nurses, and other working professionals, Talbert said. They are asked to volunteer at least two three-hour shifts a month and are trained annually in trauma-informed care, health-privacy laws, breathing techniques, and abortion procedures and laws. She said Arizona held its third doula training last month.

An optional free doula is offered to patients coming in for procedural abortions, wellness exams, birth control insertions, or gender-affirming care at the affiliate. The goal is to soon have doulas available for medication abortion services. Talbert said they’re applying for a grant through Planned Parenthood Federation of America to potentially be able to pay doulas a stipend.

Cross was part of the first training cohort and began her official volunteer duties in early 2023. When she can, she likes to volunteer at least once a week. She said she thinks of her job as comforting patients and distracting them from pain and anxiety. Even patients who do receive sedation might be nervous about the IV, and might feel nauseated afterward. She’s there to remind them to breathe, and to offer them a cold compress or some 7UP.

“I may tap you on the shoulder, if that’s okay, or I may squeeze your hand, if I’m holding your hand,” Cross said. “And I’ll remind you to take a big deep breath through your nose. We’ll practice it before sedation starts in: ‘I’m going to ask you to blow it all the way out, and then blow it out, blow it out, blow it out till you can’t blow anymore. Take another big deep breath.’ And that kind of calms people, or at least focuses their attention on something else.”

The 39-year-old patient told States Newsroom she used a doula for her oldest child’s birth more than 20 years ago and her youngest’s six years ago, both without any pain medication. She had never related doulas with abortion. But alone in the clinic that day — already stressed from waiting in a growing line of pregnant walk-ins, as abortion protesters shouted with megaphones — it made sense.

“She held my hand the entire time and made sure that I was okay, to help keep me calm and breathing through the pain of the procedure,” the patient said of Cross.

But most crucially, she said, Cross distracted her when the 5-to-10-minute procedure became suddenly overwhelmingly painful. She described the pain as similar to labor pains — without pain medication — going from zero to 10 centimeters in less than two minutes.

“I got really dizzy,” she said. “When I started to focus too much on the pain or the discomfort of what was going on, [Cross] would tap my shoulder or remind me to breathe. At one point, she even pointed out a really pretty necklace that one of the nurses was wearing and just kept talking me through … I’m not going to say that having the doula there made all the pain go away and it was like rainbows and sunshine, but it did help a lot. It helped make it manageable.”

Though the doulas focus on the patients, Talbert said they also provide many services to the staff, such as making copies, folding towels, and cleaning. She said one doula created a coloring book for patients that also includes their discharge instructions. They make care bags for patients with special candy for nausea and fidget toys.

A year later, Planned Parenthood Arizona’s chief medical director, Dr. Jill Gibson, said their doula program has been indispensable for both patients and staff. She said several affiliates across the country are currently developing similar programs.

Gibson said abortion access has been more scarce in Arizona since Roe v. Wade was overturned, especially in the northern and eastern parts of the state. Planned Parenthood has several clinics in Arizona but only the clinics in Glendale, Tempe and Tucson provide abortions. Gibson said the clinics are typically booked out and regularly turn away walk-ins. There are also several independent clinics in Arizona. Gibson said most of their patients are Arizonans, some of whom are terrified undocumented immigrants and many of whom have to drive long distances, and have to plan for two appointments 24 hours apart, one of the state’s many abortion regulations. She said absorbing patients’ hardships is a draining practice and something the doulas assist with.

“A lot of the stories that we hear are devastating, and so to have another layer who can help absorb some of that trauma has been actually extraordinarily helpful for our staff,” Gibson said. “I feel like before I worked as an obstetrician-gynecologist, I didn’t know anything about the world.”

For the patient who talked to States Newsroom, the unplanned pregnancy upended her already challenging life. She said she arrived at the clinic by 7 a.m. and barely made the cutoff for walk-ins. It was nerve wracking, she said, because she knew she was running out of time. It had taken nearly three months for her to realize she could be pregnant. Already a grandmother at almost 40, she said she mistook her pregnancy symptoms for early menopause. And by the time she obtained the abortion, she was already about 12 weeks along. If she’d waited any longer, she was told the price would climb to $1,000, and her insurance doesn’t cover abortion. And if she waited three more weeks, she would have to leave the state to get a legal abortion.

“If I’m having trouble getting the money together for this procedure, there’s no way I can raise another child, not even close,” she said. “So I went in knowing that it was probably going to be pretty rough for me. But having [the doula] there I honestly think that it made a world of difference.”

Cross said she typically does feel drained after a long doula shift spent absorbing patient and staff anxiety. But she said it’s rewarding work.

“I would recommend to anybody to be a doula with abortion care, reproductive care, [anybody] that really believes that we should have the ability to choose if and when to have children and to bring those children up in an environment that we feel is safe,” Cross said. “And this is that opportunity to help those people that are making that choice.”

Julia H. Littell, a professor at the Graduate School of Social Work and Social Research at Bryn Mawr College, said that in the post-Roe era, as abortion restrictions increase, pressure has mounted to correct the record on abortion safety. ?Littell is the lead author of a commentary in the British Medical Journal calling for the retraction of four older abortion-related studies. (Getty Images)

Health and science experts published a commentary in the British Medical Journal on Tuesday calling for the retraction of four older abortion-related studies that, despite documented flaws, have influenced major anti-abortion decisions over the past 20 years, including the 2022 U.S. Supreme Court decision that overturned federal abortion rights.

The commentary comes the same month academic publisher Sage Journals retracted studies calling into question the long-established safety record of the abortion drug mifepristone, which were produced by anti-abortion activists shortly before they sued the U.S. Food and Drug Administration over the same drug.

The timing of these two events is coincidental, lead author Julia H. Littell told States Newsroom (she said the authors submitted their article last year, and it only recently completed the peer review and editorial process). But she said that in this post-Roe era, as abortion restrictions increase, pressure has mounted to correct the record on abortion safety.

“There’s a lot of damage that has been done, and probably will continue to be done, but it’s really important that scientific and medical journals correct these kinds of mistakes so that people don’t lose faith in science,” said Littell, a professor at the Graduate School of Social Work and Social Research at Bryn Mawr College. “How that’s going to play out in courts is a whole different story. It’s quite possible that some expert witnesses, and maybe even judges, will continue to cite these papers, even if they are retracted. But we think it’s really important to get this corrected, so that the downstream effects on medicine and public policy aren’t dire.”

The authors, 17 experts on reproductive and mental health and scientific methods from around the world, are calling for the correction or retraction of four studies published between 2002 and 2011, which they say erroneously attributed women’s mental health issues to abortions they had, in some cases by confusing correlation with causation and failing to correct for factors that explained the relationship.

“It turns out that women who have abortions may be more likely to have mental health problems to begin with,” Littell said. “They tend to be living in greater situations of adversity; they tend to be more exposed to domestic violence and other forms of interpersonal violence. … And when you don’t control for that, which is absolutely a predictor of abortion, then yes, later on, it looks like they have more serious mental health problems. But the problem was there all along. Abortion isn’t really predicting that. Abortion is co-occurring with that.”

The studies were authored by a handful of longtime anti-abortion activists and have received intense scrutiny and criticism over the years, but continue to be cited by lawmakers and judges to defend anti-abortion policies, including the FDA case the U.S. Supreme Court will hear next month.

The studies are:

• “Depression and unintended pregnancy in the National Longitudinal Survey of Youth: a cohort study,” published in 2002 in the British Medical Journal (which also published?Tuesday’s commentary). The authors of this study are longtime abortion opponent David C. Reardon, who also co-authored two of the recently retracted Sage articles, and Jesse R. Cougle. The cohort study concluded that the risk of depression was higher in women who had an abortion compared with those who continued an unwanted first pregnancy. But the commentary writers say an independent re-analysis of the same data found that the study incorrectly identified unwanted first pregnancies and did not control for pre-pregnancy levels of depression. The journal made partial corrections, but the commentary authors say “serious methodological problems remain uncorrected.”

• “Generalized anxiety following unintended pregnancies resolved through childbirth and abortion: a cohort study of the 1995 National Survey of Family Growth,” published in 2005 in the Journal of Anxiety Disorders, and written by Cougle, Reardon, and Priscilla K. Coleman, a retired Bowling Green State University professor of human development and family studies, and a longtime anti-abortion activist. The study concluded that abortion was associated with higher rates of anxiety than giving birth, but, according to the commentary authors, an independent re-analysis showed that pre-existing levels of anxiety and exposure to domestic violence accounted for this association.

• “Induced abortion and anxiety, mood, and substance abuse disorders: isolating the effects of abortion in the national comorbidity survey,” published in 2009 in the Journal of Psychiatric Research and authored by Coleman, Catherine T. Coyle, Martha Shuping, and frequent anti-abortion expert witness Vincent M. Rue. This analysis concluded that abortion increased the likelihood of various mental health problems and substance use disorders, but the commentary authors say the results could not be replicated because of incorrect statements about the methodology.

• “Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009,” published in 2011 in the British Journal of Psychiatry, authored by Coleman. This was a meta-analysis that ultimately concluded that abortion accounts for a substantial increase in the risk of adverse mental health outcomes. The commentary authors say the study failed to meet methodological criteria for systematic reviews, noting that 11 of the 22 included studies were authored or co-authored by the sole author of the meta-analysis.

“We believe that journal editors and their publishers have an ethical obligation to correct the scientific record in these cases,” the commentary writers said, several of whom have been studying the health impacts of abortion for years. They are calling for the 2002 and 2005 articles at minimum to be accompanied by expressions of concern and the 2009 and 2011 articles to be retracted “because of the overwhelming and incontrovertible evidence of their methodological flaws, inaccurate results, and invalid conclusions.”

Littell, an expert on meta-analyses, said the 2011 study is the most egregious, in part because there was only one author, which is not the recommended standard for this type of difficult analysis. She said she was among several researchers who wrote letters to the editor of the British Journal of Psychiatry more than a decade ago calling for its retraction. The commentary writers estimate it has been cited in at least 25 court cases and 14 parliamentary hearings across six countries.

Neither Coleman, Cougle, or Reardon responded to requests for comment by the time of publication.

These researchers have long stood by their work and some continue to testify as expert witnesses in abortion-related lawsuits. Coleman in a rebuttal submitted to the British Journal of Psychiatry in 2022 blamed renewed calls to retract her research on pro-abortion bias. “I have not been the only recipient of this form of bullying due to publishing research results that run counter to a political agenda,” Coleman wrote.

The British Medical Journal told States Newsroom in a written statement: “We are grateful for the concerns raised in the analysis article that we have published today. The issue remains under consideration by our research integrity team. We will make our final decision public once we have completed our internal process”

The remaining three journals did not respond to a request for comment by the time of publication.

Correcting the scientific record: ‘If we don’t, who will?’

The commentary writers also say they are trying to restore public confidence in science.

“It is a concern to me that people will begin to, if they haven’t already, lose trust in science if they can’t rely on the publications out there to be valid,” said Antonia Biggs, associate professor and social psychologist at the University of California San Francisco’s Advancing New Standards in Reproductive Health, which produced the Turnaway Study. That research found that women who have abortions do not suffer worse mental health outcomes than those denied abortions. “It is the responsibility of us as researchers or publishers to adhere to science and to make sure that the scientific record is accurate. If we don’t, who will?”

UCSF professor Diana Greene Foster, who led the longitudinal Turnaway Study, also co-authored the commentary. (Editor’s note: Reporter Sofia Resnick contributed proofreading and editing to Foster’s 2020 book about the study.) UCSF professor Ushma Upadhyay, another commentary co-author and Turnaway Study researcher, is also pursuing a paper re-examining the retracted Sage research.

Chelsea Polis is another commentary co-author who has been involved in efforts to retract flawed reproductive-health-related research. She is a senior scientist of epidemiology at the Center for Biomedical Research at the Population Council, which developed the abortion pill at the center of the FDA lawsuit, along with contraceptives and other reproductive health products.

In 2022, the journal Frontiers in Psychology published?Coleman’s critique?of the Turnaway Study but,?according to Inside Higher Ed, re-examined the article post-publication after critics, including Biggs and Polis, pointed out that Coleman’s article had been edited and peer reviewed?primarily by scientists from the anti-abortion think tank the Charlotte Lozier Institute.

Also in 2022, Polis led a group of 16 scholars who submitted their concerns to the British Journal of Psychiatry about Coleman’s 2011 meta-analysis. An investigative article published by the British Medical Journal reported that an independent panel had determined that the 2011 study should be retracted. But according to the BMJ, the Royal College of Psychiatrists, which owns the British Journal of Psychiatry, overruled the panel after Coleman threatened to sue. Panelists and editorial board members resigned in protest over concerns the journal lacked editorial independence. The Royal College defended its decision not to retract in a 2023 statement, citing the “distance in time since the original article was published” and “the widely available public debate on the paper.”

Polis told States Newsroom the fear of lawsuits can deter retractions, a fear she understands firsthand. In 2020, the medical device company Valley Electronics of Zurich, Switzerland, sued Polis for defamation after she raised concerns about how their Daysy fertility tracker was being marketed as a contraceptive based on a paper that was ultimately retracted. The company lost the lawsuit.

“Editors, journals, and publishers have very little incentive to retract papers (and sometimes avoid retracting even when it really should be done),” Polis said in an email. Polis is an advocate for abortion access, but she said her research critiques have been based on concerns over methodology and not policy positions. She said this work analyzing and calling out flawed science has brought her into a community of scientists dealing with similar legal battles.

“In so many ways, people willing to do this kind of unappreciated, generally unrewarding, sometimes dangerous, and yet extremely critical scientific integrity work need more help and meaningful support,” Polis said.

Biggs told States Newsroom she doesn’t know where these new calls for retraction will lead. But she said she plans to continue pointing out the flaws in these studies, because their influence has had real-world impact.

“When we’re talking about these policies, they have real effects and can have the effects of denying someone a wanted abortion,” said Biggs, referencing the Turnaway Study she worked on, which found more negative short-term mental health outcomes for patients denied abortions, as well as more long-term health and socioeconomic outcomes. “It’s going to impact them. It’s going to impact their children and their families.”

Experts have said that mifepristone, part of a two-drug regimen, has a record of safety and efficacy in more than two decades of use. (Chris Coduto/Getty Images for UltraViolet)

Two of the key studies cited by plaintiffs and judges as evidence that medication abortion should be pulled from the market or heavily restricted have been retracted because of undeclared conflicts of interest and unreliable findings, academic publisher Sage announced Monday.

States Newsroom was the first to report last year that Sage had opened an investigation into some of the research featured prominently in the initial Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration case, whose appeal goes before the U.S. Supreme Court next month. The case is centered on mifepristone, part of a two-drug regimen used to terminate pregnancies and to manage miscarriages.

Study cited by Texas judge in abortion-pill case under investigation

Sage retracted three studies published in its journal “Health Services Research and Managerial Epidemiology,” which were funded and produced by the Charlotte Lozier Institute, the research arm of the influential Susan B. Anthony Pro-Life America, which works to elect federal and state anti-abortion lawmakers.

“Following Committee on Publication Ethics (COPE) guidelines, we made this decision with the journal’s editor because of undeclared conflicts of interest and after expert reviewers found that the studies demonstrate a lack of scientific rigor that invalidates or renders unreliable the authors’ conclusions,” reads a statement issued by Sage.

The studies are:

• “A Longitudinal Cohort Study of Emergency Room Utilization Following Mifepristone Chemical and Surgical Abortions, 1999–2015” (2021)

• “A Post Hoc Exploratory Analysis: Induced Abortion Complications Mistaken for Miscarriage in the Emergency Room are a Risk Factor for Hospitalization” (2022)

• “Doctors Who Perform Abortions: Their Characteristics and Patterns of Holding and Using Hospital Privileges” (2019)

The lead author for each study was James Studnicki, Charlotte Lozier’s vice president and director of data analytics, who was on the editorial board of “Health Services Research and Managerial Epidemiology” at the time the studies were published.

Abortion rights advocates say consequences dire if SCOTUS declines to hear pill case

“Upon submission, the lead author declared no conflicts of interest and all authors declared the same within each article; however, all but one of the article’s authors had an affiliation with one or more of Charlotte Lozier Institute, Elliot Institute, and American Association of Pro-Life Obstetricians and Gynecologists – all pro-life advocacy organizations that explicitly support judicial action to restrict access to mifepristone,” the Sage statement reads. One of those groups, AAPLOG, is a plaintiff in the Alliance v. FDA lawsuit.

In a statement, Studnicki and Tessa Longbons, senior research associate, called the Sage retraction a “baseless ideological attack on our scientific research and experts. To date, Sage hasn’t identified a single substantive objection to the studies to the research team. However, Sage has launched a political assault against an organization whose research has been cited in major pro-life legal victories, such as the Dobbs decision and the AHM v. FDA case. Even after reviewing and publishing this study and standing by it for years, Sage has now caved to outside partisan pressures that dominate elite circles,’’ Studnicki and Longbons said.

“Sadly, this incident points to a larger, newer phenomenon, which is, many of our scientific institutions no longer stand in defense of open inquiry. Rather, what we’re seeing is a biased faction in the medical community (that) holds all the power and attempts to suppress any research that cuts against their approved, pro-abortion narrative,’’ Studnicki and Longbons said.

Last year, pharmaceutical sciences professor Chris Adkins contacted Sage with his concerns about the 2021 “Longitudinal Cohort Study,” which was cited by U.S. District Judge Matthew Kacsmaryk as evidence that the anti-abortion doctor-plaintiffs had standing to sue because “they allege adverse events from chemical abortion drugs can overwhelm the medical system and place ‘enormous pressure and stress’ on doctors during emergencies and complications.”

That paper looked at Medicaid patients’ visits to the emergency room within 30 days of having an abortion and concluded that medication abortion is excessively risky.

“I can’t prove that there was intent to deceive, but I struggled to find an alternative reason to present your data in such a way that exaggerates the magnitude,” Adkins told States Newsroom at the time. “They’re misrepresenting its conclusions to begin with.”

The epidemiology and public health experts who conducted an independent post-publication peer review of the three studies ultimately agreed with Adkins. Regarding the 2021 and a follow-up 2022 paper using the same dataset, the experts found “fundamental problems with the study design and methodology,” “unjustified or incorrect factual assumptions,” “material errors in the authors’ analysis of the data,” and “misleading presentations of the data.”

The 2019 article, using a different dataset, contained “unsupported assumptions,” “misleading presentations of the findings,” and “demonstrate a lack of scientific rigor and render the authors’ conclusion unreliable,” the experts found.

Experts have cited mifepristone’s safety and efficacy with more than 5.6 million uses over the past two decades. The FDA has recorded 28 deaths but has stated that the drug cannot be identified as the cause of those deaths.

Students from Assumption High School in Wisconsin Rapids, Wisconsin, brave this year’s snowy March for Life in Washington, D.C., on Jan. 19, 2024. (Sofia Resnick/States Newsroom)

Falling snow and flight delays thinned this year’s anti-abortion March for Life in Washington, D.C., on Friday, but did not deter the most impatient activists in the movement, those unsatisfied until the entire U.S. map is red with abortion bans.

“I’m not okay with abortion states and non-abortion states. I want an abortion-free America,” said Right to Life of East Texas director Mark Lee Dickson, standing outside the White House the day before, at a sparsely attended protest organized by the Christian Defense Coalition where activists held signs of aborted fetuses.

Nearly two years into a post-Roe America, the battle over abortion rights is being waged primarily at the state level, but this year holds multiple opportunities for abortion opponents to effect a national ban. Beyond the two major abortion cases headed to the U.S. Supreme Court lies a pivotal presidential election. Many anti-abortion groups have galvanized around former President Donald Trump, who despite his more recent mixed messaging on abortion in the face of GOP election losses, personally takes credit for overturning Roe v. Wade. Dickson is among activists confident that Trump would try to fast-track national abortion restrictions through executive orders and by enforcing archaic laws like the Comstock Act, as part of the Project 2025 plan drafted by far-right groups.

“If we got Donald J. Trump back in the White House, he could end abortion in every single state in America, by enforcing the Comstock Act,” Dickson told States Newsroom.

Dickson, who is one of the architects behind Texas’s controversial SB8 abortion ban, which empowers private citizens to sue abortion providers or those who assist abortion seekers, has been helping to pass local ordinances that make it a crime for an abortion to be performed on residents of specific cities. He said many anti-abortion activists are working to enforce these ordinances by spending time outside of clinics in neighboring abortion-access states like New Mexico and asking traveling Texans where home is.

“The pro-life movement is very interconnected,” Dickson said. “There are people outside of the abortion facilities in Albuquerque. What are they doing? They’re reaching out trying to save lives. And in that process, as those discussions are happening, it’s very easy to imagine a situation where someone a sidewalk counselor is ministering and the person says, ‘Where are you from?’ And they say, ‘I’m from Abilene, Texas.’ ‘Well, abortion facility, you’re in violation of the law of Abilene, and you can be sued if you perform an abortion on this Abilene resident.’”

He said his group has been shutting down sections of major roads in Texas saying “if you cross this road then you could be sued into oblivion if you are assisting in abortion trafficking.”

It’s in this atmosphere that has deeply impacted access to abortion around the country but especially for people of color and undocumented immigrants, said National Latina Institute for Reproductive Justice Executive Director Lupe M. Rodriguez, speaking at a media briefing earlier this week organized by abortion-access advocates.

“Roe never made abortion care accessible for communities of color,” Rodriguez said. “Anti- abortion politicians have been working for decades to make abortions difficult to get. And these attacks have fallen hardest and continue to fall hardest on Latinas and Latinx and other communities of color in the U.S. who may work multiple jobs that provide no sick days or insurance coverage and often live in underserved communities. Since Roe was overturned, access to care has absolutely gone from bad to worse.”

Since the Dobbs ruling overturned federal abortion rights under Roe, patients across the country alleging they’ve been denied emergency pregnancy care have been filing lawsuits and jumping into politics. The New Yorker recently published a high-profile story about Yeniifer Alvarez-Estrada Glick, who reportedly died of pregnancy-related causes and was not offered the option to terminate her dangerous pregnancy.

Abortion opponents have largely dismissed concerns about people being denied emergency medical care because of abortion bans. At this year’s March for Life, headlined by former NFL tight end Benjamin Watson, none of the rally’s speakers brought up the issue. The theme this year was “With every woman, for every child,” focused on helping people facing crisis pregnancies.

“Roe is done, but abortion is still legal and thriving in too much of America,” said Watson, during a pre-march rally Friday, ahead of what would have been the 51st anniversary Monday of the Roe v. Wade decision. “Roe is done, but even so in the cold and the snow you have continued to travel from around the nation to this place to recognize that the fight for life is not over. … With uncommon courage we must do justice not only by protecting innocent people in life, but by correcting injustice and rebuilding opportunities so that mothers and fathers can flourish.”

But the policy prescriptions offered at the rally focused largely on public funding for anti-abortion pregnancy centers, which are largely staffed by conservative Christian volunteers and offer certain baby items. Many of these centers have a record of spreading misinformation about abortion, disrupting online searches for abortion seekers, and sometimes serving as abortion-law enforcers.

New U.S. Speaker of the House Mike Johnson (R-La.) touted two bills the House passed this week, one that would require colleges to inform students about the rights of pregnant students and one that would require the federal government to fund anti-abortion pregnancy centers.

“I am myself a product of an unplanned pregnancy in January of 1972,” said Johnson, who has fought abortion and contraceptive rights most of his career and previously worked as a lawyer for Alliance Defending Freedom. The conservative Christian legal firm is involved in both lawsuits to be heard by the Supreme Court this year, which could impact the future of receiving emergency medical care in states with abortion bans, and access to an abortion drug commonly used for first-trimester abortions and to manage miscarriages. “Exactly one year before Roe v. Wade, my parents who were just teenagers at the time, chose life. And I am very profoundly grateful that they did. … We have to build a culture that encourages and assists more and more people to make that same decision.”

But some abortion opponents think political leaders are not doing enough to address the root causes of abortion in policy.

Catherine Glenn Foster, a constitutional lawyer and a longtime leader in the anti-abortion movement, said current state abortion bans are not adequately providing support to pregnant people, and she noted concern about stories of being denied emergency medical care. Foster drew criticism shortly after Roe was overturned when during a congressional appearance she said terminating a pregnancy for a young child should not be considered an abortion. Having previously led the anti-abortion policy organization Americans United for Life and worked for ADF, Foster is now an independent speaker and writer and currently assisting Terrisa Bukovinac’s long-shot presidential campaign as an anti-abortion Democrat.

The divorced mom has spoken often about an abortion she had as a college student that she now regrets and felt pressured into. She told States Newsroom in a phone interview on her way to speak at a March for Life event that she leans progressive in a movement whose leadership is overrepresented by far-right conservatives. Foster’s is one of the quieter voices advocating for making birth free.

“I think we need to just take a step back and look at our policies of how we handle life in America, how we’re supporting pregnant people and parenting people and families and partners and make sure that we’re there for them, things like make birth free, things like parental leave, things like workplace protections, resources, taking care of people’s financial and relational needs, and just empowering them.”

Notably, Foster said states should not enact bans and restrictions without passing policies that address economic instability, which is a common driver of abortion.

“Really, I don’t think we should be introducing any kind of ban without coordinating a corresponding joint effort to simultaneously provide resources and support – even beyond the issue of abortion,” Foster said.

But she opposes the growing movement around the country to enshrine abortion rights in state constitutions and supports attorneys general fighting these efforts. While at Americans United for Life, Foster helped push model legislation passed in states all over the country that reproductive rights activists say limited abortion and reproductive care access long before Roe was overturned. These activists are now capitalizing on the momentum from the previous two elections where voters have demonstrated broad support for abortion access.

“Abortion is not a controversial issue; it’s a gerrymandered issue,” said Jennifer Driver who spoke at Wednesday’s abortion-landscape media briefing. The senior director of reproductive rights for the State Innovative Exchange (SiX), which she said does not endorse candidates, said the abortion rights movement needs to focus on the states this year and highlighted her home state of Alabama, whose lawmakers have proposed prosecuting pregnant people who have abortions for murder.

“People are being robbed of their freedom, sometimes their fertility, because they do not have timely access [to abortion],” said Nourbese Flint, the vice president of All* Above All Action Fund. Their new national political action committee Flint said is the first founded by women of color and will focus on funding candidates that support reproductive justice. “This is our rallying cry. … It is deeply important that we need to be bold, courageous in our fight for our ability to control our bodies and our future.”

“Bans off our bodies” balloons decorated the Protect Kentucky Access election night watch party on Nov. 8, 2022, in Louisville. Kentuckians rejected an anti-abortion amendment to the state constitution. The state Supreme Court has allowed the near-total ban on abortion to remain in force. (Kentucky Lantern photo by Arden Barnes)

Morgan Nuzzo, an advanced practice clinician nurse-midwife, started Partners in Abortion Care in Maryland about a year ago with Dr. Diane Horvath, an OB-GYN who specializes in complex family planning. The clinic is among the few in the country that provides abortions in the third trimester of pregnancy. Abortions that late in pregnancy are rare and often sought because of health risks to the pregnant person or because of a fatal fetal diagnosis.

In June, Nuzzo and other abortion providers and reproductive health experts told States Newsroom that, with the end of Roe v. Wade, they had begun to see a rise in later abortions in the U.S. because of diminished access and increased wait times and costs. But surprisingly, Nuzzo said that in the last few months her clinic has seen a drop-off in patients seeking later abortions, something she suspects could be due to patients not being aware or informed of other options when they can’t access abortion in other states, or because they’re unable to travel.

Some things that haven’t changed, Nuzzo said, are the significant distances people are traveling to end their pregnancies and the high number of young children who need abortions but now can’t get them in their home states. In 2017, there were nearly 4,500 pregnancies among girls under 15, with about 44% ending in abortion, according to the Guttmacher Institute. The age of sexual consent in the majority of states is 16, according to the U.S. Department of Health and Human Services’ guide to statutory rape laws and reporting requirements. Few of the abortion bans enacted since Roe was overturned have exceptions for survivors of rape and incest, and those that do typically have specific police reporting requirements.

This interview has been edited for brevity and clarity.

States Newsroom: Has anything changed at Partners in Abortion Care since June?

Morgan Nuzzo: We actually saw a decrease in later abortion patients from July until very recently. We were booked out several weeks in the spring and early summer. And then there was just this dramatic drop-off. Last year some advocacy folks did some data, and they were like, [the need for later abortion is] going to increase like a hundredfold. So I’m not really sure how to reconcile that with the reality of what we were seeing. But you know, even in California and Washington and Oregon, people were saying that they were seeing less people.

We aren’t booking out now for appointments — we have availability next week. Whereas before [the wait time] was two to three weeks on average, sometimes as much as five. We were getting a little worried about where the patients are.

SN: Why do you think you’re seeing fewer later abortion patients?

Nuzzo: I think there are more patients, and they’re not able to get where they need to go. I think hospitals are potentially seeing people, which we’ve always asked them to do. I think that people are trying, are certainly navigating to safe clinics, and maybe have that on their mind that if they are pregnant, and they need an abortion, that they should not delay for any reason and are trying, you know, realizing that they might have to travel and willing to do that maybe more than they were before.

I wonder, too, it almost feels like there’s a wall in the middle of the United States now that kind of runs from one end to the other of places you can’t get an abortion. And I wonder if people aren’t finding us because they’re not going to places that refer to us. People don’t expect to need a later abortion, or an abortion after 28 weeks. And so I think sometimes when people are told that they’re further along in pregnancy, it’s just like, well, that’s the end. And maybe those referral lists aren’t getting into the hands of people. We’re doing our best to make sure that people know that people can still access later abortion care. It might not be legal in their state, but it’s certainly legal here in Maryland.

SN: How many patients are you seeing on average a week?

Nuzzo: Ten a week now.

SN: And what are the average gestational ages?

Nuzzo: Between 20 and 34 [weeks’ gestation]. And then we’ll see first-trimester patients, too. That would make a much higher number; we can see a lot more first-tri patients.

SN: How often are you turning people away, because they are too far along or for other reasons?

Nuzzo: Once a week. The very worst thing to do is turn somebody away who wants an abortion. It’s a terrible feeling to take someone’s choice from them. I’m not saying abortion is for everyone. Some people get here and they choose not to continue, and that’s wonderful. But to say, someone who wants to not be pregnant anymore, and to say, “You have no other options,” is a terrible thing to have to do to somebody.

SN: Where are your patients coming from?

Nuzzo: Very few are local. I mean, today we have somebody from California. People come from all over. People are still traveling very far to get to us. But it’s just fewer of them.

Things are changing constantly. We’re just waiting for this Florida ban to come. [Florida’s six-week abortion ban, signed earlier this year, has been blocked until the Florida Supreme Court rules on the constitutionality of the state’s current 15-week abortion ban.] We know when that happens that we’re going to get an influx of people from Florida. We already see a good number of people from Florida.

SN: How do you deal with patients from states like Texas and Idaho that are trying to prevent people from traveling or even learning about legal abortion care in other states?

Nuzzo: I mean, we talk to our Texas patients. You know, it’s not illegal in Maryland. We can tell them the services that they can get. We often do have to do some patient education with people while they’re here and be like, ‘You know if you go home, it’s illegal in your home state, right?’ I think some people know and some people don’t really.

I’m just trying to navigate all 50 states’ changing rules all the time. What other medical practice do you have where you’re worried that it’s illegal to talk to somebody on the phone from that state?

SN: The last time we talked, you said your patients range from 10 to 53 years old? What is the age range like now?

Nuzzo: Yeah, still the range. We see a lot of kids. A lot of kids.

SN: About many kids do you usually see a week?

Nuzzo: Usually one to two.

SN: What are the risks of children giving birth?

Nuzzo: Younger people have risks for things like preeclampsia. There’s an increased risk certainly for smaller people who have not gone through puberty completely and become their full adult size. Their pelvises are very small. We see folks up to 34 [weeks’ gestation], so we usually don’t turn those kids away. But sometimes they need to be seen in a hospital. And we’ve certainly consulted for people who are younger than people we’ve seen in clinic [meaning younger than 10 years old] who needed hospital-based care.

What do you think will be some of the lasting effects of the Dobbs decision?

Nuzzo: Birth rates will increase, and then we’ll see an increase in maternal mortality and infant mortality. Maternal mortality is going to go up. If we haven’t already seen it, we know that this is what’s going to happen. We’re already a country that does not take care of their pregnant people in the way that they should be cared for. Black people who are pregnant and give birth are more likely to die than their white colleagues.

People don’t have the access that they need. We know that OB-GYNs aren’t going to places to train where abortion’s restricted. So you’re limiting OB-GYN services and L&D [labor and delivery] services in these areas. Hospitals are already closing down L&Ds all across the country. It’s going to be a ripple effect, even for pregnant people who want to have deliveries.

SN: What are some of the challenges you’ve faced this year?

Nuzzo: When we think about the things that have happened post-Dobbs, it’s like, all of a sudden, everybody’s eyes opened to how the system is just built on the goodwill of people. There isn’t a system. It’s, you know, eight dozen people being like, “All right, I know somebody who knows somebody who knows somebody, let’s try and get this done.” And taking those calls, on the weekends and at night and at your kids’ soccer games.

You want to keep your team in good spirits and also understand that they are real people with real lives. And it’s hard to do this work when every day you wake up and find out a new headline of something horrible has happened. It’s like trying to run a clinic on a foundation of quicksand. And we’ve got the 2024 election coming up. It’s going to be a stressful year.

SN: I read recently that abortion funds have been getting fewer donations. Has that affected your clinic?

Yeah, funds are going dry earlier and earlier each month. We want your readers to know that they can support their local abortion fund. That money really, really matters. It’s not just going into this pot that’s not going anywhere; it’s going directly to patients so that they can get seen. We work with over 40 abortion funds, and we couldn’t do this without their support.

SN: Is there anything else you want to share with our readers?

Make sure that you have a plan if you or someone you love were to find out that they were pregnant and they didn’t want to be or couldn’t be.

And then, you know, we are always wanting to bust later abortion stigma and let people know that these are patients that never expect to be seen by us. And something has changed in their life. And now they need a later abortion. And they’re incredibly brave and strong and resilient for being able to get from wherever they are to us. It’s incredible the things that people have to do just to get to us. And when they come here, they’re often frustrated, but not because they need a later abortion, but because of how frustrating and how many barriers it took them to get here.

Experts have said that a U.S. Supreme Court ruling on the use of mifepristone, a key abortion medication, could have implications for drug approval by the U.S. Food and Drug Administration. (Getty Images)

This year will end on a major cliffhanger for abortion access.

Last November, anti-abortion activists via a powerful conservative Christian law firm asked a federal court to effectively ban or widely restrict the abortion drug mifepristone. Finally on Wednesday, the U.S. Supreme Court agreed to take the case, making Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration the high court’s first abortion-related case since overturning the federal right to an abortion in June 2022.

As abortion access advocates, providers, people of reproductive ability and anti-abortion proponents wait until mid-2024 for the results of this case, other ongoing abortion litigation (a Texas woman left the state after her request for an emergency abortion was granted before being blocked by that state Supreme Court) and a presidential election, uncertainty and fear about the future of reproductive health access remain high.

Abortion via a two-step medication process of mifepristone and misoprostol has become the predominant way Americans terminate pregnancies post-Dobbs, particularly those living in states with bans or in areas with no providers. Mifepristone blocks the progesterone hormone, which is necessary to continue a pregnancy.

“We should never be in a position where judges are deciding whether people can get effective medicines,” said Elizabeth Ling, an attorney for the legal advocacy group If/When/How, in a statement. “Mifepristone access is essential to people’s ability to determine their own future and actualize self-determination by ending a pregnancy, including self-managed abortion.”

Though the anti-abortion plaintiffs in this case asked the Supreme Court to fully reverse the FDA’s 2000 approval of mifepristone for first-trimester abortions, the high court is expected to review questions around restrictions that were lifted during the last decade because of mifepristone’s proven safety record. Depending on how the court rules next year, mifepristone will likely remain legal but could prove much harder to access, especially if the court strikes down the ability to obtain the drug via telemedicine. Legal and pharmaceutical experts have said this case could have far-reaching implications on approval for medications beyond abortion drugs.

“The future of telehealth for medication abortion care now hangs in the balance,” said Dana Northcraft, founding director of Reproductive Health Initiative for Telehealth Equity & Solutions, in a statement. “Telehealth for medication abortion is safe and effective and helps people overcome barriers to care, whether it be long travel distances or getting time off from work or school. Everyone deserves compassionate, accessible, and inclusive abortion care.”

Mifepristone is also used for miscarriage management but has become harder to access, doctors report.

For providers who spoke with States Newsroom on Wednesday, it’s not just about what restrictions will or won’t stand after a ruling from the U.S. Supreme Court, but the fact that the case got this far in the first place.

Dr. Erin Berry, an OB-GYN in Seattle who works at 15 Planned Parenthood clinics around the West, said it’s hard to sit with the idea that nine judges are making a decision about the medical science and safety of a drug.

“That’s just unprecedented, they are not to be the experts in that, and them getting to have a say on that, that’s a big deal to me,” Berry said. “And it has implications on all of our lives.”

Berry sees patients from all across the country in various clinics, including people from as far as Louisiana and Texas who travel to Seattle, often because they know someone who can help drive them home from an appointment and offer them a place to stay. But that alone is disruptive to a person’s privacy, she said, because if care was accessible in their home state, they might have been able to keep a very personal event to themselves.

Cynthia Dalsing, a retired nurse midwife in Sandpoint, Idaho, said restrictions have made local providers more wary about how they interact with pregnant patients, including how they reflect a patient’s demeanor in a medical chart. Abortion restrictions have made people second guess their decisions about evidence-based medical care out of fear, she said.

Dr. Caitlin Gustafson, an OB-GYN in a rural area of central Idaho, still regularly prescribes mifepristone for miscarriage management, and based on evidence, she said using it for that care results in fewer visits to the emergency room and a reduced need for procedures that empty the uterus. Access to the medication in Idaho is already more restricted because only providers can dispense it, not local pharmacies. Some people already have to drive more than an hour to get to a clinic in the case of a miscarriage, she said.

“As we lose providers (to other states) and then further lose access to this medication, if that’s what the Supreme Court does, it will make that experience harder,” Gustafson said.

In the year and a half since the abortion access landscape exploded into chaos and confusion, attorneys like Ling spend their days answering desperate phone calls on the Repro Legal Helpline, which is managed by If/When/How. Earlier this year, If/When/How joined a network of reproductive rights legal assistance groups and law firms called the Abortion Defense Network.

The helpline has been around for a few years, but the end of Roe v. Wade saw inquiries increase by 2,460%, If/When/How’s legal support director Kylee Sunderlin told States Newsroom earlier this year. Sunderlin said many people call before they ever see a provider about a suspected pregnancy or a pregnancy that’s turned into a health emergency because they’re scared about the legal consequences. She said most people don’t understand what is and isn’t legal these days.

On Wednesday, Ling reiterated that If/When/How is committed to helping people navigate these complex and ever-changing laws.

“This case is a further weaponization of the courts to deny people bodily autonomy,” Ling said. “But no matter what the court says, people will always have abortions. Myself and the rest of If/When/How are here to provide people the legal support they need to access the abortions they want and help them fight back against state violence.”

In states with extremely limited abortion access, like Idaho, some people are actively avoiding pregnancy.

Makayla Sundquist, 27, lives in North Idaho and said she has been with her partner for seven years and would consider having children if abortion access was available. She lives in Sandpoint, a rural area of about 9,000 people, where OB-GYN services are no longer offered at the county’s only hospital after the unit closed in March, citing staffing issues and the political environment of the state, where a near-total abortion ban has been in effect since 2022. The closest area with OB care is Coeur d’Alene, which is an hour-long drive both ways.

“We saw it when Roe fell, the number of vasectomies in young men rose dramatically, and I think so many people in red states are realizing that if they want children, this is not the place for them, and I fall into that demographic,” Sundquist told States Newsroom on Wednesday.

Sundquist said she can’t fathom a reason why the U.S. Supreme Court would further restrict a safe and well-tested medication when the other option for an abortion — a procedure that empties the contents of the uterus — is more invasive, but she thinks it’s a real possibility. According to the FDA, 28 deaths out of an estimated 5.6 million people in 23 years have been associated with mifepristone’s regimen for terminating a pregnancy, which is a markedly lower rate than many common FDA-approved drugs, like Tylenol and Viagra. The FDA notes that a small number includes fatal cases “regardless of causal attribution to mifepristone,” including people who died from homicide, suicide, and pulmonary emphysema.

“I will be angry and scared for the people in my life that would need (an abortion), me included if it came to it, but I would not be surprised if that’s what happens, unfortunately,” Sundquist? said.

Ohioans for Reproductive Freedom hold a Bans OFF rally in Columbus on Oct 8, 2023, a month before Ohio voters approved a ballot initiative supporting abortion rights — and almost a year after Kentucky voters rejected an amendment denying them. (Graham Stokes for Ohio Capital Journal)

Anti-abortion leaders woke up Wednesday to the sobering reality that abortion rights remain the nation’s predominant political issue. Decisive wins in swing and red states in two national election cycles since Roe v. Wade was overturned last year have given momentum to reproductive rights groups, who aggressively campaigned and fundraised in key states across the country, and intend to triple down for 2024.

Meanwhile, the anti-abortion movement is scrambling for an effective 2024 strategy after crushing losses. Longtime anti-abortion activist the Rev. Pat Mahoney said in large part Republicans have been ineffective communicators on the issue and were wildly outspent.

“I think for the pro-life movement, we have to now truly recognize, when it comes to abortion bans, this is something that Americans do not want right now,” Mahoney told States Newsroom as he hustled to catch a connecting flight from Ohio – whose voters enshrined the right to abortion – home to Virginia, where Democratic candidates overtook the legislature after campaigns focused on abortion rights.

Mahoney is currently chief strategy officer for Stanton Public Policy Center, the political arm of Stanton Healthcare, a network of anti-abortion clinics headquartered in Idaho that offer limited reproductive health services. He said the anti-abortion movement needs to better coordinate a national messaging and fundraising strategy to be able to compete with the reproductive rights movement.

“Right now the pro-choice movement is more committed to funding in elections the protection and promotion of abortion than the pro-life movement is committed to ending abortion violence and making abortion unthinkable,” Mahoney said. “I live in Virginia. The state is doing well, the economy’s doing well, by all accounts. [Glenn] Youngkin is a relatively popular governor. Every ad I saw on television for every Democrat – I mean, a barrage of them – was how MAGA Republicans or pro-life anti-choice activists want to take women’s rights away. They were all about abortion.”

He said he’s expecting Republican candidates to continue “fumbling” the issue on the presidential debate stage in Miami tonight.

“Hardly any Republican has handled this well,” he said. “They’ve been all over the map.

Marjorie Dannenfelser, president of Susan B. Anthony Pro-Life America, also urged the GOP – many of whose candidates tried to ignore the abortion issue or soften their stances – to “wake up.”

“The true lesson from last night’s loss is that Democrats are going to make abortion front and center throughout 2024 campaigns,” Dannenfelser said in a statement. “The GOP consultant class needs to wake up. Candidates must put money and messaging toward countering the Democrats’ attacks or they will lose every time.”

But anti-abortion leaders say they will not give up their mission and will continue pushing controversial policies like granting “personhood” to embryos.

“Voters overwhelmingly cast their ballot to enshrine abortion into the state constitution. This is a bitter pill, and there’s no sugarcoating it,” Americans United for Life interim president Kevin Tordoff said in an email to supporters. “You and I know that constitutional justice, always and everywhere, means equal protection for all. We will continue, as we have since our founding in 1971, to strive for the day when all are welcomed throughout life and protected in law. Let us continue to stand together in this mission.”

Anti-abortion movement leader Terrisa Bukovinac, meanwhile, is calling for the anti-abortion movement to get more radical. She comes from the direct-action wing of the movement that believes voters need to see graphic images of aborted fetuses in order to be moved on the issue. The self-described atheist and leftist used to work in animal rights activism in San Francisco before moving to Washington, D.C., to found Progressive Anti-Abortion Uprising, one of the few anti-abortion groups that supports LGBTQ rights. Bukovinac is running for president as a Democrat with a targeted goal of airing campaign ads in key markets that show graphic images of fetuses she and another activist obtained outside of an abortion clinic in 2022.

“The reason that we oppose [abortion-rights amendments] is because they are widening the scope of abortion into the third trimester for elective reasons,” Bukovinac told States Newsroom. “And if we’re not showing the victims, like non stop, of abortion in these later trimesters, then we’re not really communicating with people why we oppose these measures and why they should also.”

Bukovinac told States Newsroom she is working to air her first ad in New Hampshire by the beginning of next year, but fundraising for her tiny campaign has been slow-going. She said stations typically charge more for campaign ads that feature controversial content.

Following Tuesday’s losses, Bukovinac said Maryland Right to Life reached out to her to conference on strategies ahead of the state’s upcoming abortion referendum.

“I think that they have to show the victims of abortion in an aggressive way,” Bukovinac said, of anti-abortion groups. “They need to say that abortion is murder. They need to be doing direct actions. I think those are the three most important things that we’re going to be doing in the next however many years it takes to reach left on this issue.”

Tuesday’s results were equally instructive for abortion-rights organizers in showing how effective abortion rights is as a voting issue. Ohio organizers in particular faced many obstacles, led by state Republican leaders, in trying to even get their initiative on the ballot. Despite what activists said was misleading text on the ballot, the measure carried 57%, including 18% of Republican voters.

“Looking at the results in Ohio, Virginia, Kentucky and Pennsylvania, it is pretty clear that abortion matters to voters because it matters to people in their everyday lives,” said Angela Vasquez-Giroux, vice president of communications and research of Reproductive Freedom for All, an abortion rights lobbying group formerly called NARAL Pro-Choice America. “And I think when you look down the road to 2024, and you see places like Florida, that gives you a sense of what’s possible. Even where you have hostile legislatures and gerrymandering and all of the structural inequalities stacked against you, you can still make big change when you get the power back to voters.”

Since the U.S. Supreme Court overturned Roe v. Wade in June 2022, 21 states have eliminated or restricted access because of abortion bans. And as States Newsroom has reported, even with health exceptions and especially without them, women have been denied medical care during pregnancy-related emergencies.

“[Voters] understand that life is not these one-size-fits all bans,” Vasquez-Giroux said. “They don’t account for how complex pregnancy and life are. People understand that you can’t legislate a belief system onto a medical procedure and expect that nothing bad is going to happen.”

A sample of reproductive rights wins from Tuesday night:

Kentucky: Democratic Gov. Andy Beshear, who made the state’s. near-total abortion an issue in the race, won re-election. Challenger Republican Attorney General Daniel Cameron supports the ban and has defended it in court. After the Beshear campaign began airing ads criticizing Cameron’s support of the ban, the Republican gave varying answers on whether he would support exceptions in cases of incest and rape.

New Jersey: With every legislative seat up for grabs Tuesday, Democrats retained control of both houses, after Republicans had dismissed their strategy to focus on reproductive rights over issues like state spending and crime rates.

Ohio: A win for Issue 1 means the state’s constitution will now guarantee the right to abortion through viability (and beyond for medical emergencies), as well as the right to birth control,

childbirth, fertility treatment and miscarriage management. The win means a blocked six-week abortion ban currently under review by the courts will likely be struck down. And it marks the seventh state to affirm reproductive rights on the ballot since Roe v. Wade was overturned.

Pennsylvania: Democrat Daniel McCaffery won his seat on the liberal-leaning Pennsylvania Supreme Court, and marked the second time that Reproductive Freedom for All endorsed in a judicial race.

Virginia: Democrats winning both state houses means Republican Gov. Glenn Youngkin is unlikely to push through the abortion ban he championed this election cycle. For now the state remains one of the few abortion access points in the South.

Vasquez-Giroux said Reproductive Freedom for All will continue to support local reproductive-rights groups with their ballot measures and state and local elections, and will help to coordinate strategy at the national level.

“No matter how you apply abortion as an issue, in elections, it’s successful because people understand exactly what’s at stake – your ability to live in a place where it’s safe to become pregnant. It’s a pretty big deal,” Vasquez-Giroux said. “Folks understand that it means that you have to protect it at every opportunity. … I think we can expect to see repeats of last night and 2022 in 2024.”

Cancer is one of several conditions for which mifepristone is a potentially effective treatment. (Getty Images)

One of the anti-abortion doctors suing the U.S. Food and Drug Administration to rescind its 2000 approval of a medication abortion regimen on the basis that one of the drugs is dangerous is now consulting on the development of a breast cancer treatment that involves the same drug: mifepristone. It is the family doctor’s latest foray into medical consulting outside his medical certifications.

Dr. George Delgado is joining the scientific advisory board of Res Nova Biologics, Inc., which is developing a breast cancer treatment using mifepristone, despite plaintiffs’ arguments in the lawsuit that federal approval was illegally rushed (it was a four-year process) and that the drug’s approved use for first-trimester abortion should be reversed.

But in the press release announcing his role with Res Nova, he said: “In my opinion the concept of leveraging the effects of the abortion pill in life-saving as opposed to a life-taking scenario is extremely exciting. I am proud to join such a specialized team of therapeutic developers in advancing this novel approach to tumor immunotherapy.”

Delgado is among the four anti-abortion doctors and four conservative Christian medical groups whose claims are largely based on anecdotes and research that has raised red flags. And they contradict overwhelming evidence that mifepristone is safe after 5.6 million uses and effective for first-trimester abortions, miscarriage management and other medical conditions. The American Medical Association has accused the conservative courts that have advanced the case of? “elevat[ing] speculative pseudoscience over data and evidence, arbitrarily rolling back access to a safe and effective drug and leaving millions of women without a critical medication for reproductive health care.”

Nevertheless, the fate of U.S. abortion access once again rests on a forthcoming decision from the U.S. Supreme Court, to either take up this case, or effectively reinstate old restrictions to the drug. Conservative judges in lower courts have relied on plaintiffs’ claims along with testimony from Delgado and the other doctors alleging personal harm because mifepristone is FDA-approved for abortion.

In a legal declaration submitted in November 2022, Delgado wrote that he has treated women who “suffer complications from chemical abortions,” but he gave only examples of women whom he says felt regret and emotional distress. As an argument for standing, Delgado also said he loses money when patients have a medication abortion instead of seeking prenatal care services at his family practice in Escondido, California, which also offers anti-abortion counseling and a controversial protocol claiming to reverse the effects of mifepristone. The American College of Obstetrician Gynecologists says this protocol is “not supported by science.”

“[T]here is a tangible financial loss to my practice in losing the opportunity to render professional prenatal care for the mother or to care for babies who are never born,” he wrote.

Delgado is an outspoken anti-abortion activist best known for so-called “abortion pill reversal,” which is unregulated by the FDA and whose unverified claims led the AMA to sue North Dakota in 2019 over a state law promoting the procedure. Delgado serves on the American Association of Pro-Life Obstetricians and Gynecologists’ board of directors, despite not being an OB-GYN. At the height of the Covid-19 pandemic, Delgado also testified as a medical expert to keep mega churches open, though he is not a public health expert or epidemiologist. In legal filings he claimed expertise from having “treated many people with infectious diseases, including viral illnesses such as influenza, which tend to occur in epidemics.”

Now the family doctor has been recruited to the scientific advisory board of the biotech company based in Chula Vista, California, that is developing a breast cancer treatment using mifepristone.

Res Nova, a breast-cancer-focused spinoff of Therapeutic Solutions International, Inc., is developing FloraStilbene, a “proprietary formulation of RU-486 and pterostilbene which has been shown to overcome tumor associated immune suppression and increases responsiveness to chemotherapy and immunotherapy.” According to the press release (which refers to mifepristone as RU-486, the name the drug had during laboratory testing), the company “seeks to enter clinical trials of ‘repurposed’ abortion pill for breast cancer” and has signed with a compounding pharmacy.

“The similarities between pregnancy and oncology, including angiogenesis, immune modulation, and rapid growth are striking,” Delgado said.

Delgado is certified in family medicine and hospice and palliative medicine by the American Board of Family Medicine, and is not specialized in oncology or immunology. The Res Nova advisory board members currently listed on the website (Delgado has not yet been added) includes members with diverse specialties, including a board-certified neurologist and neuro-oncologist, a pharmacist, an attorney, a technology executive, and an IT consultant.

Res Nova president and CEO Famela Ramos—who is a nurse, an unsuccessful congressional and school board candidate, and on the board of an anti-abortion pregnancy center in Chula Vista—said she recruited Delgado partly because of the so-called abortion reversal technique he’s spent more than a decade developing and promoting.

“Having known the work of Dr. Delgado for many years and his great success in defending both the mother and the baby, it is exciting to have the opportunity to utilize his scientific and medical expertise in this unique intersection of reproductive medicine, immunology, and oncology,” Ramos said in the announcement, which refers to Delgado as an “expert in the biology of pregnancy and the abortion pill” and does not mention his lawsuit against mifepristone.

Delgado has also suggested that abortion is linked to breast cancer, a common anti-abortion claim. But according to the American Cancer Society, “scientific research studies have not found a cause-and-effect relationship between abortion and breast cancer.”

Ramos and Delgado declined to respond to States Newsroom’s questions.

Major U.S. medical groups have argued that Delagado’s lawsuit could have long-term consequences unrelated to pregnancy termination—and could upend drug research and development. Mifepristone is currently being investigated in clinic trials for a variety of cancers and mental health disorders. This lawsuit targets mifepristone for the specific use of abortion, and the drug’s manufacturers have said restrictions on the medication abortion regimen would not apply to clinical trials investigating mifepristone for non-abortion use. However, researchers have reported that even before Roe v. Wade was overturned anti-abortion policies made it difficult to study mifepristone.

Already mifepristone can be difficult to access for people who want abortions, but now the drug is also hard to access for the off-label use of miscarriage management because of high demand and confusion around medication abortion laws, according to States Newsroom affiliate Stateline.

“Dr. Delgado’s research interest in mifepristone as a potential preventive for cancer demonstrates the significant medical value that mifepristone provides,” said Molly Meegan, chief legal officer and general counsel for the American College of Obstetrician Gynecologists, which has filed friend-of-the-court briefs defending mifepristone’s approval and safety record in the FDA lawsuit.

Delgado helped create a network of anti-abortion health care providers willing to perform the so-called abortion pill reversal treatment without much data behind it and based on the doctor’s training at an institute that teaches a Catholic-friendly approach to reproductive health. The anti-abortion pregnancy center network Heartbeat International now manages the Abortion Pill Rescue Network.

The FDA’s medication abortion regimen, which is currently recommended for up to 10 weeks’ gestation, involves mifepristone to block the hormone progesterone, followed by the medication misoprostol which causes contractions. The “reversal” protocol has patients forgo the second drug in the regimen and receive doses of progesterone. States Newsroom has interviewed a patient who remained pregnant and gave birth to a healthy baby after going through this treatment at an anti-abortion pregnancy center in Idaho. But medical groups like ACOG and the AMA say there’s not enough evidence to show that it’s the progesterone that continues the pregnancy versus not completing the abortion regimen. The one attempt at a controlled study of this protocol ended prematurely because the OB-GYN and mifepristone expert leading the study determined it was unsafe after three patients hemorrhaged.

Though several states have passed laws requiring abortion clinics to tell patients they could potentially reverse their abortions if they change their minds, some states are now pushing back on the promotion and marketing of this treatment.

The California attorney general is suing Heartbeat International and another California-based crisis pregnancy network that have widely marketed “abortion pill reversal” despite its unproven claims, under the state’s False Advertising and Unfair Competition laws.

Earlier this year Colorado became the first state to ban the procedure, which was followed by a lawsuit from a Catholic clinic. State regulators have ruled that so-called “abortion reversal treatments” are not an accepted medical practice. But over the weekend, a federal judge appointed by former President Donald Trump blocked the new state law, citing the plaintiffs’ religious freedom.

The U.S. Supreme Court could decide the future of a key abortion pill, mifepristone, more than a year after the nation’s highest court overturned Roe v. Wade allowing states to decide their own abortion laws and bans. (Getty Images)

More than a year after the U.S. Supreme Court decided states could set their own abortion laws, including bans, the nation’s highest court now could cut off abortion access in states where abortion is still legal.

The Supreme Court began its new term last week and has yet to announce whether it will hear Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration, before the term ends in June 2024. This case was designed by the religious right to overturn the approval of the commonly used abortion drug mifepristone. But whatever the court does — even if it declines to hear the case — will further alter healthcare access in the U.S., reproductive health advocates said on a call to reporters Thursday.

“The restrictions that the Supreme Court could reimpose would drastically reduce access to mifepristone and create barriers that are impossible to overcome for many patients who are seeking abortion care,” said Leah Koenig, data analyst and medication abortion researcher, at the University of California San Francisco’s Advancing New Standards in Reproductive Health.

Alliance Defending Freedom, the Christian right legal powerhouse representing the plaintiffs, has asked the court to fully reverse the approval of mifepristone and/or to remove restrictions that were lifted over the course of two decades, as the drug regimen maintained a high safety and efficacy record. The FDA’s most recent and not fully implemented change was to allow pharmacies to directly dispense the drug to patients. The U.S. Fifth Circuit Court of Appeals in its August ruling granted part of plaintiffs’ requests: Instead of removing approval altogether, the three-judge panel ruled instead to undo changes the FDA had made to the protocol since 2000.

Post-Roe, medication abortion and especially telehealth medication abortion have improved abortion access, especially for people living in states where it is banned or widely unavailable, said Dr. Julie Amaon, a family medicine physician and the medical director for the nonprofit Just the Pill, which launched in 2020 and connects patients with abortion pills via mail or mobile clinic in Colorado, Minnesota, Montana, and Wyoming.

Amaon said demand from patients exploded by 400% after Roe v. Wade was reversed. She said they’ve seen more than 6,000 patients who have traveled from more than 34 different states. But if the Supreme Court upholds the appellate decision, it will effectively re-apply old restrictions and increase mifepristone’s dosage against FDA’s current data-based protocol. The out-dated policy also shortens the gestational age from 10 to 7 weeks, before many know they are pregnant, and requires patients to make three in-clinic appointments. These new barriers would be difficult to overcome, Amaon said.

“This decision will also have far reaching implications on not only those who need access to safe abortion, but also on countless other established medical treatments as politics override science,” Amaon said. “The fear and urgency is palpable in our patients’ voices. They are frustrated with the confusing laws that vary from state to state and sometimes day to day.”

Science and legal experts have said plaintiffs’ arguments that the FDA illegally approved mifepristone and that the drug is dangerous are meritless. One of the primary sources Texas federal Judge Matthew Kacsmaryk cited to decide that a handful of anti-abortion doctors who don’t provide abortions have standing was a study now being investigated by health journal publisher Sage Publishing for allegations that the anti-abortion research team misrepresented its findings. Kacsmaryk has been involved deeply in the religious right legal movement.

Another federal judge favored by the far right, U.S. Judge James Ho, was one of the three judges on the Fifth Circuit appellate panel, who in a separate dissent voted to fully overturn the drug’s approval. He made the roundly criticized argument, based on environmental case law, that plaintiffs might suffer “aesthetic injury from the destruction of unborn life.”

The Fifth Circuit has a growing reputation of having extreme conservative opinions reversed by the Supreme Court. And former FDA attorney Eva Temkin told reporters she is confident that will be the case for Alliance for Hippocratic Medicine v. FDA. Otherwise, she said, the Supreme Court would likely upend current regulatory law.

“The Supreme Court can and should take this case and can and should reverse,” Temkin said. “I do think it is quite clearly a matter of national importance, not only because of the abortion impacts and the patient care impact, which of course can’t really be understated, but also because of the impacts on the drug regulatory environment and the industry and the investment and the way that patients access medicine more broadly. So I do have a lot of confidence.’’

In the event, this case changes the legality of mifepristone, abortion providers have been preparing to switch to a different medication abortion regimen that is still safe but less effective and has more side effects.

Whatever the Supreme Court ultimately does in this case will not be the last word in medication abortion access. But advocates are ready for the continued struggle.

“I think what happens then is a real all out fight about, again, an approved medication that’s been on the market for 20 plus years,”? said Kirsten Moore, director of the Expanding Medication Abortion Access Project. “And they’re just going to take it away from us? That will probably show up in the ballot boxes, in legislative fights.”

The men of Operation Save America close out the group’s weeklong anti-abortion protest in front of the Nathan Deal Judicial Center in Atlanta, Georgia, on July 22, 2023. (John McCosh/Georgia Recorder)

Wendell Shrock doesn’t believe in condoms. “We should leave the uterus to God,” the street preacher from Tennessee tells States Newsroom, in front of an abortion clinic outside of Atlanta, mid-morning in late July. Sweat drips from his cowboy hat into his salt-and-pepper beard that stretches halfway down his red-plaid shirt. The retired police officer is running security for the conservative Christian group Operation Save America’s annual national event. Their followers interpret the Bible literally. Some believe constant procreation is God’s will.

Shrock surveilles the crowd while his wife, Dawn, cares for six of their 11 children on the opposite end of a sidewalk crowded with warring abortion messages. One of their daughters walks over, and Shrock explains she will wed soon. He’s been praying God will give her 20 children. (For privacy reasons, he doesn’t share her age.) One of his sons got married about six years ago at 18 and has had a child every year since. Shrock says with pride that Dawn, who wears a hair covering and a long dress, has never held a public job.

“God created a woman, not only to have a baby and a baby to grow inside of her, but to nurture a baby,” says Shrock, who is not a spokesperson or leader for the group. “I could never have the closeness to my children that my wife has. That’s because God created her that way. He created her different from me. And I know that goes against some of today’s norms. ‘We’re all the same’— that’s not what my Bible says.”

Overwhelmingly, men are driving the quest to restrict and remove women’s reproductive rights in as many states as possible. Women leaders are and have always been involved in this decades-long fight. But in the post-Roe era, when more mainstream anti-abortion groups are trying to navigate increased bipartisan support for reproductive rights, a more extremist male-dominated faction has risen up. Groups like Operation Save America want to put women on trial for abortion. They want to eliminate all abortion exceptions and certain forms of birth control and fertility treatments. And they are finding support for these messages across the U.S. — in conservative churches and among conservative Christian lawmakers.

But even beyond the militant corner of the anti-abortion movement lies a male-dominated network of academics, attorneys, judges, lawmakers and lobbyists working on legal arguments that position fertilized eggs as constitutionally protected persons. And now that federal abortion rights no longer exist, these men are able to say the quiet part out loud: that somewhere between conception and the first few weeks of pregnancy, the rights of the zygote, embryo, or fetus trump those of the pregnant person.

South Carolina Supreme Court Justice John Kittredge recently argued as much in his opinion upholding the state’s so-called “heartbeat” ban, which was approved by the majority on what recently became the only all-male state supreme court in the nation.

“To be sure, the 2023 Act infringes on a woman’s right of privacy and bodily autonomy,” Kittredge wrote. “The legislature has made a policy determination that, at a certain point in the pregnancy, a woman’s interest in autonomy and privacy does not outweigh the interest of the unborn child to live.”

For South Carolina right now, that point is approximately four weeks of pregnancy.

Protecting and punishing women

Shrock recently texted States Newsroom about the gender roles he’s laid out for his daughters.

“As my daughters were growing up, I would from time to time ask them what they wanted to be when they grow up. Regardless of their answers, I would take them to this scripture and tell them that this is what God has said they should do when they grow up,” Shrock wrote, then quoted from the second chapter in the New Testament’s book of Titus, his version varying slightly from other translations:

Older women likewise are to be reverent in their behavior, not malicious gossips nor enslaved to much wine, teaching what is good, so that they may instruct the young women in sensibility: to love their husbands, to love their children, to be sensible, pure, workers at home, kind, being subject to their own husbands, SO THAT THE WORD OF GOD WILL NOT BE BLASPHEMED.

Asked to explain the verse on the phone, Shrock warned, “You won’t like it.”

“God in the Bible, in Genesis, God created a man to provide, protect,” he said. “And he gave the man a mission. And he created the woman; he said he needs a helper. God gave me a mission, and it’s my wife’s job to come alongside me and help me with that mission. And I know that goes against the world’s grain. They’ll say, ‘Wait a minute, what if she wants a career and what if she wants recognition? What if she wants to climb the corporate ladder?’ Well, God created my wife to have babies, to — literally what it says in Titus.”

Operation Save America’s pervading message is about empowering men and boys to adopt an old, punitive Christian worldview, one more widely embraced when women had few rights and power. But they also take their roles as provider and protector seriously.

For its national director Jason Storms and his father-in-law, longtime anti-abortion radical Matthew Trewhella, that partly means buying guns and building militias. Trewhella has shared his 2013 manifesto calling for government defiance with many interested state lawmakers.

“We live in a culture of so many weak and pathetic Christian men who couldn’t fight their way out of a paper bag if their life depended on it,” Storms said in August 2022, from the pulpit at Mercy Seat Christian Church in Brookfield, Wisconsin, where he is the minister of evangelism and Trewhella is the lead pastor. “It’s not being a protector to your family that God has called you to be. Get yourself in shape. Cultivate some physical strength. Buy guns. If you need to, buy a lot of guns. It’s no limit on gun purchases; you have my blessing. … And if you buy a gun and you buy ammunition, train with it, and get around a group of men that you can train with. Get around a group of courageous men who will fight, bleed, and die with you, for you, and for your families and for your liberties.”

A 2021 YouTube video that was posted on Operation Save America’s website featured suggestive and violent imagery involving scenes of a man with an assault rifle, then cutting to a Planned Parenthood facility, while reciting the biblical verse that begins, “To everything there is a season” and includes the line, “a time to kill.” That video “was removed by the uploader” Tuesday afternoon after the initial national publication of this States Newsroom report.

Storms, in an interview Tuesday afternoon, said his organization doesn’t advocate for violence against abortion providers and believes in advancing its causes through peaceful persuasion. He said the film was produced by a friend for a Christian film festival and is not an endorsement by OSA to commit any violence against Planned Parenthood or abortion providers. When asked why the video was on OSA’s website, Storms said ?that he’d been meaning to take it down because of its “mixed messaging.” It was removed a short time later.

Storms said, under his leadership these past few years, he is trying “to teach our boys to be hardworking, responsible, sacrificial, caring, thoughtful.”

This year Operation Save America hosted its first Manhood Restored Bootcamp for boys and young men in Frankfort, Indiana, which involved hand-to-hand combat training and an event referred to in the schedule as “shooting range.” “Aborting your own child is a betrayal of every godly masculine virtue,” reads an OSA Facebook post leading up to the bootcamp. “Making alllowance [sic] for others to abort their own children emasculates society, decimating its soul and conscience. Abortion will end in America when Men become Men again.”

Storms said this bootcamp is also about teaching men to be responsible and good to women, including when it comes to sex and reproduction. He said he’s against “toxic masculinity” and noted that women participate in his organization.

“We do have a lot of very active women, and women that have jobs outside the home, like, all my kids.”

In addition to claiming to protect women, OSA approves of penalizing them for their reproductive decisions. They call what they support “abolitionism,” and use language from anti-slavery and civil rights movements.

“Thirteen states have banned abortion,” Storms said during the last protest of OSA’s summer event in front of the Nathan Deal Judicial Center in Atlanta, on July 22 (at the time it was actually 14 states that banned abortion at all stages; now it’s 15). “In all those states they’ve given immunity to mothers, and mothers are still killing their children with immunity. That is a problem. We must pursue equal protection, equal justice, equal weights and measures.”

In a follow-up interview post-publication, Storms said the purpose of including criminal penalties for women is as a deterrent.

“I don’t want any woman to go to jail,” Storms said. “The bigger debate is more about the humanity of the preborn child than it is about the punishment for the moms. The whole reason why pro-life organizations exempt the mothers from punishment is because they think that that’s going to help them politically, with public opinion, to make it more palatable. But that’s actually not true. Now 15 states have banned abortion, right? Every single one of those exempt the mothers from punishment, so moms can still legally do self-managed abortion in every one of those states.”

Storms acknowledged there is a difference of opinion among members and leaders about how harsh penalties should be.

“We readily acknowledge the place for various mitigating circumstances which would cause a massively reduced sentence if a woman did procure an abortion under an equal protection law. We certainly do not want to pursue the harshest of penalties. … Our heart is not to see women executed or anything like that,” Storms said in an interview.

OSA sees Georgia as a key battleground state, because, like South Carolina, it still allows abortion for the first few weeks of pregnancy, when electrical activity can be detected on an ultrasound. This law, whose constitutionality the state Supreme Court will determine this fall, does something legally strategic. It defines personhood with potentially future-history-making clauses:

“‘Natural person’ means any human being including an unborn child.”?

‘“Unborn child’ means a member of the species Homo sapiens at any stage of development who is carried in the womb.”?

But this near-total ban doesn’t go far enough for OSA and its partner groups like End Abortion Now, who’ve been lobbying for a much more extreme bill that was introduced earlier this year but has not advanced out of the state House. Under the “Georgia Prenatal Equal Protection Act,” doctors could be convicted under homicide charges unless they could prove the abortion was necessary to prevent “imminent death or great bodily injury.” Pregnant people suspected of having abortions could also be convicted under homicide charges, unless they could prove they were coerced into having the abortion. The bill says nothing about pregnant teenagers and children accused of this crime. Georgia is among 27 states where capital punishment is a possible sentence for homicide.

“In keeping with our oaths of office, the God-given right to life shall be secured and the impartial and equal protection of the laws shall be provided to all unborn persons from the moment of fertilization and at every stage of development, and abortion shall be abolished in this state, so help us God,” reads the bill.

OSA and its partners have lobbied for similar bills, many of them crafted by the Foundation to Abolish Abortion and advanced by sympathetic lawmakers, in more than a dozen states, including Alabama, Arizona, Kentucky, Missouri, and Oklahoma.

Men’s laws

The largest uterus in Washington, D.C., is made of reflective stainless steel. It’s embedded within a nearly 4,000 pound, 10-foot-tall bronze statue of a serenely pregnant Virgin Mary that now sits on the lawn in front of the Catholic University of America’s Theological College. Curled up inside what looks like a giant bowl is a bronze unborn Jesus.

Canadian sculptor Timothy Paul Schmalz says he believes it’s the first representation of Jesus as a fetus. Schmalz, whose work has been commissioned by the Vatican, opposes abortion. He toured the globe with this“Advent” statue before bringing it to its permanent home in May, in D.C., where it is now known as the National Life Monument. Schmalz’s goal is to get one in every U.S. state Capitol building. There’s a bill to erect “Advent” in Texas. One could end up in Arkansas, whose secretary of state is actively seeking design submissions for an anti-abortion monument.

It’s an appropriate representation in a statue of what many state legislatures are trying to do in statute: separate a woman from her womb.

This past spring, Washington Archbishop Wilton Cardinal Gregory blessed D.C.’s new giant uterus while surrounded by other male Catholic leaders. After the ceremony Schmalz told Catholic News Agency that he sculpted Mary’s uterus like a halo, one made of “mystical material.”

But in real life, the uterus is shaped more like a pear than a halo, located between a woman’s bladder and her rectum. Pregnancy begins when a fertilized egg implants in the uterus, which will nourish the egg until it develops into an embryo, then a fetus, and then a full-term baby. As the uterus expands, the woman’s other organs start to work exponentially harder to sustain this new life. Nearly every part of the human body changes during pregnancy and impacts the pregnant person’s comfort and mobility. Pregnancy for some causes temporary or permanent health conditions of varying severity. In the U.S., many people die during or soon after pregnancy or birth, especially pregnant people who are Black and Indigenous.

In 1973’s Roe v. Wade decision, the U.S. Supreme Court prioritized the rights of the pregnant person over the fetus until it reached a later stage of development. Even then, the court allowed states to give discretion to medical providers to weigh the physical and mental health risks women face against those of the fetus. A half-century later, in 2022’s Dobbs v. Jackson Women’s Health Organization, Justice Samuel Alito described each stage of the unborn’s development, but wrote not a word about the bodily developments of the person gestating that life.

The Court did not expressly address personhood in this ruling, but it’s expected to in a future case. That’s why anti-abortion legal architects are now toiling away at the legal definitions that they hope will crack the federal personhood code.

Some states are testing the constitutionality of so-called “heartbeat” bills that ban abortion around six weeks’ gestation, about two to four weeks after a missed period. According to the American College of Obstetricians and Gynecologists, an actual heart is not detectable by ultrasound until roughly 17 to 20 weeks’ gestation. What exists now is electrical pulses. At this gestational point, pregnant people often begin to feel extremely tired or dizzy or short of breath as their hearts begin pumping what will eventually be a 40 to 45% percent increase in blood volume.

South Carolina recently became the second state, after Georgia, with a six-week ban, and Florida could be next, which would make abortion virtually inaccessible in the South. The South Carolina Supreme Court made national headlines after its lone female justice retired, and the country’s only all-male high court promptly reversed her majority-approved opinion that a nearly identical six-week ban was unconstitutional.

Helping Republican lawmakers advance increasingly restrictive anti-abortion laws are longtime legal strategists like Robert P. George and Harold Cassidy, who live-streamedtheir recent strategy chat at Our Lady of Perpetual Help-St. Agnes Parish in Atlantic Highlands, New Jersey. George says he became an anti-abortion activist as a young teenager in West Virginia, shortly before the Supreme Court made abortion a federal right. The Princeton University law professor has spent his entire academic career trying to overturn Roe and block LGBTQ rights. He has advised several Republican presidents and founded many influential political groups.

For decades, the professor and co-author of the 2008 book “Embryo: A Defense of Human Life,” has been refining his legal personhood argument, which he submitted in a co-authored “friend of the court” brief in Dobbs, that the U.S. Constitution’s 14th Amendment already guarantees the right to life for unborn human beings. During his conversation with Cassidy, George said that abortion should not be allowed at any stage, because embryos’ unique DNA make them fully separate humans from the moment the sperm fertilizes the egg.

“Harold is the same guy who was the embryonic Harold, the fetal Harold, the infant Harold, the adolescent Harold,” George said, gesturing to Cassidy. “All of our lives begin from the earliest embryonic stage. And at all stages, and in all conditions, human life is valuable. So the first thing we’re up against is that people have been mis-instructed by the law itself.”

Universities across the country have begun to reproduce the conservative legal training ground George created at Princeton University’s James Madison Program in American Ideals and Institutions. He and his peers have been influencing young anti-abortion legal scholars with their brand of intellectual rather than overtly religious-based anti-abortion reasoning,

Cassidy’s legal career has centered around the so-called woman-protective argument, which the mainstream anti-abortion movement pivoted to during the Roe years in order to pass onerous legislative restrictions. Cassidy has represented women who claim to be victims of abortion, including Norma McCorvey and Sandra Cano, the anonymous plaintiffs in Roe v. Wade and its companion case, who would eventually oppose abortion. Cassidy asserts all women suffer mental traumas after having abortions. In a major legal victory, he drafted a provision in South Dakota’s law (which was upheld by an appellate court in 2008) stating that abortion terminates “the life of a whole, separate, unique, living human being.” Abortion is currently banned in South Dakota, but Cassidy is trying to advance this language in future federal abortion challenges. He twists up the rights argument, saying allowing abortion violates a woman’s right to parent.

“We have to protect the real rights of pregnant mothers: their right to give birth to their child, their right to keep and maintain the relationship with their children, their right to enjoin the equal protection of the laws that say it’s a homicide to kill their child, and their right to an interest in their child’s welfare and life,” Cassidy said.

Cassidy and George and many of their legal peers have long claimed to oppose abortion laws that would penalize women. But their arguments have helped spawn bills that do create criminal penalties for the pregnant person. And mainly men are advancing them.

Personhood laws will diminish the rights of pregnant people, says Khiara M. Bridges, a law professor at the University of California, Berkeley.

“It’s kind of like a zero sum type of game in the sense that the more rights you give to fetuses, the fewer rights you give to the people that actually gestate them,” Bridges told States Newsroom in a phone interview. “We have to acknowledge the conflict as opposed to obscuring it, which I think George and Cassidy participate in that. They need to say with a straight face, like looking people dead in the eye, that the fetus’ well-being is much more important to them than the well being of the person who gestates it. Otherwise they’re just lying and trying to win by obscuring this truth.”

Pregnant people are already facing the legal and medical consequences of abortion bans and onerous restrictions, including bans on information-sharing and attempts from anti-abortion activists and lawmakers to prevent minors and women from traveling out of state for legal abortions in Alabama, Idaho, and Texas.

Determining personhood from conception has terrifying implications for pregnant people, legal experts say. But it would affect more than abortion. If applied broadly, it could affect population counts and tax benefits. Many lawmakers advocating for personhood are unable to fully articulate the full implications or even how to enforce these laws. But even aggressively anti-abortion state governments like Texas’s have indicated personhood laws might only be used to prevent abortion rather than in ways that could benefit the pregnant person or fetus. The Texas attorney general’s office recently rejected a personhood argument in a lawsuit brought by a former prison guard who partially blames the state for her stillbirth.

That Texas’s government was suddenly uninterested in calling fetal life a person when it was unrelated to an abortion law wouldn’t surprise writer Gabrielle Blair, who believes most anti-abortion politicians are disingenuous. The Mormon mom of six behind the popular DesignMom blog has injected a new framework in the reproductive rights debate: Men are disproportionately responsible for unwanted pregnancies, and they should not leave pregnancy prevention exclusively to women, or criminalize women’s pregnancy decisions.

“We’ve put the burden of pregnancy prevention on the person who is fertile for 24 hours a month, instead of the person who is fertile 24 hours a day, every day of their life,” Blair wrote in the 2022 book adaptation of her viral 2018 X (formerly Twitter) thread, titled “Ejaculate Responsibly: A Whole New Way to Think About Abortion.”

Blair’s manifesto, like Matthew Trewhella’s, is also finding an audience among lawmakers, many of them women. She told States Newsroom that she’s heard from lawmakers receiving the book in Ohio, South Carolina, and Utah. South Carolina Republican Sen. Katrina Shealy read it into the legislative record. Blair said she’s also had encouraging conversations with men about making reproductive rights their issue too — working with rather than against women.

“For almost fifty years, a lot of men were focused on what it would take to overturn Roe v. Wade, claiming they wanted to reduce abortions,” Blair wrote in her book. “At any point, men could have eliminated elective abortions … without ever touching an abortion law, without legislating about women’s bodies, without even mentioning women. All men had to do was ejaculate responsibly. They chose not to. Today, they continue to choose not to.”

Pharmaceutical sciences professor Chris Adkins, who has questioned the accuracy and data used in a 2021 study authored by anti-abortion doctors about the key abortion drug mifepristone, says U.S.-based academic publisher Sage Publishing is reviewing the paper. (Courtesy Chris Adkins)

Pharmaceutical sciences professor Chris Adkins was perusing news on his computer in December when he came across an item that fascinated him: Anti-abortion groups had sued the U.S. Food and Drug Administration to force a recall on a commonly used abortion drug.

Adkins teaches future pharmacists at South University School of Pharmacy in Savannah, Georgia. His early-career research focused on cancer drugs, but mifepristone is among the many drugs he’s familiar with. Adkins understood from the medical literature that the FDA-approved two-drug abortion regimen has a high safety and efficacy record. So, it surprised him to read plaintiffs arguing this medication is so unsafe it needs to be pulled from the market. But what he still can’t get over is the research U.S. District Judge Matthew Kacsmaryk cited liberally to order a suspension of mifepristone’s FDA approval earlier this year.

That ultimately blocked April 7 ruling in Alliance for Hippocratic Medicine v. FDA relied on a handful of studies authored by many of the same anti-abortion activists directly involved in suing the FDA. Kacsmaryk leaned hard on a 2021 study that was designed, funded and produced by the research arm of one of the most powerful anti-abortion political groups in the U.S. The judge cited this paper — which looked at Medicaid patients’ visits to the emergency room within 30 days of having an abortion — to justify that a group of anti-abortion doctors and medical groups have legal standing to force the FDA to recall mifepristone.

“Here, the [plaintiff medical] associations’ members have standing because they allege adverse events from chemical abortion drugs can overwhelm the medical system and place ‘enormous pressure and stress’ on doctors during emergencies and complications,” Kacsmaryk wrote.

But U.S.-based global academic publisher Sage Publishing, which publishes thousands of journals including “Health Services Research and Managerial Epidemiology,” is now investigating this study and the peer review process it went through after Adkins contacted the journal in April with a pile of red flags. Last week Sage published an “expression of concern” about the paper.

“As part of the investigation, we are looking into Dr. Adkins’ concerns as well as any concerns related to conflict of interest,” Sage spokesperson Camille Gamboa told States Newsroom in an email. The lead author of the paper, James Studnicki, who works for the anti-abortion think tank Charlotte Lozier Institute, is also on the editorial board of “Health Services Research and Managerial Epidemiology.” Gamboa said that Studnicki, in accordance with his journal’s ethics guidelines, was “not involved in the decision-making process for this article.”

Adkins dissected this paper the way he used to as a onetime peer reviewer. He told States Newsroom that the authors exaggerated their findings and visually misrepresented them in ways that are “grossly misleading.” And that’s led to legal consequences. Except, he said, their study doesn’t actually show what Kacsmaryk said it does: that medication abortion leads to significantly high rates of complications.

“I can’t prove that there was intent to deceive, but I struggled to find an alternative reason to present your data in such a way that exaggerates the magnitude,” Adkins said. “They’re misrepresenting its conclusions to begin with. That’s my frustration with this whole process.”

For now, mifepristone remains legal (except in the 14 states with total abortion bans). But this high-stakes federal lawsuit is ongoing, awaiting a decision from the conservative 5th U.S. Circuit Court of Appeals. And while Sage determines whether this study should have been published in the first place, plaintiffs continue wielding it as one of their best defenses against a safe drug protocol that is now the most common method of terminating a pregnancy (and managing miscarriages) post-Roe v. Wade.

Wading into politically charged science fights is new territory for Adkins. So is advocating for abortion rights, something he says he didn’t believe in when he was growing up in Amarillo, Texas, where the lawsuit was coincidentally filed. He said his views on abortion (and gender and climate science) radically shifted when he left his conservative hometown for graduate school and then became a scientist.

“I have significant concerns about the merits, legality, and use of shoddy studies and personal anecdotes to upend national healthcare policies essential to women’s reproductive health and bodily autonomy,” Adkins told States Newsroom. “To go out and say this drug needs to be, you know, removed from the market, it’s not honestly paying tribute to what the true science really is saying.”

Roe v. Wade was overturned on Adkins’ birthday last year — about a year before he would meet his first child. Living in South Carolina, where laws about pregnancy termination have toggled throughout the year, Adkins has been thinking often about the consequences of ending federal abortion rights. He’s grateful his wife didn’t have any pregnancy complications, but he worries about her reproductive freedom going forward, and that of their weeks-old daughter.

“I now have a daughter that is born in a world where there is no Roe v. Wade, no federal recognition that women have the right of bodily autonomy,” Adkins said. “And just, I don’t know. … I’m going to support her in whatever way I can.”

Studnicki et al.

This lawsuit ultimately hinges on scientific questions: Was the science strong enough to justify the FDA’s approval of abortion drugs more than 20 years ago and then its relaxing of certain restrictions? And does the data predominantly show that medication abortion is safe and effective? Evidence in the affirmative, presented by the FDA’s defense team, outweighs that of plaintiffs in volume and medical journal prestige.

Most drugs approved by the FDA come with some risk of side effects, but mifepristone’s risk level is significantly lower than many commonly used over-the-counter drugs. In 23 years, 28 out of more than 5 million medication-abortion patients have died, but not all necessarily because of mifepristone. Some died of sepsis, ectopic pregnancies, homicide and drug overdoses.

Still, plaintiffs who sued the FDA to revoke mifepristone’s approval rely on studies that have been criticized — and on speculation about a potential spike in future adverse events.

Many U.S. scientists and mainstream national medical institutions like the American Medical Association have asked the courts not to overturn FDA approval of mifepristone, and have called out the misuse of science in the lawsuit. And yet, the conservative federal judges assigned to the case have been nodding along to plaintiffs’ hyperbolic arguments that abortion via medication leads to overwhelmed emergency rooms and blood supply shortages.

One study that appears to have convinced Kacsmaryk that mifepristone causes high amounts of severe adverse events was authored by a half-dozen longtime anti-abortion activists. The study, “A Longitudinal Cohort Study of Emergency Room Utilization Following Mifepristone Chemical and Surgical Abortions, 1999–2015,” was funded by the Charlotte Lozier Institute, the research arm of the influential Susan B. Anthony Pro-Life America, which works to elect federal and state anti-abortion lawmakers. The study was published in November 2021, exactly one year before plaintiffs filed in the Amarillo court. Charlotte Lozier filed a “friend of the court brief,” citing its research.

All but one of the eight authors are affiliated with the Charlotte Lozier Institute, including principal author James Studnicki, who is the institute’s vice president and director of data analytics. Currently everyone on the editorial board of “Health Services Research and Managerial Epidemiology” works for a university except for Studnicki, who until 2016 was a university professor focused on health policy and management for most of his career. Now he works for an anti-abortion think tank and in recent years has served as a paid expert witness that defends anti-abortion laws in federal court.

Dr. Donna Harrison, another co-author, was until recently the CEO of the American Association of Pro-Life Obstetricians and Gynecologists, one of the plaintiff medical groups suing the FDA over mifepristone. Another author is longtime anti-abortion activist David Reardon, who has a record of criticized research that tries to directly link abortion to depression and suicide.

The Studnicki et al. 2021 longitudinal study looked at people who had a surgical or medication abortion between 1999 and 2015. The researchers used data from 17 states that allow state Medicaid funding of abortion, and identified more than 400,000 abortion patients. Of those they found that more than one-quarter visited an emergency department within 30 days of having the abortion. Over the 16 years, they found that there were progressively more emergency room visits following a medication abortion than a surgical procedure. The authors claim that between 2002 and 2015, there was a 500% increase in emergency room visits from people who had had a medication abortion within 30 days.

Following the study’s release in 2021, Studnicki penned an opinion piece in Newsweek, calling the study’s findings “clear and alarming.” “Post-abortion emergency room visits are increasing following any type of abortion, but visits following a chemical abortion are growing faster,” Studnicki wrote.

But Adkins and other researchers told States Newsroom that some of these findings are missing important context, and that the study’s major flaws are related to methodology and in how they communicate their findings:

• The study captures emergency room visits broadly and does not distinguish between routine medical care and adverse events. The codes they use lump in issues like ectopic and molar pregnancies, which are medical emergencies not necessarily related to having taken abortion drugs. University of California San Francisco reproductive health researcher Ushma Upadhyay led a similar study in 2015 and found that less than 1% of medication abortion patients have major complications. Upadhyay told States Newsroom that just looking broadly at emergency department visits among people on Medicaid does not give the most accurate picture of the abortion drug protocol’s safety, as many of the visits are observation-only. A medication abortion is an induced miscarriage and necessarily involves bleeding. First-time medication abortion patients often go to the ER because they don’t know what is normal. And that’s especially true if they don’t have a regular medical provider, like many people on Medicaid, Upadhyay said.

• Adkins said the study’s findings appear in line with increased use of the FDA’s medication abortion protocol between its approval in 2000 and 2015. The amount of patients on Medicaid also grew toward the end of that time frame, reflecting Medicaid expansion following the Affordable Care Act in 2014. “What they find is exactly what you would expect to find when you expand coverage and expand care,” Adkins told States Newsroom. “And so, you know, that really made me wonder, what degree of scrutiny was provided during the peer review process?”

• The researchers do not offer an estimated total of emergency department visits among Medicaid patients to contextualize the estimated abortion-related visits. “Nowhere in the article do the authors provide estimates of the total number of ER visits during 2015 among Medicaid patients in these 17 states,” Johns Hopkins Bloomberg School of Public Health professor Suzanne Bell told State Newsroom in an email. “I imagine the 790 ER visits they identified as associated with a recent medication abortion is a very small percentage of the total number of ER visits and in no way would risk overwhelming the medical system as Judge Kascmaryk suggests.”

Studnicki did not respond to a request for comment. He continues to defend the study, and recently told the Washington Post that abortion rights groups are discounting ER visits as serious matters and underplaying potential complications from abortions involving mifepristone. He blames academic and media bias for the criticism the Charlotte Lozier Institute’s work has received.

“We have a very biased media,” Studnicki said on the Canadian podcast Pro-Life Guys earlier this year. “Our media outlets are largely pro-abortion in their ideological posture. And we fight against that every day. But we’re just going to keep pounding on the rock basically.”

‘Dishonest science’

Adkins argues there is bias within Charlotte Lozier’s science and within the conservative courts hearing the Alliance for Hippocratic Medicine v. FDA lawsuit. Federal Judge Kacsmaryk used this paper (and a follow-up 2022 analysis published in the same journal, by the same researchers) to argue that mifepristone leads to high complication rates. This summer the Charlotte Lozier team produced yet another study using Medicaid data, this time published in the International Journal of Women’s Health, which concludes that a first pregnancy abortion compared with birth is associated with “significantly higher subsequent mental health services utilization.”

“The fact that, you know, the judge really gives a lot of credit to a very niche, a very small pocket of doctors that don’t fully represent consensus, that’s one of my big problems,” Adkins said.

In his April 7 ruling, Kacsmaryk also echoed plaintiffs’ arguments that the FDA has been undercounting adverse events related to mifepristone and cited the other big finding in the Studnicki paper, which is that some patients who have taken abortion drugs but come to the emergency room for observation or treatment are miscoded as miscarriage patients.

“Consequently, the treating physician may not know the adverse event is due to mifepristone,” Kacsmaryk wrote. “Studies support this conclusion by finding over sixty percent of women and girls’ emergency room visits after chemical abortions are miscoded as ‘miscarriages’ rather than adverse effects to mifepristone. Simply put, FDA’s data are incomplete and potentially misleading, as are the statistics touted by mifepristone advocates.”

The 5th Circuit Court of Appeals in its ultimately blocked April ruling to temporarily reinstate old restrictions on medication abortion, referenced many of the same studies as Kascmaryk to justify the plaintiff doctors’ position, writing: “the risk of severe bleeding with chemical abortion is five times higher than from surgical abortion.”

Adkins said he believes that how the Charlotte Lozier team presented their data visually lends for judges to be misled about the significance of the paper’s findings. For example, Figure 3 showed about 800 emergency room visits in 2015 within 30 days of a medication abortion, out of more than 5,000 abortion-related visits, but the authors inexplicably used two different y axes to plot these numbers, making it possible to conclude that medication-abortion-related visits were numbered in the thousands.

“Scientific communication is something I deeply value, and I think this is an example of one way that misuse of science through improper communication can influence how public policy manifests itself, through a result of dishonest science,” Adkins said. “It really makes the likelihood of someone misreading that and then, for instance, Kacsmaryk coming back and saying the alleged adverse events from chemical abortion drugs can overwhelm the medical system. Well, maybe he didn’t scrutinize these figures if he read this paper. That’s a highly plausible outcome here because he’s basically thinking, ‘Oh, my gosh, look at these numbers. They’re skyrocketing.’ When they’re really kind of not.”

For now, Adkins impatiently awaits the results of Sage’s probe into this study. A few months ago, he wrote a letter to Georgia U.S. Rep. Earl L. “Buddy” Carter, one of the few licensed pharmacists in Congress, who joined other Republicans in supporting the plaintiffs’ lawsuit against the FDA. Carter is outspokenly anti-abortion, but Adkins tried to appeal to the congressman’s inner pharmacist.

“All practicing US pharmacists publicly recite an oath which affirms pharmacists’ embracement and advocacy for ‘changes that improve patient care,’” Adkins wrote in the letter, which he says the congressman never answered. “The case rendered in Amarillo only deteriorates patient care and sows unnecessary distrust of scientific and medical institutions in the United States.”

Opill, a progestin-only contraceptive pill, will be available without a prescription in the first quarter of 2024, according to its manufacturer. (Photo courtesy of Perrigo Company.)

The U.S. Food and Drug Administration announced Thursday it has approved the country’s first daily birth control pill that can be used without a prescription, a move that reproductive health advocates celebrated after more than 20 years of advocating for an over-the-counter option.

The contraceptive, called Opill, is a progestin-only oral pill that could soon become available in drug stores, convenience stores and grocery stores, as well as online, without requiring a visit to a health care provider.

Frédérique Welgryn, an executive at Opill’s manufacturer, Perrigo, said during a press conference Thursday that the company will work with its regional partners to build distribution plans nationwide, and said Perrigo is committed to making Opill affordable, but the retail price is not yet available. The company anticipates the pill will be on sale in major retail stores across the country and online by early 2024 and also plans to work to list Opill as an option with private insurance and Medicaid.

Other reproductive-focused organizations, including the American College of Obstetricians and Gynecologists, celebrated the announcement, as did the American Medical Association. But Dr. Jesse M. Ehrenfeld, president of the American Medical Association, said in a statement that it should be the first step of approval for a variety of oral contraceptive options for over-the-counter use.

“It is important that patients have options when choosing which type of birth control works best for them. We hope this is just the first of several to be approved,” Ehrenfeld said. “We must continue to remove barriers to affordable care for those in underserved, high-poverty and rural communities. We know barriers to oral contraceptives can lead to inconsistent or discontinued use.”

The FDA said Opill should not be used by those who currently have or have ever had breast cancer, and those who have had any other form of cancer should ask a doctor before use. It should not be used with any other hormonal birth control product, including other oral pills, patches or injections, vaginal rings or intrauterine devices. The most common side effects of Opill are irregular bleeding, headaches, dizziness, nausea, increased appetite, abdominal pain, cramps or bloating, according to the approval announcement.

Unintended pregnancy associated with poor outcomes

Welgryn said it took more than eight years to conduct the research for approval and complete the lengthy application process with the FDA.

“This has been a journey fueled by the passion of our team, researchers, health providers, advocates and women themselves, along with the unwavering belief that the women and people of this country should have greater access and fewer barriers when it comes to their reproductive health,” Welgryn said. “Today’s decision follows nearly 50 years of data and research showing that progestin-only pills such as Opill are safe and effective. It follows the joint FDA advisory committee’s unanimous votes recommending Opill … because the benefits of having access to Opill over the counter overwhelmingly outweigh the potential risks.”

Welgryn said an estimated 40 million women in America need contraception, and approximately 15 million of those are using a less effective method or no method at all, while 10 million are already using an oral contraceptive pill with a prescription.

According to research from the Guttmacher Institute, nearly half of the 6.1 million pregnancies in the U.S. in 2011 were unintended, and 18% of those pregnancies were considered unwanted. Further research has determined unintended pregnancy is significantly associated with higher incidences of depression during pregnancy and postpartum, along with higher rates of preterm birth and low infant birth weights.

Dr. Stephanie Sober, global lead of medical affairs for Perrigo, said during the press conference that the country’s current reproductive health landscape makes the pill’s approval all the more important. Fourteen states have near-total bans on abortion, and Iowa could soon join Georgia with a gestational ban at six weeks, before many people realize they are pregnant. Indiana’s abortion ban, which applies to all stages of pregnancy with exceptions for rape, incest, fetal anomalies and the life of the pregnant person, is expected to take effect Aug. 1.

“Opill over-the-counter paves the way for improved access by removing barriers for the people who struggle to access contraception most, particularly people working to make ends meet, people of color, young people, and those who live in rural areas,” Sober said.

“For some, the ability to secure insurance, find a provider, make an appointment, and then obtain child care and access reliable transportation, all can create an insurmountable obstacle to obtaining contraception. Being able to pick it up at a pharmacy knocks down those obstacles, and it’s truly game changing.”

Abortion providers and support groups are reporting delays in seeing patients and higher demand for help. (Gloria Rebecca Gomez/States Newsroom)

Editors’ note: This report is part of a special States Newsroom series on abortion access one year after the U.S. Supreme Court decision struck down the federal right to abortion.

In April, a Reddit user in Alabama posted a breathless message to the abortion subreddit the morning after learning she was pregnant. She guessed she was early, two or three weeks maybe.

“there’s a clinic in GA about 3 hours away. They said they will do it as long as no heartbeat is found on the ultrasound. If they find a heartbeat what do I do then??”

Alabama, where abortion is a crime, is surrounded by states with abortion bans. But nearby Georgia currently allows a tiny window, which shuts once the embryo’s cardiac activity registers on an ultrasound. This happens generally by six weeks’ gestation, and the user was running out of time. In reality, she had to have been farther along, as pregnancy is counted from the first day of one’s last period. And now she was sick to her stomach and passing gelatinous blood clots.

This very active subreddit is moderated around the clock by the Online Abortion Resource Squad, a group of mostly volunteers that debunk abortion misinformation and help users navigate a labyrinth of abortion bans and restrictions. The end of federal abortion rights changed access nationwide. Even ending a wanted pregnancy is now more difficult based on your income, how far along you are, and your state’s ever-changing abortion laws.

In a plot twist for the user in Alabama, it turned out she had likely miscarried. “UPDATE!!!!! My uterus is empty,” she wrote. “Basically alabama politicians made me drive across state lines and pay $250 because I was too scared to go to my regular doctor .”

But then there’s the Reddit user who described weeping in a Planned Parenthood clinic because her pregnancy measured just a few days beyond its 19.6-week cutoff. Staff helped her make an appointment at another clinic. “I really want this to be over with,” she wrote. “Now to just figure out transportation for next Saturday. Easy enough. *fingers crossed*”

It’s been a year since the U.S. Supreme Court ruled in Dobbs v. Jackson Women’s Health Organization that states could criminalize all or most abortions, and now 15 states?fully or mostly ban the procedure, while others have begun enacting gestational limits and other restrictions. That’s left the?hundreds of thousands?of U.S. women and minors who annually seek abortions forced to travel if they can, overwhelming the abortion clinics in states where it’s legal. This has led to astronomical patient costs and major care delays.

As a result, abortions in the second and third trimester of pregnancy appear to be on the rise, abortion providers, public health researchers, and patient advocates told States Newsroom. Many patients, they say, are experiencing the higher risks of complication, anxiety, and trauma that sometimes come with abortion later in pregnancy. And advocates say this situation is likely to get worse, with an abortion-provider shortage and states continuing to throw up new legislative barriers.

“Right now, in any state, there’s just no scenario where people aren’t getting delayed because of wait times for appointments,” said Ariella Messing, who founded OARS.

Messing told States Newsroom she spends about 80 hours a week managing the abortion subreddit and helping connect people to abortion providers and financial and practical support. OARS has been monitoring the subreddit since 2019, but activity spiked after Texas outlawed most abortions in 2021. Since Dobbs, it’s exploded. Messing said OARS decided to keep r/abortion open during the Reddit blackout protest.

Some of the abortion cases are so complicated and medically necessary that Messing, who previously worked as a case manager for the Baltimore Abortion Fund, personally gets involved, sometimes spending a whole day trying to help someone desperate to terminate a pregnancy under a ticking clock.

The woman for whom it took eight weeks to terminate a pregnancy that had become dangerous? kept Messing up at night, until that person terminated, finally, at 27 weeks.

“This wasn’t how they should be getting care – by a random stranger on Reddit,” Messing said.

Overwhelmed abortion providers and assistance groups

While the true extent to which Dobbs has prevented people from getting abortions remains to be seen,?emerging research?suggests that women and minors are increasingly unable to end a pregnancy, especially people of color and people living in poverty.

The Society of Family Planning has been measuring the number of abortions reported by abortion clinics and hospitals. In the nine months after the Dobbs decision, the rate of medication abortion jumped, but overall, providers reported more than 25,000 fewer abortions nationwide.

The Society’s latest?#WeCount report?did not capture how many people self-managed outside the formal health care system, or how far along patients were. But University of California San Francisco professor Ushma Upadhyay, who co-chairs the #WeCount project, said it would be logical for gestational ages to be rising, given the increased obstacles in accessing care quickly.

Additionally, brand-new research from the university’s Advancing New Standards in Reproductive Health program finds a nationwide increase in providers?offering abortion later in gestation?than they were previously due to rising demand, as well as more clinics?offering telehealth medication abortion. But the demand is still overshadowing the need, especially later in pregnancy.

“The states where there are bans now, there were very few clinics in those states, because there were so many restrictions,” Upadhyay said. “But those clinics that were open did offer abortion care till later, usually midway of the second trimester. … So, right now there’s huge swaths of the country where later abortion is simply unavailable.”

Part of the problem is that so few clinics in the U.S., especially post Dobbs, go beyond 20 weeks’ gestation. The vast majority are independent clinics not part of the Planned Parenthood network, which has?more resources and political clout?than the independents.

There is a tiny cluster of clinics that provide abortions in the third trimester, on a case-by-case basis. One is in Boulder, Colorado, and the others are concentrated in and around Washington D.C., which has become a major national abortion destination.

Abortion providers say they are scheduling visits weeks out.

“Anecdotally, we are seeing in some places, people are being pushed, or people are having to delay their care, and it has resulted in people having procedures one to two weeks later than they then we saw the previous year,” said Melissa Fowler, chief program officer of the National Abortion Federation, which provides resources for abortion clinics and funds some patient costs. “And of course, we’re also seeing a delay with people who need later care as well.”

Dr. Sarah Traxler, the chief medical officer for Planned Parenthood North Central States,?testified?before the Minnesota lawmakers back in March about a 40% rise in second-trimester cases since Dobbs. The region encompasses Iowa, Minnesota, Nebraska, North Dakota, and South Dakota, with the bulk of patients going to Minnesota.

“Since June, I have cared for patients from everywhere,” Traxler testified. “I’ve seen patients who’ve flown from Louisiana, only to find that their complex pregnancy condition kept them from being seen in a freestanding clinic like mine, forcing them to continue a dangerous pregnancy because hospital-based care was not available to them.”

Astronomical costs

A first-trimester abortion can range from $500-$1,000 to tens of thousands in the second trimester, and up to $25,000 in the third, said Jade Hurley, communications manager for the DC Abortion Fund, one of more than 100 mutual aid organizations to crop up during the?past two decades?to help cover these steep costs, which are compounded by travel, transportation, and child care costs.

Financial and logistical barriers to abortion are not new, but Dobbs has exacerbated them. Shortly after the Supreme Court originally enshrined federal abortion rights in 1973, anti-abortion lawmakers began passing public-insurance bans on abortion, as a way to at least prevent part of the population from accessing this medical procedure.

“I would certainly like to prevent, if I could legally, anybody having an abortion – a rich woman, a middle class woman, or a poor woman,” said the late U.S. Rep. Henry Hyde (R-Ill.)?during a floor debate in 1976?to defend a ban on the use of Medicaid insurance for abortion. “Unfortunately, the only vehicle available is the [Medicaid appropriations] bill.”

Just over a dozen states allow Medicaid to cover abortion using state-only funding. And as costs rise, abortion and practical-support funds around the country report receiving more higher dollar requests. These days funds typically have to work together, pooling grants from multiple funds just to serve one patient. Representatives from multiple abortion funds told States Newsroom they are also receiving more donations than at any other time, but they say the need is still overwhelming demand.

Hurley told States Newsroom in an email that since Dobbs, the fund has pledged nearly $2.3 million to more than 3,000 callers seeking abortions in the D.C. area. Their average pledge has jumped from $260 to $710, a 173% increase. Last month the highest gap they filled was $4,500, Hurley said.

“We’re seeing a huge amount of people coming from all over the country,” Hurley said during a?recent webinar?hosted by the abortion-rights activist group Reproaction. “We had a person come from California very recently, which is honestly, you know, it’s shocking, because that’s so far away. … We’re dealing with funding gaps that we didn’t even know existed. And I think overall we don’t even know the true need that’s out there, from D.C. to across the country.”

Medication abortions are getting later, too

Two months ago, a 40-year-old woman in Arizona delivered a lifeless 13-week-old fetus into a plastic food storage container. The woman, who asked not to be named out of fear of criminal prosecution, told States Newsroom that the fetus had obvious deformities. She was a much wanted rainbow baby, the term given to a baby born after a pregnancy loss.

Until recently this mother of seven was “1,000% against abortion.” One stillbirth separates two sets of three kids. Her eighth pregnancy, last year, resulted in a twinless twin. But this pregnancy was even grimmer: What started out as triplets became one surviving embryo. At 13 weeks, the remaining living fetus was diagnosed with trisomy 18, a fatal genetic condition.

She voraciously read the literature on trisomy 18 and learned that the vast majority of babies born with this disease die before their first birthday, within months, days, or hours. For her the decision to terminate was simple. “Imagine bringing this baby home and all my kids love her and get attached, and then she died at 3 months or something?” she said.

But getting timely, legal care was a different story.

Her state currently allows abortion up to 15 weeks’ gestation, while an 1864 total abortion ban works its way through the courts. However, Arizona criminalizes something only?a handful states?do: Terminating a pregnancy?because of fetal genetic abnormalities. Her doctor said she couldn’t terminate the pregnancy but suggested she go to an abortion clinic and not disclose she’d had genetic testing done. But the nearest clinics were booked out until May and June. A clinic in Nevada could see her, but she didn’t have the money or ability to travel.

Because she’s had so many kids and two stillbirths, the Arizona woman decided to go outside the medical system. She had her stepdad get her misoprostol over the border in Mexico. This medication is typically used to treat ulcers but is also an abortifacient, and it’s available over the counter for around $30 in Mexico. The typical two-drug regimen approved by the U.S. Food and Drug Administration two decades ago comprises the hormone-blocker mifepristone followed by misoprostol, which causes the uterus to contract and expel the embryonic or fetal remains.

Medication abortion – whether obtained at a clinic or via legal telemedicine, or by?ordering pills from abroad?– has helped fill an access gap since Dobbs. Most often women are terminating with the same two-drug regimen approved by the FDA. However, that protocol is approved only for?up to 10 weeks’ gestation, while the World Health Organization?okays the protocol for 12 weeks.

But many women are taking the medication as soon as they get them, even if that means well into the second trimester, because of travel and shipping delays, which fundamentally changes the experience. Rather than experiencing what may describe as moderate to heavy bleeding and moderate to excruciating cramps, second-trimester medication abortions involve delivering a more developed fetus, with its umbilical cord and placenta.

It took the Arizona woman about seven hours to deliver the fetus and placenta using the misoprostol-only regime, followed by weeks of bleeding. This method is considered safe and effective, but is associated with higher rates of incomplete abortion, and pain. Days later, the woman’s doctor found retained placenta inside her. She says she couldn’t imagine having done this without her birthing experience or guidance from her regular medical providers.

“Being like my basically ninth delivery, I knew what to do,” she said, “I would never just give the pills to somebody that has never had a baby. … I understood delivering the baby and then delivering the placenta, and my water breaking. But if you’re like a first-time mom, and you had to go through the pills at the gestation I did, they would freak out.”

And that’s exactly what’s happening, says family physician Linda Prine, who co-founded the Miscarriage and Abortion Hotline to help guide pregnant people seeking information on where to get abortion drugs and how to self-manage their abortions safely. She said at least once a day now the hotline is hearing from women who took the medication in the second trimester and were unprepared to deliver an intact fetus.

“Prior to the fall of Roe, we probably only had two calls per year of anyone using pills past 13 weeks. Now we have several every week and sometimes daily,” Prine told States Newsroom a few months ago, for a?previous story. “The issues we see are the psychological trauma if they are not prepared for the experience, and the potential legal risks.”

Abortion access advocates note that all of this will be compounded if the U.S. Supreme Court ultimately orders a recall or severely restricts the abortion drug mifepristone in a?high stakes lawsuit?currently making its way to the high court.

‘End of the line’

For the many years that Roe v. Wade protected abortion rights, the vast majority of abortions happened in the earliest stages of embryonic and fetal development. In 2020, the?Centers for Disease Control and Prevention reported?that 93% of abortions took place before 13 weeks, less than 6% performed between 14 and 20 weeks, and less than 1% after 21 weeks’ gestation.

That 1% represents the most expensive, complex, and controversial abortion cases. They are multi-day procedures that involve on-call care and are performed by a vanishingly small number of providers. A physician well known for this work, Dr. George Tiller, was villainized by Fox News years before an anti-abortion activist assassinated him in 2009.

At 84, Dr. Warren Hern, a former colleague of Tiller’s, is the oldest doctor doing this work, in Colorado. Another Tiller colleague, Dr. LeRoy Carhart, who provided later abortions in Maryland,?died this past April?at 81.

Shortly after Dobbs, Hern said his Boulder Abortion Clinic was seeing an uptick of 50% more patients but has been unable to sustain the demand. Hern told States Newsroom that his small clinic sees a weekly average of six to 12 cases from around the country, which is still more than before Dobbs. Whereas before his clinic would coordinate aftercare with patients’ regular doctors, now Hern said he rarely communicates with OB-GYNs in banned states and sends patients with generic letters hoping they will receive necessary aftercare.

“This is a national catastrophe,” Hern said. “The details are in our face every single day, every week. It has unfolding complications and consequences across the country for women, many of whom are not wanting an abortion, but they can’t get medical care for the pregnancy because the doctors are afraid.”

Slowly a younger crop of third-trimester abortion providers is emerging. Morgan Nuzzo, an advanced practice clinician nurse-midwife, started an all-trimester abortion clinic Partners in Abortion Care in College Park, Maryland, seven months ago with her partner Dr. Diane Horvath, an OB-GYN who specializes in complex family planning and has provided abortion for almost two decades.

Nuzzo says colleagues refer to clinics like hers as the “end of the line,” one of the last?places?in the country they can go for a safe and legal abortion. They see people on the spectrum of disability, from the very rich to the very poor. The oldest patient Nuzzo has seen is 53; the youngest is 10. Children over-represent Partners in Abortion Care’s patient population, Nuzzo said. As research shows, many people seek abortions into the later stages of pregnancy because they found out new information about the pregnancy (such as a fatal fetal anomaly or a new health risk) or their life circumstances, or because they didn’t know they were pregnant.

What her patients and their parents do share in common these days is confusion and anger, Nuzzo said.

“Even people who are dismayed by grief, by this horrible fetal diagnosis they might have received later in pregnancy, are still angry and frustrated at the chaos that they have to navigate in their times of greatest need,” Nuzzo told States Newsroom. “It is confusing, it is constantly changing, and it is chaotic. And sometimes you start to believe that that’s on purpose.”

Partners in Abortion Care treats an average of 10 to 12 patients weekly, Nuzzo said, prioritizing abortions after 20 weeks, with growing wait lists. They have to turn away at least one patient a week, she said, often because the patient is too far along, or has complicating health factors. Then it’s time to talk to patients about other options: carrying to term, or adoption. Partners requires patients to secure an ultrasound in advance to confirm how far along they are, but she said patients in states with bans are often too scared or unable to obtain an ultrasound outside of religious anti-abortion pregnancy centers, which are typically unregulated and offer non-diagnostic ultrasounds.

“The number of fetal genital pictures that people are given with no accurate dating associated with it has been astronomical since we opened,” Nuzzo said. “So, ‘I’m a girl,’ ‘I’m a boy,’ and a picture of a penis or a vagina. And a lot of times, that’s the only picture they’ll give to a patient. And I’m like, What am I supposed to do with this? This gives me no information.”

Consequential compromises on later abortion

In 2015, North Carolina Rep. Tricia Cotham made national headlines when she told her colleagues on the House floor about the painful and heartbreaking “induced miscarriage” she once had for a wanted but doomed and dangerous pregnancy. “This decision was up to me, my husband, my doctor, and my God,”?she testified. “It was not up to any of you in this chamber.”

Then a Democrat, Cotham was testifying against a 72-hour abortion waiting period, which opponents argued would exacerbate abortion delays and which ultimately became law. Cotham?told Time magazineshe’d wanted to quell later-abortion stigma.

But in April, Cotham, who campaigned on abortion rights,?switched parties. Soon after, she helped state Republicans?override the governor’s veto of a new 12-week abortion ban, which has limited exceptions for fetal anomalies. She also switched her own abortion narrative, now calling it a spontaneous miscarriage, contradicting her?own words.

More GOP-led states (and presidential candidates) are leaning away from radioactive total abortion bans, and into these so-called gestational compromises. Like North Carolina, Nebraska recently prohibited abortions after 12 weeks. Florida’s new 6-week ban is on hold while courts litigate the state’s 15-week abortion ban.

A few Democratic-led states, meanwhile, are working on efforts to lift or relax their third-trimester gestational limits,?like in Maine?and?Minnesota. But many others?still ban abortion by or before 24 weeks’ gestation, with some exceptions. And many of the state abortion-rights amendment initiatives underway also maintain this Roe-era standard.

Like Cotham, Erika Christensen is a white woman with enough privilege to have accessed a later abortion because of fetal anomalies. Because even in 2016, the abortion-access landscape and policies already made it incredibly difficult to access and,?for her, emotionally harrowing. But Christensen’s pregnancy experience took her in a different professional direction than Cotham.

“We were radicalized by the plane,” said Christensen, who was turned away in New York City and flew to Colorado for a multi-day procedure that cost thousands of dollars out of pocket. She and her husband soon after started Patient Forward, a later abortion advocacy group that successfully lobbied New York to relax its abortion law. Christensen said Roe-era gestational limits are too restrictive for this current landscape, and she criticizes Democratic-led initiatives that attempt to compromise on later abortion.

“There used to be a path where you could care for your patients up to a point, and then you sent them out of state,” Christensen said. “And you wouldn’t really have to put yourself out on the limb because there was somebody else who would take care of your patient. That path is gone. It’s dead, and it’s never coming back, not while we have what we have. So when we compromise on this population, we are really condemning them to forced pregnancy and birth.”

The U.S. Food and Drug Administration approved mifepristone in 2000 as part of a two-drug regimen that’s currently used up to 10 weeks in a pregnancy. (Photo illustration by Anna Moneymaker/Getty Images)

America’s major medical institutions and drug policy scholars have roundly denounced as “pseudoscience” many of the claims brought by anti-abortion groups in a high-profile federal lawsuit asking the Food and Drug Administration to revoke its 23-year-old approval of mifepristone, one half of a two-drug regimen that has become the most common form of pregnancy termination post-Roe v. Wade.

But the three-judge panel of the 5th U.S. Circuit Court of Appeals that heard oral arguments Wednesday appeared to be persuaded not by the medical consensus in this case, but by some of the evidence brought forward by plaintiffs that consists largely of anecdotes, speculation, and cherry-picked studies brought by a handful of anti-abortion medical groups and doctors.??

Medical and public health societies led by the American Medical Association submitted a “friend of the court” brief before the 5th U.S. Circuit Court of Appeals, stating that the lower court’s ruling “relies on pseudoscience and on speculation, and adopts wholesale and without appropriate judicial inquiry the assertions of a small group of declarants who are ideologically opposed to abortion care and at odds with the overwhelming majority of the medical community and the FDA.”

While asking a question of U.S. Deputy Assistant Attorney General Sarah Harrington, Judge Jennifer Walker Elrod referred to mifepristone cutting off “nutrition” to the fetus, which is a false claim cited in the initial ruling written by Texas federal Judge Matthew Kacsmaryk in April. Kacsmaryk referred to mifepristone as a “synthetic steroid that blocks the hormone progesterone, halts nutrition, and ultimately starves the unborn human until death.”

According to Johns Hopkins Medicine, the progesterone hormone is produced in early pregnancy to help thicken the lining of the uterus to support implantation of a fertilized egg. Without that hormone stimulation, which mifepristone blocks, the lining breaks down and the pregnancy cannot continue. It is then followed by doses of misoprostol to induce contractions and expel the pregnancy.??

Former President George W. Bush appointee Elrod – like her fellow Donald Trump appointee Judges James C. Ho and Cory T. Wilson – shares ideological views on abortion with the plaintiffs’ anti-abortion coalition, which is represented by the Alliance Defending Freedom. So does Kacsmaryk, whose since-blocked decision to suspend FDA approval of mifepristone cites anecdotal evidence from plaintiffs.?

Mifepristone remains legal and on the market as the case winds its way through the legal system, and data from the FDA since the drug’s initial approval in 2000 shows it is overwhelmingly safe to use. Out of an estimated 5.6 million people in 23 years, 28 deaths have been associated with the FDA’s abortion medication regimen, which is a markedly lower rate than many common FDA-approved drugs, like Tylenol and Viagra. And as the FDA has noted, that number includes fatal cases “regardless of causal attribution to mifepristone,” such as people who died from homicide, suicide, and pulmonary emphysema.?

If the plaintiffs prevail, health care providers, medical institutions and pharmaceutical industry organizations have warned of its potentially catastrophic consequences. In addition to radically reducing access to abortion nationwide, removing mifepristone from the market would reduce access for miscarriage treatment, public health experts say, and have far-reaching consequences beyond abortion.

“The implications of this case are extraordinary, and they include the potential termination of access to mifepristone, a precedent for court interference in the FDA’s rigorous and science-based testing and approval process not just for mifepristone, but for any drug,” said Joanne Rosen, a senior lecturer in the departments of Health Policy and Management and Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health, during a media briefing hosted by the university Thursday. “This would be the first time in history that a court has abrogated the FDA’s approval of a drug over the objections of the FDA.”

Sympathetic, cynical and combative exchanges

The appeals court judges seemed sympathetic to the narrative brought by the plaintiffs that mifepristone is a dangerous drug, as they were in their previous opinion blocked by the Supreme Court, which would have restricted the use of mifepristone. A big question in this case has been whether the coalition of anti-abortion medical groups and four doctors, including Indiana state Sen. Dr. Tyler Johnson, have standing to sue. Plaintiffs have argued their doctors would suffer direct harm if mifepristone remains on the market.

Like medical and legal scholars following this case, Rosen said plaintiffs’ arguments for standing are weak, and if accepted would open the door to any group that wants to challenge the FDA’s approval of a drug for any reason.??

Plaintiff groups argue that their member doctors could be overwhelmed with a potential future influx of emergency room visits from mifepristone patients, or forced to treat an abortion patient against their will. These claims are based not on robust data but largely on the testimony of handful of plaintiff doctors, three of whom give mostly non-specific anecdotes about treatment they performed for women who allegedly had taken some form of medication abortion, but it’s not clear when the procedures took place and whether it was the FDA’s regimen.?

Harrington argued on behalf of the federal government that plaintiffs had not made claims of being forced to treat abortion patients against their will.?

“They claim injury from speculative downstream effects of choices made by a chain of other people who are not parties to this lawsuit,” Harrington said.

But Wilson pushed back.

“The declarants here said they’ve seen these patients, they’ve cared for them,” he said. “I take that to mean that they treated them and that they expect to see more in the future. How’s that not enough for standing if the doctor also has a conscience objection to doing so?”

The judges made a series of sometimes snarky and combative comments and questions aimed at the attorneys for the U.S. Department of Justice, representing the FDA, and the mifepristone manufacturer Danco Laboratories, and called into question trust in the FDA’s expertise and judgment.?

Echoing plaintiffs’ criticism of the FDA approving mifepristone as part of a particular category of drugs for serious illnesses, Ho said pregnancy is not a serious illness, quipping, “When we celebrated Mother’s Day, were we celebrating illness?”

A question of evidence

And they misstated non-scientific assertions by plaintiffs, such as claiming that non-fatal adverse reporting is no longer required by the FDA. Mifepristone manufacturers (but no longer medical providers) are still required to report non-fatal adverse reactions.

Much of the anti-abortion evidence submitted in this case was authored by researchers who work for the anti-abortion Charlotte Lozier Institute, whose role is to defend abortion bans and restrictions with research. Regarding mifepristone, Charlotte Lozier’s researchers have published articles that mostly speculate large amounts of under-reporting when it comes to abortion complications, and argue the true risk of mifepristone is unknown.?

Another anti-abortion organization, the Family Research Council, also submitted a 125-page amicus brief with false claims that the drug approval was expedited by former President Bill Clinton. It also cites research from the Charlotte Lozier Institute to back claims that the drug is unsafe.?

Judges echoed this sentiment and speculated on the safety of telemedicine abortion and questioned the FDA’s process of loosening restrictions over time. Elrod asked Harrington if a medical provider could examine someone via email rather than video, and if people could use telemedicine as an “intermediary” to send the medication to a state with an abortion ban. Elrod referenced amicus briefs that alleged individuals were engaging in those tactics to skirt state laws.?

Harrington said the statements referenced by Elrod in the briefs are unsupported and irrelevant to the central issue.

“None of that is dictated by the FDA, and none of that is relevant to whether the FDA’s determination that this drug is safe and effective with these conditions in place,” Harrington said.

Elrod pushed back, asking if it was a relevant factor to consider in issuing an injunction that would limit access to the drug.?

“If it’s violating other law, which we have to determine, perhaps, then we have to decide whether or not it’s appropriate to enter an injunction or not and that’s one of the factors we would consider,” Elrod said.

Public health experts say the appeals court’s attitudes toward the science in this case are deeply concerning.?

“Judges and lawmakers should not be substituting their own opinion for the experience, expertise, and authority of the U.S. Food and Drug Administration. Nor should they ignore the substantial weight of scientific evidence from hundreds of studies and millions of patients confirming the safety and effectiveness of mifepristone, which has been used for decades in both medication abortion and miscarriage management,” said AMA President Dr. Jack Resneck Jr. in a recent statement.?

Even if the appeals court rules to restrict or revoke approval of mifepristone, the federal government will most likely appeal the case to the U.S. Supreme Court. Regardless, the 5th Circuit Court judges’ reasoning could prove influential to the Supreme Court’s eventual decision.?

The contraceptive drug norgestrel sold as Opill, which was approved by the FDA decades ago for prescription-only use. If the FDA approves, it would be the first time a birth control pill would be available without a prescription. (Screenshot FDA)

Dyvia Huitron started having sex when she was 16. Worried about getting pregnant, she talked to her parents about getting on hormonal birth control. Instead, they grounded her.

The now-19-year-old had expected pushback – she was living in a religious community in conservative McAllen, Texas. But she underestimated how many years it would eventually take to get on a reliable form of birth control. She watched a number of friends get pregnant during that time.

“Accessing birth control should not be this complicated,” Huitron told the Food and Drug Administration’s advisory panel tasked with determining whether a low-dose contraceptive pill is safe and effective enough to be recommended for over-the-counter use. “At 16, 17, 18, and now 19 my needs have been unmet, yet have remained the same for years.”

Now a college student in Alabama, Huitron said she still faces barriers to accessing birth control and was among dozens of reproductive health care providers and advocates who publicly testified during the FDA’s two-day hearing on the contraceptive drug norgestrel sold as Opill, which was approved by the FDA decades ago for prescription-only use. Overwhelmingly, public commenters urged the agency to address a lack of access to effective birth control, faced by millions of women and teenagers of reproductive age at a time when options to terminate unintended or risky pregnancies have become extremely diminished.

The FDA advisory committee not only agreed with advocates that improving access to contraception for marginalized groups is a vital public health need, but were convinced by the science presented by drugmaker HRA Pharma that Opill is overwhelmingly safe and effective to take over the counter.

The 17 advisers – whose collective experience includes obstetrics and gynecology, complex family planning, breast cancer, and consumer health behavior – unanimously voted for the FDA to immediately approve Opill over the counter. This would be the first time a birth control pill would be available without a prescription, something many experts on the panel and public testifiers say presents a huge barrier, especially to adolescents and people with less health care access, like people with low literacy.

“Adolescents really urgently need this,” said adolescent medicine specialist Dr. Leslie Walker-Harding, one of the advisers, who said teens are intelligent and savvy enough to follow the drug’s label. And she said she was very comfortable with the drug’s high safety record. “The safety profile is so good that we would need to take every other medicine off the market, like Benadryl, Ibuprofen, Tylenol, which causes deaths, and people can get any amount of that without any oversight.”

Referred to as “mini pill,” Opill contains only one hormone, progestin, and has been established as having lower health risks than so-called combination contraceptive pills, which contain both progestin and estrogen and carry a risk of blood clots in some populations. Major medical groups, including the American Medical Association, support making the drug over the counter.

The panel’s green light came a day after scrutinizing and meticulously analyzing the HRA Pharma’s studies of over-the-counter use of Opill, which has been around for decades. Many of the advisers addressed flaws with some of the data and studies’ design, as well as concerns that people with contraindications would erroneously take Opill, or that young people or people with trouble reading would not be able to properly follow the drug’s directions and diminish its efficacy, leading to unplanned pregnancies. People with breast cancer are advised not to take Opill, as are people taking certain medications and herbal supplements, such as St. John’s wort. A key understanding of progestin-only contraceptives – which can be taken by women who are breastfeeding – is that they need to be taken approximately the same time every day, within a three-hour window in order to work effectively.

But advisers determined the benefits in this case vastly outweigh the risks, noting high rates of teen pregnancy and unplanned pregnancy in America, as well as data showing that the current over-the-counter contraceptives, like condoms, sponges, and spermicides, have high failure rates given common incorrect use. In the face of limited options and limited access to health care, many people use nothing for contraception, the experts said. Though, there are increased efforts to bring better and more accessible options to market, including a male contraceptive.

“It is past time for an over-the-counter birth control pill, which has the potential to advance reproductive justice and expand health equity,” said Victoria Nichols,?project director of?Free the Pill, a project of Ibis Reproductive Health, in a statement following the advisory committee’s vote on Tuesday. “Now, we look to the FDA to follow the committee’s recommendation, in addition to the overwhelming data, and approve the first-ever over-the-counter birth control pill in the U.S. The days of the current prescription requirement are numbered.”

FDA proceeding cautiously

The FDA could approve the drug for over-the-counter use this summer, moving the U.S. in line with at least 100 other countries that offer contraception over the counter. But FDA representatives expressed skepticism with some of the data presented by the drugmakers. The agency – which is currently being sued by anti-abortion activists for its approval of medication abortion 20 years ago appeared to be proceeding with caution.

“The FDA has been put in a very difficult position of trying to determine whether it is likely that women will use this product safely and effectively at the nonprescription setting,” said Dr. Karen Murry, deputy director of the FDA’s office of nonprescription drugs, during the second day of the advisory hearing on Wednesday.

Though public opposition to approving over-the-counter use of Opill has been limited to a small group of conservative Christian anti-abortion groups, the anti-abortion voice has been loud when it comes to birth control access in the U.S. The same federal Texas judge, Matthew Kacsmaryk, who ruled that medication abortion should be taken off the market based on scientifically unsound claims also recently blocked access to birth control for minors without parental permission.

Some anti-abortion groups like Students for Life of America, falsely conflate certain types of birth control with abortifacients, while simultaneously speaking out against premarital sex. SFLA, which actively fights against access to birth control on college campuses, opposes Opill and suggests that allowing it over the counter will be a boon to sex predators.

“Most parents do agree that reckless distribution of certain products is not in the best interests of children who need to hear from someone other than a salesman or abuser,” said SFLA President Kristan Hawkins. “The FDA should care more about the people who receive a product than the people who want to sell it.”

Now, as the FDA considers the panel’s recommendation, advisers urged the FDA to act quickly, and emphasized being moved by public testimony outlining the public health crisis.

Jacquiline Marcel Blanco, a clinical nurse leader from Washington state, identified herself during Monday’s public comment session as “a person with a uterus who cares for many people with uteruses.”

While Washington state has made efforts to expand abortion access, Blanco said it’s still increasingly difficult to access abortion care because of nationwide bans and delays and provider shortages. One of her recent pregnant patients had to wait eight days to get a life-saving abortion for a pregnancy that was no longer compatible with life, Blanco said. Thus she urged for better efforts to promote pregnancy-prevention, beginning with approving Opill over the counter.

“BIPOC people like me bear the burden of the maternal mortality crisis, being two to three times more likely to die than white peers,” Blanco said. “Preventing unintended pregnancies is the primary recommendation of our global leaders and evidence-based health promotion, and we have failed.”

May 2 marks a year since an early draft of the Dobbs decision was leaked, a precursor to the U.S. Supreme Court decision in June that overturned the federal right to abortion, a victory for anti-abortion protesters, above. (Getty Images)

Anti-abortion leaders could not stop paraphrasing Winston Churchill last June after the U.S. Supreme Court overturned Roe v. Wade, a victory that took 50 years to realize.?

“While we celebrate the momentous ruling in Dobbs, we must remember that overturning Roe was not the beginning of the end, but it was the end of the beginning,” said Kristen Waggoner, CEO of the leading anti-abortion law firm Alliance Defending Freedom, on a webcast days after the Supreme Court overturned federal abortion rights in Dobbs v. Jackson Women’s Health Organization.

Waggoner was one of several leaders on the “Life Beyond Roe” webcast to echo the late British prime minister after a pivotal World War II victory for Western Allies in November 1942. Defeating Roe was far from the end of the war on abortion rights, but it opened wide the frontier to diminish access for as many people as possible, she said.?

“We are Christ’s hands and feet. He has used us in this victory, but he still desires to use us to help women and children and to promote human flourishing. And to do that, we need … to use the influence that God has given us to promote sound policy,” she said. “We now have 50 different battles.”?

As it turns out, abortion foes’ post-Dobbs strategy has been even more sprawling than state-level bans and restrictions. Today (May 2) marks one year since an early draft of the Dobbs decision was leaked to Politico, and in that time anti-abortion activists have flooded state legislatures and city governments with proposals to criminalize pregnancy termination or to add burdensome regulations, and are defending many of them in state and federal court.

Activists managed to return to the Supreme Court with a controversial lawsuit – brought by an anti-abortion coalition represented by Alliance Defending Freedom – that is trying to ban medication abortion nationwide. The high court has, for now, preserved access to abortion-inducing drugs while the lawsuit folds. Legal and FDA experts say the plaintiffs in the case likely lack standing to sue and their claims that medication abortion is unsafe are deeply flawed. But this case is just the beginning of bold and ambitious efforts to restrict abortion as much as possible.

The consequences thus far have been sweeping. In addition to creating confusion and fear of jail time for health care providers and patients, state abortion bans have led to women and girls being denied emergency medical care in states like Kansas and Missouri, to maternity wards shuttering in Idaho, and to an increasing shortage of OB-GYNs in Tennessee.?

But anti-abortion activists are far from finished in their quest. Because many of the more than a dozen state abortion bans are currently being litigated, activists continue to introduce new anti-abortion regulations just in case those bans are ultimately struck down. Here are a few of their legislative and legal strategies.

Reviving Victorian era laws

Of the 14 states with active total abortion bans, three of those states – Oklahoma, Texas, and Wisconsin – are operating under laws passed in the mid-1800s to early 1900s with other hundred-year-old state bans currently blocked in court.?

But the entire country could soon be transported back to 1873, if anti-abortion activists are successful at getting the U.S. Supreme Court to uphold an anti-obscenity law known as the Comstock Act, which bans abortion drugs and medical equipment from being sent in the mail. The law was intended to prevent the mailing of anything that promoted non-procreative sex. It has long-remained dormant in the U.S., and narrowed by federal courts and Congress, which in the 1970s removed from the statute mailing contraceptives.

However, Congress never officially repealed the law, and anti-abortion activists have invoked the Comstock Act in the Alliance for Hippocratic Medicine? v. FDA case, to receptive ears, and in a lawsuit involving a city abortion ban in New Mexico. Additionally, attorneys general in 20 Republican-led states cited Comstock to stop national pharmacy chains from shipping abortion pills to their states.?

Legal and historical experts have told States Newsroom this law is destined to receive a hearing from the Supreme Court. But reviving Comstock could once again have devastating consequences for the same people who lacked rights when this law was passed: people of color and women. For many women and girls across the U.S., medication abortion has become the only available option. And this medication regimen is used not just for abortion, but to treat miscarriages, as well.?

?Environmental laws

For two decades, anti-abortion activists have focused on federal drug policy as a way to curtail access to medication abortion. Now their focus has shifted to exploring environmental regulations, an atypical avenue for their allied conservative lawmakers who typically oppose environmental regulations.?

Though it had already banned abortion, this year West Virginia introduced the West Virginia Chemical Abortion Prohibition Act, which restricts how medication abortion can be prescribed, administered – and disposed of. Many women experience medication abortion – like those who experience miscarriage – in their homes or in a private space; some miscarry over the toilet. This bill would require women – many of whom are traveling long distances to get abortions – to dispose of embryonic and fetal tissue in a special medical waste bag and return the remains to the health care provider. The law would not, however, apply to women taking the abortion drugs for a serious health condition. Providers would face up to a $1,000 fine and/or three years in prison for violating this regulation.?

The West Virginia bill also holds abortion drug manufacturers liable for the disposal of their drugs: “The manufacturer of any abortion drug is responsible for proper disposal of discarded abortion drugs. If abortion drugs are found in wastewater, the pill manufacturer company shall be responsible for cleanup, remediation, and further preventative measures.” The manufacturer would face a $20,000 fine per violation.

The bill did not move during this legislative session, but likely would in the event that the state’s abortion ban were blocked. Students for Life of America, the national anti-abortion group that drafted this wastewater language, is pushing these regulations and petitioning the FDA to study the environmental impacts of the abortion drug mifepristone, despite no present evidence of the drug having an adverse impact on the environment.?

Talking about the environment has also been a way for anti-abortion organizations to appeal to Gen Z.??

Restricting medication abortion at state level?

If the attempts to pass prohibitive federal regulations on medication abortion don’t work in the long run, more and more states might begin passing more restrictions or explicit bans on abortion-inducing drugs, including states with total or near-total bans, like Tennessee and Texas. Wyoming’s governor recently signed a ban on medication abortion, and similar laws have been introduced in Arkansas (died this week) and Iowa.

Meanwhile, attorneys general in Alabama and Idaho have simply asserted that their states’ respective chemical endangerment and abortion bans prohibit distribution or use of abortion-inducing drugs in their states. Alabama Attorney General Steve Marshall has since attempted to walk back claims that women in his state could be prosecuted for taking medication abortion.?

And Idaho Attorney General Raúl Labrador also attempted to walk back his interpretation of his state’s law, which was influenced by anti-abortion activists. Labrador’s legal analysis is now the subject of an ongoing lawsuit brought by Planned Parenthood and the American Civil Liberties Union, which also challenges the attorney general’s statement that merely giving information about how to access abortion in a state where it is legal would violate Idaho’s law.?

Restricting credit card purchases, and other financial restrictions?

Several states this year have introduced different bills regulating insurance coverage and public funding as it relates to abortion and abortion information, including in states where abortion is still legal. A bill in Indiana would prohibit the state from covering costs associated with an abortion, which includes allowing the use of hospitals or surgical facilities to perform abortions.

A lawmaker in Texas, which strictly bans abortion, proposed a bill that would prohibit credit card companies from processing transactions for the sale of abortion pills. Like other Texas abortion laws, this one would allow any citizen to sue a credit company over an abortion pill sale. Lawmakers in Texas have also proposed legislation that would censor abortion pill websites.?

?Fighting for abortion rights

These new laws and proposals merely scratch the surface. Utah, where abortion remains legal through 18 weeks’ gestation, is currently trying to ban abortion clinics. But abortion rights activists and lawmakers at the state and federal level have not backed down.?

They are fighting restrictions and bans in court, in addition to stockpiling abortion medication ?and trying to enshrine abortion rights in more states (something GOP lawmakers in Ohio are trying to defeat by making it harder for voters to amend the state constitution). The federal government, in addition to defending medication abortion access, has also continued to investigate hospitals – recently in Kansas and Missouri – that deny emergency care to pregnant women for fear of violating states’ abortion bans. (Kansas still allows abortion, but the law governing a state university hospital bans abortion on its property.)?

At a U.S. Senate Judiciary Committee hearing last week, Senate Democrats invited reproductive rights expert witnesses to explain the practical and legal impact of these new anti-abortion policies on U.S. residents.

“This period of time since Dobbs has unleashed criminal actions against women and their doctors — it has also unleashed civil surveillance,” said Michele Goodwin, chancellor’s professor of law at the University of California Irvine School of Law. “What we see is the dismantling, the vulnerability of constitutional principles that date back centuries, and abortion is being used as a proxy to dismantle fundamental constitutional principles, including the right to travel.”

African-american female patient touching belly and telling a mature worried doctor about stomachache at hospital appointment. Healthcare specialist showing concern about symptoms

These days Kylee Sunderlin is often the first person people will talk to about needing or wanting to terminate a pregnancy, even though she’s not a nurse or doctor or a loved one. She’s a lawyer.?

This is Sunderlin’s third year overseeing a national hotline dedicated to helping people navigate legal questions around abortion in their states. Calls have been at an all-time high, she said, as have callers’ fear and confusion.

“It’s just all really scary right now — I can hear it in people’s voices,” said Sunderlin, the legal support director for the nonprofit If/When/How. The organization is part of a nascent network of reproductive rights legal-assistance groups and law firms called the Abortion Defense Network, which formed in response to sustained legal uncertainty around abortion rights in the U.S.

“There’s a real sense that people are scared that if they share their pregnancy, or any information at all, that they are necessarily going to put someone else at legal risk, not just themselves. And so I’m just seeing and sensing a type of isolation that I hadn’t seen previously,” Sunderlin said. “People are navigating this alone.”

It’s been nearly one year since the U.S. Supreme Court overturned the federal right to terminate a pregnancy, followed by confusion and fear about contradictory state abortion laws and unresolved legal challenges. In this legal chaos emerged the Abortion Defense Network, which publicly launched in February and is trying to make providers and patients feel less alone. The network is a one-stop shop for patients and loved ones, and providers and practical support groups. Working together, the six reproductive rights groups in the network provide free legal advice, pro bono representation, and help paying legal expenses.?

“We believe this is a very robust system with serious legal and practical support that we are trying to get out to the community so that people who provide and support abortion care can continue to perform their vital services,” said Cassie Ehrenberg, senior counsel for pro bono initiatives for the Lawyering Project, which manages the intake calls and operations of the network. Its five partners are: the American Civil Liberties Union, the Center for Reproductive Rights, If/When/How, the National Women’s Law Center, and Resources for Abortion Delivery, in addition to seven anchor law firms.

The Supreme Court is once again about to make a consequential decision about medication abortion in the Texas-based Alliance for Hippocratic Medicine v. U.S. Food and Drug Administration case, one of several federal cases related to the abortion drug mifepristone. And though nobody knows whether and in what states the most common form of abortion post-Roe will remain legal and available by the end of this week, abortion rights advocates told States Newsroom they are determined to find ways to help people access safe abortion care and understand their rights.

“These federal rulings, particularly from the judge in Texas, it’s creating even more chaos and confusion for people who are seeking abortions,” said Sunderlin, who along with a small team of trauma-informed attorneys field calls from people of various ages, races and backgrounds from around the country. “And every time this happens, we see an increase in calls.”

A more than 2,000% increase in abortion patient calls

Sunderlin said If/When/How transformed its Repro Legal Helpline in June 2020, from an informational helpline to one where people seeking abortions could be promptly connected to legal services. More staff were hired after Roe v. Wade fell in June 2022, when the helpline saw a whopping 2,460% increase in inquiries, Sunderlin said. She noted that the helpline has been consistently receiving hundreds of calls every month since then.

A lot of the questions that helpline attorneys are fielding these days are about the legal risks of seeing a health provider at all, Sunderlin said, whether it’s just to confirm the pregnancy or to seek care for complications of a self-managed medication abortion or to seek care for a medical emergency in a wanted pregnancy. Her group’s legal advice depends on each individual’s circumstances, including their geography and relationships.?

“You’re really responding to people’s legal questions, but also responding to their needs as whole humans coming to us in a really chaotic, difficult time,” Sunderlin said. “If there’s anything we can do to help alleviate people’s fear, that’s my primary goal and what I’m constantly thinking about.”

If/When/How, which has researched abortion-related criminalization in the U.S., published a report last year showing that people who go to jail for having or assisting with an abortion were often reported to law enforcement by health care providers or family members and acquaintances. If/When/How created a legal guide with Physicians for Reproductive Health, which says patients are within their legal rights not to disclose a medication abortion to an emergency room doctor or other health care provider. The guide notes that an abortion via medication presents like a natural pregnancy loss and usually requires the same care if complications arise.?

Right now only Nevada and South Carolina have laws on the books criminalizing self-induced abortions, Sunderlin said, though that hasn’t stopped states from charging pregnant people under various statutes. If/When/How found 61 cases between 2000 and 2020 across 26 states of people investigated or arrested for ending their own pregnancies or helping others to do so. And presently more states are floating policies to charge pregnant women who have abortions.?

Anti-abortion efforts to police health information and criminalize out-of-state abortion travel have only perpetuated the difficulty of accessing abortion for many Americans, especially those without the means to travel, Sunderlin said.?

“People have taken their health care into their own hands throughout the course of history,” Sunderlin said. “With all of this chaos and confusion, that is increasingly becoming the reality for people as access becomes more and more scarce. And with this increased need for people to end their own pregnancies, for people that take their medical care into their own hands, there’s a very real risk of being criminalized for doing that.”

Abortion providers are not going away

Abortion providers, meanwhile, are scrambling to figure out how to provide care, depending on which way the Supreme Court rules on Friday in the Texas federal case, which concerns mifepristone, part of the two-drug medication abortion regimen. The high court could uphold the appeals court’s decision that keeps mifepristone on the market while the lawsuit unfolds but also re-implements old, out-of-date restrictions, including shortening the timeline when people could access the drugs from 10 weeks to seven weeks’ gestation, and would potentially eliminate access to the generic version of the drug.?

Dr. Gabriela Aguilar, the regional medical director for Planned Parenthood of Greater New York, told States Newsroom that Planned Parenthood providers are determined to keep providing patients with abortion care no matter what happens. They have been planning for different scenarios that could come out of the Supreme Court’s ruling and are preparing to potentially provide only misoprostol, the other drug in the regimen. Providers say this is safe and effective, but still less effective and generally more pain-inducing than the current FDA two-medication regimen, which has a two-decade-long high safety and efficacy record.?

“We’re sitting in a holding pattern right now where we’re trying to stay optimistic – hope for the best, plan for the worst,” Aguilar said. “We’re going to continue providing medication abortion no matter what.”

Aguilar said patients are very confused right now, especially when they see constant news headlines of mifepristone being banned, even though that has not yet happened. She said she worries how a sudden change to medication abortion law will impact her patients.?

“What needs to be recognized is that mifepristone is not just used for abortion,” Aguilar said. “It’s also used for management and treatment of miscarriages. So this entire community of people who have early pregnancy losses are being left out of the conversation and potentially put in these scenarios where they’re not going to have as effective or patient-centered experience.”

On a press call organized by reproductive rights groups Tuesday, public health and FDA regulatory experts expressed frustration that the legal questions about mifepristone in this case are medically baseless and will likely lead to public health harm and massive confusion among health providers and public health departments nationwide.

Ushma Upadhyay, a professor and public health scientist at the University of California, San Francisco, said that if mifepristone is even temporarily taken off the market or if old out-of-date restrictions are returned, “that will send the abortion provider field into a little bit of chaos.”

“I think that was the intention of this, of these court cases in the first place,” Upadhyay said. “Providers will have to figure out what is the best course forward based on the state they’re in, based on their patient populations.”

But in all of the anxiety over what will happen next in the fight over abortion access, the Lawyering Project’s Ehrenberg said she’s been heartened to see the determination among providers to continue providing health care in a frightening legal landscape.

“What I wish other people could see is that the resolve and the commitment to continuing to bring this care forward to patients and community members is so steadfast and so strong, that it really is heartening in the midst of this,” Ehrenberg said. “[Providers] are looking to navigate this horrible new landscape, but they are resolved to do that.”

“Bans off our bodies” balloons decorated the Protect Kentucky Access election night watch party on Nov. 8, 2022, in Louisville. Kentuckians rejected an anti-abortion amendment to the state constitution. The state Supreme Court has allowed the near-total ban on abortion to remain in force. (Kentucky Lantern photo by Arden Barnes)

Though the U.S. Supreme Court has temporarily blocked an effective ban on medication abortion, anti-abortion groups are not giving up on trying to fast-track a national abortion ban. And that means continuing to try to squash nationwide access to the most common form of abortion post-Roe, by whatever means necessary.??

“Obviously, the pro life community is disappointed that there wasn’t an outright decision made concerning banning chemical abortions,” said the Rev. Patrick Mahoney, chief strategic officer for the Stanton Public Policy Center, the lobbying arm of a powerful Idaho-based network of crisis pregnancy centers which has heavily influenced Idaho’s attorney general. “But either way, for the pro life movement and Stanton Public Policy Center, this does not deter us. We have many, many avenues out there to try to ban chemical abortion.”

Legally challenging the U.S. Food and Drug Administration’s two-decades-old approval of the drug mifepristone despite its high safety and efficacy record in Alliance for Hippocratic Medicine v. FDA has been just one of the anti-abortion movement’s many strategies to further curb abortion access. As this case continues to wind its way through the courts, activists are testing other regulatory and legal avenues.

Just this week, anti-abortion activists once again petitioned the FDA to revoke the approval of mifepristone, but this time on (disputed) environmental grounds. The national anti-abortion group Students for Life of America is arguing that trace amounts of the hormone blocker mifepristone could be posing a risk to endangered or threatened species and is trying to compel the FDA to study these impacts if the agency is forced to restart the approval of mifepristone as a result of the Alliance case, according to Politico. The group has also floated state model legislation adding environmental restrictions to medication abortion, which has been introduced in West Virginia.??

But this is part of SFLA’s years-long campaign to curtail access to the abortion pill. SFLA also opposes contraception and fertility treatments, and its board co-chair is Federalist Society co-chairman Leonard Leo.

“When I launched Students for Life more than 16 years ago, we knew we were going to need a trained army, ground troops ready to go in states and communities around the country the moment Roe versus Wade was reversed. And we began looking at this issue of chemical abortion five years ago,” SFLA president Kristan Hawkins said on a webcast in February.

Anti-abortion legal activists are also currently leaning hard on the Victorian era anti-vice Comstock Act, which plaintiffs in the Alliance lawsuit argue legally prevents abortion pills from being sent in the mail, something the federal government disputes.

Meanwhile the Alliance case is far from over. Early this month, U.S. District Judge Matthew Kacsmaryk of Texas ruled to suspend the FDA’s approval of the abortion pill. That order never went into effect; neither did the Fifth Circuit Court of Appeals’ decision to keep medication abortion on the market but revive out-of-date restrictions lifted after 2016. Public health and legal experts have been warning that letting either decision stand would have severe public health and legal implications beyond abortion.

And though abortion rights advocates around the country count today’s decision as a victory, groups like the American College of Obstetricians and Gynecologists say the case has already caused damage.?

?“Although the Supreme Court has kept mifepristone available to patients for the duration of this legal battle, much of the damage of this process remains in place – and we know that the attacks on abortion care will not stop, no matter how many times medical professionals declare that abortion is essential, evidence-based health care and that interference in the patient-physician relationship must stop,” said ACOG president Dr. Iffath Abbasi Hoskins and ACOG CEO Dr. Maureen G. Phipps, in a statement. “We will continue to lead the medical community in providing the clear, strong evidence about mifepristone so that the Supreme Court can make the right decision in the end. ACOG remains steadfastly in opposition to interference in the patient-physician relationship.”

And meanwhile, the uncertainty and confusion over abortion rights in the U.S. marches forward, as are multiple lawsuits related to expanding medication abortion access. A recent order in the federal case out of Washington protects medication abortion in 17 states plus the District of Columbia. More states are trying to expand as abortion haven states. Oregon just joined Massachusetts, Maryland, and Washington in their efforts to begin stockpiling mifepristone. The governors of California and New York have announced plans to begin stock-piling misoprostol, the second drug in the FDA’s two-step regimen for abortion and miscarriage care.?

Providers in states not part of the Washington lawsuit have proposed pivoting to misoprostol-only protocols if mifepristone becomes unavailable. The method is said to be less effective and more painful.

Many legal experts have argued that were it not for a biased judge, this lawsuit would likely have already been dismissed for failing to meet certain legal standards. And its legal and medical arguments have been widely disputed. Kacsmaryk has been open about his anti-abortion and anti-contraceptive views but has recently come under fire for failing to disclose his part in a law-review article and radio interviews where he spouted off his anti-abortion and anti-LGBTQ ideology. In his ruling the judge adopted the same rhetoric as the anti-abortion political movement: using terms like “unborn human” to describe embryos and “abortionists” to describe health care providers.??

If plaintiffs in the case ultimately prevail, public health and regulatory experts worry about the public health and regulatory fallout. During a press call earlier this week organized by abortion rights groups, Dr. Joshua Sharfstein, a vice dean and professor at Johns Hopkins Bloomberg School of Public Health and a former principal deputy commissioner of the FDA, said that suspending or changing the medication abortion protocol to before 2016 is not based on scientific evidence and sets a dangerous precedent of separating the science from the reasons to regulate drugs.?

“These are the kinds of unfortunate questions you have to consider when you rip apart the evidence in public health from the legal framework, because they’re designed to go together,” Sharfstein said. “And you pull them apart, and you’re left with all these truly unique questions. Because, this is so unprecedented, like, what’s the state medical board to do? What’s the state health department to do? What’s the FDA to do under these circumstances? We rely on an alignment between evidence and the law. And when that’s broken, it’s, you know, it becomes a completely different scenario.”

Abortion access could see further decline if case is ultimately victorious

?Access to abortion has already significantly diminished since Roe v. Wade was overturned, with people having to travel and endure extended waits. But providers are determined to continue providing care to as many people as possible.

?Florida, a state with a challenged 15-week abortion ban (a newly signed six-week ban won’t go into effect before the 15-week ban challenge is resolved), and North Carolina, a state with a 20-week abortion ban, are critical access points in the Southeast. In the six months after the Dobbs decision, Florida saw the largest increase in clinician-provided abortions, followed by Illinois, North Carolina, Colorado and Michigan, according to a recent report released by the Society of Family Planning. Overall, there were more than 30,000 fewer abortions in the six months post Dobbs, though that figure does not include any self-managed abortions.

?The increased threats to medication abortion have created heightened fear of criminalization and uncertainty among patients and providers. Abortion rights attorneys who provide free legal services and advice to abortion providers and patients as part of the newly formed Abortion Defense Network have told States Newsroom that many patients have become scared to seek needed medical care related to their pregnancies or abortions.

In the face of abortion provider shortages, travel barriers, and highly restrictive state laws, more people have begun to rely on the two-drug medication abortion regimen of mifepristone and misoprostol. According to the Guttmacher Institute, an abortion rights research organization,10 states would be especially impacted if access to medication abortion is suspended, such as Maine, where the share of counties with an abortion provider would drop from 88% to as low as 19%.

A Woman’s Choice provides abortions at clinics in Jacksonville, Florida, and three cities in North Carolina, along with taking out-of-state patients from Alabama, Georgia, Louisiana, Mississippi, and Texas, according to Amber Gavin, vice president of advocacy and operations. The organization’s leadership is looking at the possibility of providing misoprostol-only abortions if mifepristone access is restricted, Gavin said.

?But Gavin noted that the fight to preserve access to abortion is far from over, regardless of the end result of this lawsuit.

“The goal of anti-abortion protesters has been to completely eliminate access to abortion care across the entire U.S.,” Gavin said, emphasizing that abortion rights opponents could also attack birth control next. “They’ll keep coming and finding ways to control our lives, our families and our futures,” she said.

?Elisha Brown and Kelcie Moseley-Morris contributed to this report.

Idaho-based Stanton Healthcare parked its anti-abortion mobile clinic in front of the new Planned Parenthood clinic in Ontario, Oregon, on the same day that the new clinic opened, in response to Idaho’s abortion ban. (Courtesy of Brandi Swindell)

A fast-food restaurant was the last place she expected to have an abortion.

A month had gone by since the 26-year-old had found out she was about seven weeks pregnant. She’d gone to her closest Planned Parenthood, near Boise, Idaho, last August – the same week that abortion became a criminal act in her state. The woman, who asked not to be identified to protect her privacy, told States Newsroom that Planned Parenthood staff explained she could go across the border into Oregon for a legal telehealth medication abortion.?

She says the Idaho Planned Parenthood helped her set up the telehealth appointment with a provider in Oregon, where she would pick up the abortifacient mifepristone, which blocks progesterone from sustaining the pregnancy. She would need to take the mifepristone in Oregon before driving back home. And in one to two days, she would need to return to Oregon to take the misoprostol, which would cause her uterus to expel the pregnancy. For a surgical procedure, the nearest provider was at least 300 miles away.

“It was really crazy,” she says of all the legal and logistical questions she was trying to navigate, all the while feeling pressured by her boyfriend to have an abortion she wasn’t sure she wanted.?

Four weeks later she took the?mifepristone pill?and immediately felt regret. But, the next day,?after confiding in a relative who told her about an ad that the procedure could be reversed, she found hope at Stanton Healthcare, an international network of anti-abortion pregnancy centers headquartered in Meridian, Idaho, right by Planned Parenthood. In addition to counseling against abortion and limited health services, Stanton offers a controversial and unregulated treatment which has been?denounced by the American Medical Association?for its limited data and unproven claims.

To Stanton Healthcare founder and CEO Brandi Swindell, this woman’s story sounded like a potential legal case for the organization’s influential policy arm that is at the forefront of an emerging legal anti-abortion strategy: to push states with abortion bans to criminalize abortion-related assistance and information as a way to prevent patients from accessing abortion in abortion-rights states. Their strategy is a window into how the anti-abortion pregnancy center movement has gotten into the game of trying to find the magic legal key to banning abortion nationwide in the absence of a federal ban.

Organizations like Stanton present a public mission of trying to save the unborn and offer resources. Stanton also has been the driving force to test the boundaries of Idaho’s strict abortion ban. Months after lobbying, gathering intel on Planned Parenthood and abortion-rights activist groups in Idaho, and sharing its?client’s story, Stanton recently convinced its state’s most powerful prosecutor to adopt their extreme interpretation of what is already one of the nation’s strictest abortion laws. The Idaho attorney general has since rescinded his initial letter outlining his legal analysis, but it has added to chaos and uncertainty among Idahoans who need abortions and don’t know where to turn, reproductive rights advocates told the States Newsroom.

“Laws like the one in Idaho, you know, laws that ban abortion, have a chilling effect, not only on lawful conduct related to obtaining abortion care, but also other kinds of essential health care for pregnant people, like miscarriage management,” said Stephanie Toti, a reproductive rights lawyer who has argued major anti-abortion cases before the U.S. Supreme Court and whose organization the Lawyering Project is part of a new coalition of abortion-rights legal groups that offer mostly pro bono services to providers and patients. “It’s a terrible consequence of the Supreme Court’s decision to withdraw constitutional protection from abortion, and something that I think we’re going to see continue to play out in the courts in the coming months and years.”

AG opinion letter adds to confusion

Stanton Healthcare says it exists to help women experiencing crisis pregnancies, but it doesn’t want those same women to go to places that offer help accessing legal abortion care in other states. Shortly after Idaho’s abortion ban took effect, the organization started building its case, telling reporters that giving women information on how to access abortion in other states was “potentially criminal,” even though that is not explicitly stated in Idaho abortion law.?

“They were coaching her in essence to skirt the law,” Swindell told States Newsroom. “[T]here are entities that think that they can be above the law and are engaging in potentially criminal activity. And the reality is there is precedent for a lawsuit in this situation.”

In early March, Swindell, who dates Idaho Congressman Russ Fulcher, said her organization’s national lobbying arm, Stanton Public Policy Center, asked Idaho state Rep. Brent Crane, R-Nampa, to seek an opinion from state Attorney General Raúl Labrador on whether Idaho’s anti-abortion laws precludes the type of help Planned Parenthood gave to Stanton’s new client. Is that what the statute means, when it talks about “assist[ing] in performing or attempting to perform an abortion in violation of this subsection”??

Stanton – which has been campaigning against abortion drugs for years and has tried to unmask the secret headquarters of mifepristone distributor Danco Laboratories – also asked whether Idaho law specifically bans the provision and promotion of abortion drugs. She included in her letter to Crane pictures and video of a mobile billboard with instructions on accessing abortion pills produced by the abortion-rights group Mayday Health as it roamed Boise.?

The attorney general quietly clarified Stanton’s legal questions in a letter to Crane, which echoes Stanton’s belief that abortion assistance and referrals and information on medication abortion violate the law. Stanton published the attorney general’s letter in a press release warning abortion rights advocates and providers in the state not to talk to patients about where to go for a legal abortion.?

Planned Parenthood and the American Civil Liberties Union quickly sued the attorney general’s office, saying the opinion blatantly violates federal free speech and commerce laws.

“The Attorney General’s interpretation also demonstrates that he is taking the position that at least some abortions in other states are banned by Idaho criminal law—a truly novel, shocking and blatantly unconstitutional interpretation of Idaho’s Total Ban that risks further isolating Idaho patients by cutting them off from critical health care in other states that is legal in those states,” reads the complaint.

Labrador tried to backtrack, at least publicly. He wrote Crane a new letter, 11 days after the first, chastising the lawmaker for allowing the letter to become public, and telling him to consider his letter “withdrawn” and his analysis “void.” But the new letter attempted to delete itself without explicitly taking back the opinion that health providers in Idaho could lose their medical licenses for referring women to a provider in another state or calling in an abortion-drug prescription.

The attorney general’s office did not respond to a request for clarification on his opinion of Idaho’s abortion laws.?

Mack Smith, the communications director for Planned Parenthood Great Northwest Hawaii, Alaska, Indiana, Kentucky, said Planned Parenthood will keep fighting what she called “an extremely extreme legal opinion” in court until the attorney general further clarifies.?

For now, Planned Parenthood is declining people’s questions about where to access abortions legally. Smith noted that Labrador’s office has said it is not currently investigating Planned Parenthood, but his previous letter represents a real threat to providers.?

“[The Idaho attorney general] has not been explicit in what revoking the letter means for our providers on the ground, and obviously, we won’t be risking their licenses and safety,” Smith said. “So at this point, we’re not providing referrals until the judge returns.”

And Stanton is once again seeking clarification from the attorney general, and has asked for a meeting.?

“While it is profoundly disappointing and confusing that Idaho’s Attorney General Labrador has publicly rescinded his letter regarding important and valid legal analysis on chemical abortions in Idaho, Stanton Public Policy Center believes the information he provided in a letter to a state representative is still accurate and affirms the law,” Swindell told States Newsroom. “So while Attorney General Labrador has rescinded his letter, he has not ‘rescinded’ the facts and criminal sanctions detailed in the letter and those who violate them will face criminal violations.”

The quagmire over Idaho’s abortion laws coincides with legal uncertainty over the legality of the abortion pill nationwide and has intensified a political climate that threatens maternal health care throughout the state. As States Newsroom originally reported, two hospitals in rural Idaho are losing their entire maternity wards in part because of the stringent liability around pregnancy termination, even when it’s medically indicated.

“The people who bear the brunt of that are the patients in Idaho,” Smith said. “They’re the people who now don’t have an understanding of the medical options available to them, because their providers aren’t able to give them all of the medical options provided to them. And that simply cannot happen in any state in the country.”?

Labrador’s reading of his state’s abortion ban is further indication of his anti-abortion pursuit. Idaho has become an incubator for extreme anti-abortions laws, and recently became the first state in the nation to ban abortion travel for minors without parental permission. He has argued in an ongoing federal lawsuit against Idaho’s law that emergency room doctors do not need to be explicitly protected from prosecution, and he is among several state attorneys general interjecting in a Washington lawsuit trying to lift restrictions to medication abortion.

Labrador is among several attorneys general who have received campaign funding from major conservative legal influencer Leonard Leo, who co-chairs the conservative legal group the Federalist Society, which heavily backed judges and prosecutors with a history of anti-abortion views, including Texas Judge Matthew Kacsmaryk, who recently issued the controversial ruling to temporarily halt the approval of mifepristone. Leo donated approximately $2,000 to Labrador’s primary campaign in February 2022, according to a campaign funding report shared with States Newsroom by liberal watchdog group Accountable.US. During his campaign, Labrador vowed to be a more aggressive attorney general unafraid to sue the federal government.?

‘Abortion reversal’ as prosecutorial tool

Swindell founded the Stanton Health network almost two decades ago with a bold but yet-to-be-realized mission to replace Planned Parenthood with a network of clinics that offers reproductive health services except for abortion and birth control. Stanton’s flagship clinic in Meridian, Idaho, is licensed, unlike the typical anti-abortion pregnancy center. But like more traditional centers, Stanton leases buildings next to abortion clinics and advertises alternatives to abortion including reversal. They’ve even launched a new mobile clinic to follow a new Planned Parenthood clinic in Ontario, Oregon, and clinics with limited health services in California, Michigan, Ireland, and Scotland.?

Swindell says her mother regretted an abortion, and that inspired her to promote and offer an unregulated and disputed medical treatment called “abortion pill reversal.” Over the years her clinics have seen a handful of women like the 26-year-old who wanted to try the treatment after regretting their decision to have a medication abortion, sometimes because of outside pressure.?

Though people can experience regret for any medical decision, the mainstream scientific consensus is that women overwhelmingly do not regret their abortions. There is data, however, showing that risk factors for “negative emotions” following an abortion (at least initially, but not necessarily over time) include community and personal attitudes about abortion, something that is denounced as murder by many religious groups and lawmakers in the U.S.??

Stanton’s client told States Newsroom that she “grew up Christian, of course,” and that her mom, whom she’s very close to, never believed in abortion. She hadn’t planned on getting pregnant just yet, but it was her boyfriend who was adamant it was the wrong time to have a baby.?

“I just felt not confident in my decision if I wanted to keep it because he was putting a lot of fear in my head,’’ she said. “He was thinking that if I [had the baby], it would ruin our lives. And so I just decided to make somebody else happy.”

But after a sleepless night, she was eager to try the treatment, whose ultimate champion is also a plaintiff in the high-profile lawsuit asking the U.S. Food and Drug Administration to revoke its approval of mifepristone and the two-drug medication abortion regimen.?

California family doctor George Delgado’s protocol involves a woman interrupting that FDA-approved regimen he’s trying to outlaw. After she takes mifepristone, she must forgo the second drug, misoprostol. Then a provider – usually referred at anti-abortion pregnancy centers – floods her body with progesterone for a couple weeks.

The anti-abortion movement – and several state governments, including Kansas – have been promoting this medical intervention in the absence of any evidence that it works or robust data on potential health consequences of not completing the abortion. Their websites advertise that abortion is reversible, which the American College Of Obstetricians and Gynecologists says sends the problematic and unfounded message that an abortion decision can wait till midway through a medication regimen. An OB-GYN who tried to scientifically test the abortion pill reversal protocol canceled the study after three of the subjects experienced excessive and abnormal bleeding.

Stanton’s client acknowledges that maybe it wasn’t progesterone capsules she took for two weeks that “reversed” her abortion. She had found out she was farther along – around 12 weeks pregnant – when medication abortion generally becomes less effective. But in another way, she believes those capsules made her a brand-new mom. Stanton says its client gave birth to a healthy baby earlier this month.?

“I thought of that progesterone just entering life back into him,” she said. “I felt like life was kind of going back into my baby again. I don’t know if it was like a placebo thing maybe, or like a spirit thing.”

And for Stanton, their client’s story helped them learn exactly how Planned Parenthood was helping women access legal abortion elsewhere, as they consider legal avenues.?

Though more and more states are floating proposals to prosecute women who have abortions, Stanton is among many anti-abortion groups that oppose criminalizing women for obtaining abortions, including self-managed abortions. Swindell said they have seen two patients who self-managed since Roe v. Wade was overturned. But they do believe in criminalizing advocacy and volunteer-based organizations that help women access abortions.??

“Our approach is dealing with the organizations and the entities that we feel are being predatorial and preying on these women,” Swindell said. “We are very pro-woman, very life-affirming in our approach, and we would never consider reporting a woman for a self-abortion. And in fact, we have not.”

Activists in other states are playing the same strategy Stanton is: going after organizations that offer assistance as a way to enforce and expand state abortion restrictions. Activists in Texas found their plaintiff – an ex-husband suing his wife’s friends for giving her information about how to access abortion pills.?

And these types of challenges are likely to spread, with the help of national groups that float model legislation, like the National Right to Life Committee’s model bill, which recommends that states permit civil actions against people or entities that allegedly violate abortion laws.?

These lawsuits and threats of lawsuits for helping women have abortions add to the general growing fear of criminal prosecution and can deter people from seeking care, or help from support systems, said Toti, the reproductive rights attorney.?

“I can’t speak to what the attorney general of Idaho will or won’t do, but I know that there are politicians across the country who have made false threats for the purpose of scaring and intimidating people who want to obtain abortion care or provide abortion care or help others obtain abortion here,” Toti said.

And that is Stanton’s ultimate goal: to end support and access for abortion care beyond Idaho’s borders.?

“We believe in the humanity and human rights of the preborn child,” Swindell said. “And so we’re continuing to work with the AG here in Idaho, and encouraging people to do that in states across the nation,” Swindell said.

Stanton’s client said she wants people to know they could try abortion pill reversal if they regret abortion, but was reluctant to talk about the politics around abortion in her state and across the U.S.

“I’m not talking about anyone else’s experience but mine,” she said, and declined to say whether she would get involved in any related legal action.

At which point, Swindell, who organized the interview with States Newsroom, interjected, “Maybe another interview down the road.”

(Photo by Peter Dazeley/GettyImages)

A Texas federal judge with a history of anti-abortion beliefs has thrown into jeopardy the most common form of abortion since Roe v. Wade fell last summer.

U.S. District Judge Matthew J. Kacsmaryk released his decision on the cusp of Easter weekend to pause the Food and Drug Administration’s 2000 approval of the abortion drug mifepristone while a lawsuit against the agency proceeds. However, whether this ruling will ever be enforced remains to be seen. Legal experts have called into question the judge’s ability to suspend an FDA approved drug without going through agency protocol.?

Doctors and abortion providers around the country told States Newsroom the decision will likely exacerbate abortion care that has already been delayed and diminished following the U.S. Supreme Court’s decision to let states regulate abortion laws.?

The order is scheduled to go into effect by April 14, but that could change because of appeals. The U.S. Department of Justice launched an appeals process Friday within hours of Kacsmaryk’s ruling.

“Any delay in abortion care is unnecessary and cruel, and it’s a dangerous precedent to deny access to a safe medication that science tells us is safe,” said Dr. Mollie Nisen, a family physician and abortion provider in Washington state.

Nearly simultaneously on Friday afternoon, a Washington District Court judge issued a contradictory ruling preventing the FDA from taking adverse action on mifepristone. That ruling affects the plaintiff states who brought the case, which includes 17 Democratic-led states, while the Texas case has nationwide implications. It remained unclear how the two rulings might be resolved on Friday.

?As of 2020, use of mifepristone in conjunction with the drug misoprostol accounted for more than half of abortions nationwide. But in the eight months since Roe v. Wade was overturned and the FDA loosened certain regulations, the prevalence of medication abortion regimen has expanded, especially for women living in one of the 13 states that currently fully or mostly ban abortion.

?Nisen said about half of her patients seeking abortion use the mifepristone and misoprostol combination rather than a surgical procedure. She also knows of patients who have managed their own abortion care at home after obtaining the drugs by mail. Like abortion providers in so-called abortion-haven states, Nisen sees patients from everywhere and is bracing for a surge in new patients following this ruling. On a recent workday, she saw patients for medication abortion from seven different states.

?“People coming from as far as a seven-hour plane ride to get a five-minute procedure is what we’re looking at right now,” Nisen said.

?People seek medication abortion over surgical procedures for different reasons, including cost and allergic reactions to anesthesia. But for many, it’s the only accessible abortion method, given how abortion clinics are now scattered across the country and separated by vast distances, and many of them don’t offer the surgical procedure. Until now many people have been able to avoid traveling significant distances and other delays that lead to later abortions by taking advantage of the telehealth option allowed in some states.

?Additionally, doctors worry this ruling could have serious health consequences for women experiencing miscarriage, which can be life-threatening. Already providers around the country have reported that their state’s restrictive abortion laws have forced them to turn away pregnant patients even if they’re experiencing, or at risk for, serious health complications.

?Ruling has implications for miscarriage management, doctor says

In a “friend of the court” brief filed in the lawsuit in February, leading medical and public health societies that include the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, and the American Medical Association wrote: “Recent research has shown that prescribed mifepristone, in conjunction with misoprostol, improves safety outcomes for patients experiencing pregnancy loss.”

Mifepristone blocks the hormone progesterone, which a pregnancy needs to progress. It’s followed by the drug misoprostol, which has other indications but also causes the uterus to expel the embryo or fetus. The FDA has recommended it be used up to 10 weeks in pregnancy; the World Health Organization says 12.?

Dr. Loren Colson, a primary care physician in Idaho who is also a fellow with national advocacy group Physicians for Reproductive Health, is among those concerned for his miscarrying patients. Idaho has a near-complete ban on abortions at any stage of pregnancy. Doctors who provide abortions must prove they were trying to save the pregnant person’s life. (Similarly, survivors of rape and incest who want an abortion have to first file a police report.)?

Colson said he has seen many patients at his clinic seeking care for miscarriages since the ban went into effect, and while the clinic has had difficulties securing mifepristone, the doctors have been able to use it to help those patients.

When a pregnant person miscarries, which happens in as many as 26% of all pregnancies, the pregnancy often does not completely end for weeks if not months, Colson said. According to his estimates, about 80% of patients’ pregnancies will resolve within one month, while the remaining 20% could take six weeks or longer. Mifepristone and misoprostol taken in combination after an early miscarriage has a success rate of completing miscarriages by day two in 84% of Colson’s patients, according to his data.

Misoprostol alone – which is what many doctors currently prescribe for an early miscarriage, depending on the situation – will still be faster for some patients than using no drugs at all, Colson said, but by itself, the number of prescribed doses would increase, which creates more cramping and other side effects. The ruling bothers him because the medicine now pulled from shelves has fewer side effects than misoprostol and creates a better outcome for patient comfort.

“(Mifepristone is) an incredibly safe medication, and there’s no real reason to get rid of it except to inhibit access to a standard of care,” Colson said. “And for folks that are advocates of banning abortion, that means not getting the standard of care for an abortion, but the unintended consequence is for miscarriage management as well.”

Adapting to new challenges

Abortion-rights advocates and providers have been preparing for this legal outcome since plaintiffs sued the FDA last November. Some advocates have been forming an underground network of abortion pills and helping people access the medication outside of the U.S. legal system.?

Some abortion clinics have already promised to keep offering medication abortion, regardless of Kacsmaryk’s ruling.

Some doctors plan to recommend misoprostol alone for patients who want or can only access abortion via medication – something OB-GYNs sometimes did before the FDA approved mifepristone in 2000.

Dr. Deborah Nucatola, chief medical officer for Planned Parenthood Great Northwest Hawaii, Alaska, Indiana and Kentucky, has practiced abortion care in nine states for more than 25 years, which includes a stretch of about five years before mifepristone. When the drug was introduced, effectiveness and speed to complete an abortion rapidly increased, she told States Newsroom.

“Losing access means patients still have access to options, but it takes longer, and the risk of failure is higher,” she said.?

Nucatola expects more patients will have incomplete abortions and will need to return for the surgical procedure, called aspiration, which involves using suction to empty whatever tissue remains in the uterus.?

Time is the most important factor when it comes to optimizing women’s recovery from spontaneous or induced abortion, Nucatola said. Medication abortion works quickly, and has a low infection rate. She expects infection rates will remain low with misoprostol-only, but the longer it takes for a pregnancy to fully end, the higher the chances of infection and other complications.??

Misoprostol is still a safe and effective medication, she said, but the higher doses cause more side effects, such as chills, nausea, vomiting, gastrointestinal distress and fever. The recommendation is 12 misoprostol pills, as opposed to four for medication abortions before eight weeks.?

“(Patients are) just going to have a lot more discomfort for longer,” Nucatola said, underscoring that providers will continue to support patients amid the coming challenges. “We trust our patients to do the best thing for themselves, and we’re going to do everything we can to support them, whether or not we have access to mifepristone.”

But for anti-abortion lobbying groups, today is a huge victory, years in the making.

Students for Life of America (SFLA) – a national group that fights against abortion and birth control access on college campuses – has for years campaigned against mifepristone and against the FDA’s loosening of restrictions, which most recently included allowing retail pharmacies to dispense the medication abortion regimen directly to patients.

SFLA president Kristan Hawkins said on a recent webcast. “When I launched Students for Life more than 16 years ago, we knew we were going to need a trained army, ground troops ready to go in states and communities around the country the moment Roe versus Wade was reversed. And we began looking at this issue of chemical abortion five years ago.”

Like the plaintiff anti-abortion medical groups in this lawsuit, Students for Life uses the number 28 to argue that mifepristone should be banned. It’s the same number the FDA uses to argue that it’s safe: 28 deaths out of an estimated 5.6 million people in 23 years have been associated with the FDA’s abortion regimen, which is a markedly lower rate than many common FDA-approved drugs, like Tylenol and Viagra. And as the FDA notes, that small number includes fatal cases “regardless of causal attribution to mifepristone,” including people who died from homicide, suicide, and pulmonary emphysema.??

But Hawkins did acknowledge that the procedure her movement is trying to ban terminates pregnancies early, in the first trimester – which is something most Americans favor, in public opinion polls.?

“We became very concerned that there were legislative advances to make chemical abortion pills the preeminent type of abortion that’s offered in our country,” Hawkins said. “Because the abortion industry reads the same polls that we read. They know that the majority of Americans oppose second- and third-trimester abortions.”?

A recent Public Religion Research Institute poll contradicts Hawkins, finding that 52% of Americans oppose restrictions that make it illegal to obtain an abortion after 15 weeks of pregnancy.??

Asked via email if SFLA expects an increase in second- and third-trimester abortions if this ruling makes first-trimester abortions harder to access and what the impacts of banning abortion drugs will be, Hamrick said, “Lives will be saved.”

Many doctors across the country disagree with her.

“Making mifepristone unavailable nationwide — even in states where abortion remains legal — will impose a severe, almost unimaginable cost on pregnant people throughout the United States,” write the American College of Obstetricians and Gynecologists and the other medical and public health societies in its brief.

“Medication abortion’s relative availability makes it more accessible to patients who otherwise face challenges to access medical care, including low-income patients and patients of color—the very people who are most likely to experience severe maternal morbidity and more likely to die from pregnancy-related complications.

Dr. Loren Colson, a primary care physician in Idaho and a fellow with national advocacy group Physicians for Reproductive Health, does not provide abortion services, as incorrectly reported in a story about a federal judge’s ruling on abortion medication.

In addition to creating confusion and fear of jail time for health care providers and patients, state abortion bans have led to women and girls being denied emergency medical care to maternity wards closing to an increasing shortage of OB-GYNs. (Getty Images)

At the center of the federal anti-abortion lawsuit against the U.S. Food and Drug Administration is the abortion drug mifepristone and the regimen that reportedly accounts for the majority of abortions in post-Roe America. That’s why the whole country is bracing itself for a ruling from a notoriously anti-abortion judge in Amarillo, Texas.?

The attention and confusion around this case might end up being the most impactful aspects about it, as many legal scholars doubt the judge has the legal authority to do what plaintiffs are asking for, which boils down to forcing the FDA to essentially recall a drug that for two decades has maintained a record of efficacy and safety. But regardless of the lawsuit’s outcome, legal experts still think a ruling that even briefly or partially favors plaintiffs will likely have lasting consequences on U.S. abortion access and affect medication policy beyond abortion.

“What this case is doing is only increasing the politicization of mifepristone and abortion, as well as the entire FDA approval process, and [it’s] calling into question the impartiality and the legitimacy of our court system, as well as our FDA approval process,” Georgia State University law professor Allison M. Whelan told States Newsroom.

Last month Whelan along with 18 other FDA legal scholars co-signed a “friend of the court” brief on behalf of the FDA, arguing that U.S. District Judge Matthew Kacsmaryk doesn’t have the authority to force the FDA to immediately withdraw approval of mifepristone, which plaintiffs have asked him to do via preliminary injunction while the rest of the lawsuit unfolds.?

Theoretically, the judge could decline to order the total withdrawal of the drug but could grant some of plaintiffs’ other demands, which include ordering the FDA to reinstate regulations that were lifted within the last several years. In 2000 the FDA approved a medication abortion regimen involving the hormone blocker mifepristone followed by misoprostol to expel the pregnancy. Later the FDA extended the gestational age that this protocol could be used from seven weeks to 10, eliminated the in-person dispensing requirement, and most recently has allowed pharmacies to dispense the drug directly to patients under certain restrictions – though that policy is still being rolled out.?

The FDA scholars and other legal experts say the process to withdraw drug approval (or to undo decisions made around a drug) can take years, requires public input, and discretion ultimately falls to the FDA. And in the meantime, the agency could choose whether or how to enforce any order that the drug is unapproved, said Whelan, whose scholarship and teaching focus includes FDA law and reproductive justice.?

“(T)he FDA would issue this policy statement that signals for manufacturers that from the FDA’s perspective, the FDA is not going to bring any sort of a civil or criminal action against the company for continuing to sell their drug,” Whelan told States Newsroom. “The FDA has issued enforcement discretion policies many times, including recently with the infant formula crisis.”

Even Kacsmaryk questioned his own powers during last Wednesday’s injunction hearing.?

“(I)s it that you expect this Court to order the FDA to begin a suspension or withdrawal, almost like a writ-type scenario, or that the Court itself can withdraw or suspend on its own accord?” Kacsmaryk asked, according to the court transcript.

“The latter,” replied Erik Baptist, senior counsel for Alliance Defending Freedom, the conservative Christian legal shop representing plaintiffs. “We take the position that the Court, on its own accord, can order the FDA to withdraw or suspend the approval of the drug.”

“And explain to me your argument on why this Court has that sweeping authority,” Kacsmaryk replied.?

Baptist replied vaguely that the court has the power to “enjoin and take whatever action to prevent harm.”

Despite plaintiffs’ claims that medication abortion is dangerous, there is ample evidence of its efficacy and safety. In more than two decades, there have been 28 reported deaths associated with mifepristone and a generally low rate of adverse events, according to the FDA.

The issue of drug approval is just one among several reasons defendants (and legal analysts) argue the case should be thrown out. Others include that the statute of limitations on plaintiffs’ complaints has expired and that plaintiffs did not exhaust administrative remedies to challenge FDA’s approval of mifepristone.?

Attorneys for the government have argued that plaintiffs do not have standing to bring their claims and have not shown how they would be directly harmed by keeping mifepristone on the market. Plaintiffs have largely argued that doctors represented in the lawsuit might see an increase in workload in their emergency rooms if more medication abortion patients experience complications and seek medical treatment. Even if that were a viable argument, plaintiffs have not provided evidence that medication abortion is causing a large amount of adverse effects and problems – beyond speculation and minimal anecdotes.?

Plaintiffs have also asked the court to weigh in on a dormant federal law from the 1800s known as the Comstock Act, which anti-abortion advocates have been trying to argue legally prevents abortion pills from being sent in the mail, but the Biden administration contests this. Defendants have argued that whether a drug can be legally mailed has no bearing on this case about drug approvals.

A Trump appointee, Kacsmaryk previously served as deputy counsel for a Christian conservative legal group called First Liberty Institute, where he worked on cases fighting access to reproductive health care. “As a federal judge, Kacsmaryk has struck down protections for LGBTQ workers and trans youth and ruled that a federal family planning program’s policy of offering confidential birth control to teens violates federal law and Texas state law, potentially making it harder for Texas teens to access contraception (the ruling has been appealed).

But given all of the legal problems with the abortion pill case, legal journalist Chris Geidner suggests there are a lot of reasons why this case could fail, despite Kacsmaryk’s ideology and sympathies to some of the plaintiffs’ arguments.

“Anything could happen — and much has been made of Kacsmaryk’s background and rulings thus far on the bench — but DOJ and Danco’s lawyers made as strong a case as possible that Kacsmaryk would be going far afield of the law by doing anything about the 2000 approval of mifepristone, especially with these plaintiffs on these facts.”

This case is ongoing (as are several federal lawsuits about medication abortion), and Kacsmaryk’s preliminary injunction is likely to be appealed. Additionally, the ruling itself would only apply to the FDA and Danco Laboratories, one of the manufacturers of the abortion pill. Still, a decision that favors the coalition of national conservative Christian medical associations known as the Alliance for Hippocratic Medicine, and the four plaintiff doctors is sure to have far-reaching legal consequences, and could add more distress and confusion for manufacturers, pharmacists, and health care providers. Beyond abortion, Whelan said a favorable decision could open the door to lawsuits against politically controversial vaccines and hormone replacement therapies.?

A favorable decision could also embolden more states to try to ban mifepristone using the argument – if Kacsmaryk buys it – that the medication abortion regimen was not lawfully approved or properly vetted, which many legal and policy analysts say is patently false. A ruling that limits medication abortion in some way – even if it’s not enforceable – will add yet another confusing legal layer to the panoply of state anti-abortion laws that have led to pregnant women frantically traveling for abortion care outside their states, even for medical emergencies.

“It’s like there is no light at the end of the tunnel as to when this is going to end, and it’s just so problematic from a patient and provider perspective because of the uncertainty,” Whelan said. “I cannot imagine being a healthcare provider who does reproductive health care going to work every day thinking, ‘Can I do this today? I was allowed to do it yesterday. Can I do it today? Will I be able to do it tomorrow?’”

Nearly 22 million women, girls and gender-nonconforming persons of reproductive age are now living in states where abortion has been banned or is in other ways inaccessible, a contingent of U.S. and global human rights groups noted in a letter to the U.N. (Photo by Jennifer Shutt, States Newsroom)

Ahead of International Women’s Day, hundreds of U.S. and global human rights groups, doctors, and attorneys have asked the United Nations to intervene on behalf of the millions of women in the U.S. who have been left without access to legal abortion and vital forms of reproductive health care in the wake of last summer’s monumental U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization.

?“Eight months on from this catastrophic legal decision, it is now apparent that the consequences are even worse than feared,” states a letter signed by nearly 200 rights and justice groups and individual health care providers and attorneys, which was first shared with The Guardian last week. “Women and girls in need of reproductive health care are being met with systematic refusals, huge financial burdens, stigma, fear of violence, and threats of criminalization. Thousands are being forced to remain pregnant against their will.”

?Addressing the United Nations Working Group on Discrimination against Women and Girls and more than a dozen UN officials specializing in a wide range of human rights, the letter’s authors write that nearly 22 million women, girls and gender-nonconforming persons of reproductive age are now living in states where abortion has been banned or is in other ways inaccessible.

The more than 50-page letter – dense with devastating anecdotes from news articles and studies and doctor interviews – argues that the effects of Dobbs and the resulting state and local anti-abortion policies have compromised Americans’ rights to life, health, privacy, and liberty. The letter authors argue that the U.S. is violating various human rights treaties it has signed.??

?“These human rights obligations include, but are not limited to, the rights to: life; health; privacy; liberty and security of person; to be free from torture and other cruel, inhuman, or degrading treatment or punishment; freedom of thought, conscience, and religion or belief; equality and non-discrimination; and to seek, receive, and impart information,” the authors write. “The US has committed to respect and protect these rights; instead, it is infringing them through restrictions on abortion access.”

They ask the UN officials to make an official visit to the U.S. to witness these harms, to convene a virtual stakeholder meeting with U.S. civil society, and to call for private companies to take action to protect reproductive rights. They also call on the UN to ask the U.S. to comply with its obligations under international law.

?“The Dobbs decision abandoned the constitutional right to abortion, violated U.S. legal obligations under treaties such as ICCPR [International Covenant on Civil and Political Rights], and exposed the fact that Roe was never enough,” said Lauren Wranosky, research and program associate at Pregnancy Justice, one of the signatories, in a statement. “Many will continue to be jailed, convicted, and sentenced to prison for having abortions, experiencing pregnancy losses, or giving birth to healthy babies. This destroys families, inflicts trauma, and targets the most vulnerable by replacing healthcare with criminalization. We know this humanitarian crisis will only get worse, and we demand that the U.S. government join international peers as a leader in securing reproductive justice for all.”

?As the authors note, the end of federal abortion rights has led to 13 states criminalizing the procedure (with Georgia effectively outlawing the procedure with its six-week ban); dozens of clinic closures around the country; and increased travel times and delays for abortion care, even in situations when the pregnancy has become life-threatening. They write that the UN Human Rights Committee has already established that denial of abortion in other countries can cause suffering and amount to torture.?

And they stress that in the U.S., racial minorities and marginalized groups disproportionately face health and legal harms because of the policies enacted after the Supreme Court overturned Roe v. Wade.

?“Dobbs is devastating for all people who can become pregnant, but it has had and will have an?outsized impact on certain marginalized groups who already face documented discrimination?within and outside the healthcare system,” the authors write.

“This includes BIPOC women, people of diverse gender identities and sexual orientations, migrants, persons with disabilities, people who are low-income or living in poverty, children, and rural residents. These groups often have poorer health outcomes compared to other populations, Dobbs will worsen these disparities, since individuals who belong to these groups have fewer resources and face discrimination from the healthcare community.”

Kentucky obstetricians have warned that even with exceptions when a mother’s life is in danger, the abortion ban “could force physicians to wait for a patient’s condition to deteriorate so severely that significant bodily harm or even death could occur.” (John Fedele/Getty Images)

Researchers at the University of California San Francisco (UCSF) are trying to piece together how the end of Roe v. Wade has so far transformed pregnancy-related medical care in America, and the yet-to-be-released preliminary data are alarming, the lead principal investigator told States Newsroom in an exclusive interview.

The team has already received dozens of stories about health care providers directing patients to continue very high risk or doomed pregnancies, which they might not have done before their states criminalized abortion.

“The stories are really heart-wrenching,” said Dr. Daniel Grossman, who directs Advancing New Standards in Reproductive Health (ANSIRH) at UCSF, which last October launched the Care Post Roe study, which draws from a survey in which participants share anecdotes either anonymously or stripped of identifying details.

Through this limited qualitative study, researchers are learning how clinical care deviated from “the usual standard,” since last June, when the U.S. Supreme Court overturned Roe. Grossman said his researchers have so far received around 50 “valid complete submissions” about patients who live in about half of the approximately dozen states that currently or previously banned abortion (totally or partially), including Arizona, Georgia, and Indiana.

A theme of fear is emerging from the data, Grossman said. Not only are providers scared of flouting new laws, but some patients are terrified just to be pregnant in states with abortion bans and are traveling long distances when problems arise.

“[T]hey were too scared to even go seek care in that state because they were worried about what might happen to them,” Grossman said. “So, they traveled long distances to another state to be evaluated. And sometimes it turned out they weren’t even pregnant. Sometimes it turned out they had had a miscarriage that had actually already been completed and they didn’t need any treatment. And in one case, the patient had an ectopic pregnancy, where she should have been able to get that treatment where she lived.”

‘Patients were being sent home’

Providers told researchers about cases of premature rupture of membranes in the second trimester, Grossman said, noting that the standard of care in these cases is to offer termination, given the high risk of infection and low probability of a live birth.

“And instead, in these cases, patients were being sent home,” he said. “And then they come back with infection, and several of them developed very severe infection that required very complicated management in the intensive care unit.”

Additionally, UCSF researchers have learned about several cases of patients whose fetuses had no chance of survival but had to leave their state to have abortions, an increasingly common story.

Grossman said providers have described having to jump through hoops to treat patients with ectopic pregnancies, a dangerous condition that occurs in approximately 1 to 2% of pregnancies in the U.S., in which the embryo has implanted outside the main cavity of the uterus. More than 90% of the time, the embryo gets stuck on its way to the uterus in the fallopian tube, where it does not have enough room to grow and cannot survive. If caught early, ectopic pregnancies are most commonly treated with one of the drugs in a typical medication abortion, or with surgery. Left untreated, the tube can rupture and cause uncontrollable bleeding.

Currently, less than 50 people die from ectopic pregnancies annually, according to University of California Davis complex-family-planning specialist Dr. Mitchell Creinin. However, OB-GYNs have expressed concerns that that number could rise due to new post-Roe policies.

And through the Care Post Roe qualitative study, Grossman has become concerned that some doctors are hedging how to treat the rarest type of ectopic pregnancy, which occurs when the embryo implants in a woman’s scar from a previous cesarean section. As the pregnancy grows, the uterus can rupture and cause what Grossman calls “catastrophic bleeding.” The Society for Maternal-Fetal Medicine recommends terminating cesarean scar ectopic pregnancies because they pose fatal risks to pregnant people (the complication rate can be as high as 44%) and rarely result in live births.

Despite being a rare condition — an estimated 1/1,800 to 1/2,500 of all C-section deliveries — Grossman said his team has already heard about a few cases in which patients could not access recommended treatment for cesarean scar pregnancies. What’s trickier about this type of ectopic pregnancy, he said, is that the outcome is not necessarily 100% fatal. There have been reported cases of survival for the pregnant person and baby, and if the embryo has cardiac activity, sometimes providers are reluctant to recommend termination.

“[There have been] several cases where it’s been hard to arrange treatment for those patients in the states where they live,” Grossman said. “And sometimes they just have to follow the patient because the patient can’t travel elsewhere. And they’re just watching the placenta kind of grow through the uterine wall into surrounding structures. It’s really very concerning.”

Texas high-risk OB-GYN Patricia Santiago-Munoz says the option to continue a risky pregnancy like this should be up to the patient. The maternal fetal medicine specialist at the University of Texas Southwestern Medical Center in Dallas published a blog post last August to inform patients that treatment for cesarean scar ectopic pregnancies are legal under Texas’s abortion law.

But as has been true in Texas and in many of the 12 other states where abortion is currently banned, patients have been reportedly experiencing denials and delays in care. These laws level harsh penalties for doctors, many of whom are confused how to navigate narrow or vaguely worded “life of the mother” exceptions.

Lawmakers and health officials in multiple states are currently trying to adopt more explicit health exceptions in their abortion bans. But Grossman says determining what constitutes life-threatening and how immediately life-threatening can be difficult — and daunting.

“The problem in general with these exceptions is that medicine is not black and white; there’s a lot of gray,” Grossman said. “In many situations a patient can be okay and kind of slowly start deteriorating, and then a condition can suddenly deteriorate very quickly. How big a chance of that happening is considered too big? That is what physicians and hospital administrators are facing now in this new era.”

Fear, not fear mongering

Many anti-abortion groups, meanwhile, are lobbying GOP lawmakers to oppose proposed health exceptions. In Tennessee, anti-abortion groups are clashing with state lawmakers who support changing the way the law criminalizes doctors. Sen. Richard Briggs (R-Knoxville), a heart surgeon, last year said he regrets voting for the ban after realizing how it could exacerbate medical emergencies, including cesarean scar ectopic pregnancies.

Grossman acknowledges that Care Post Roe is a very limited study that relies on a relatively small number of anecdotes, many of which are submitted anonymously. He said this was the best way to protect the identity of health providers and patients, many of whom currently fear prosecution for their medical decisions.

That fear is not unfounded, given that many hospital systems have instructed doctors not to talk publicly about the public health effects of overturning Roe. One OB-GYN, Indiana Dr. Caitlin Bernard, is being investigated for telling a reporter about treating an Ohio child, who had been denied an abortion even though she was 10 years old and had been raped.

The study also invites participants to do in-depth follow-up interviews with UCSF researchers, and Grossman said they’ve done about a dozen so far. Otherwise, they don’t verify the submissions they receive beyond assessing whether they make clinical sense. He also said the submissions have so far been very detailed.

And they mirror many similar stories recounted to journalists and researchers around the country, and borne out in other recent research, like a Commonwealth Fund study that found higher rates of maternal and infant mortality in states with strict abortion restrictions, and a Women’s Health Issues study that concluded that OB-GYNs practicing in states with heavy abortion restrictions are less likely than OB-GYNs in states with abortion rights to have received abortion training, and thus less likely to offer optimal care in all cases.

The anti-abortion movement, meanwhile, has shrugged its collective shoulders at these outcomes. Among many anti-abortion groups, the American Association of Pro-Life Obstetricians and Gynecologists has engaged in a concerted media campaign to dispel stories about care denials as fear-mongering. Instead they blame doctors for their decisions.

“False claims abound that state abortion restrictions will prevent physicians from being able to treat ectopic pregnancies, miscarriage, and other life-threatening complications in pregnancy (such as an intrauterine infection). This is blatantly absurd, as not a single state law restricting abortion prevents treating these conditions,” AAPLOG president-elect Dr. Christina Francis testified before Congress last July.
The group is one of the plaintiffs in a lawsuit that would ban an abortion-inducing drug that pregnant people post-Roe have relied on to have safe early terminations, under the false narrative that the drug is unsafe.

An AAPLOG email to members sent on Jan. 6 urged the providers in its network to participate in the Care Post Roe study, but to give different stories from what the UCSF researchers are asking for.

“We encourage members to submit their stories about the abysmal care that medication abortion patients are receiving and the horrendous complications which you are treating in the Emergency Room because the abortionists abandoned their patients to the ER for management of complications,” the email read. That’s also the crux of one of their main arguments in the lawsuit — that patients are flooding emergency rooms because of increased use of medication abortion. Yet they’re basing that claim on speculation and a small number of anecdotes.

Grossman is not aware of any such submissions. But he noted that the team has excluded submissions that were incomplete or vague or didn’t make clinical sense and didn’t meet the inclusion criteria, which was to reflect changes in care after a change in law.

AAPLOG did not respond to a request for comment.

As doctors and abortion providers continue to warn about dire consequences to come, Grossman said his team has been receiving new stories every week about changes in medical care because of abortion bans. He said UCSF continues to solicit study participants and will begin releasing their preliminary findings in the coming month or two.

“We hope that these findings will be useful for hospital systems as they’re trying to figure out workarounds to provide care,” Grossman said.

The FDA approved mifepristone under the brand-name Mifeprex in 2000 and an abortion-drug regimen that has seen few deaths and a low rate of adverse events in more than two decades of use. (Photo by Peter Dazeley/GettyImages)

Emergency rooms across America are teeming with women and girls bleeding from abortion drugs in such copious amounts that it’s exacerbating the national blood shortage.?

Or, at least, that’s the grim – but false – narrative a group of small conservative Christian medical associations have painted for a federal judge in Texas. Their mountain of evidence, they say, shows abortion via a specific drug regimen is incredibly dangerous and should never have been approved by the Food and Drug Administration more than 20 years ago.

The openly anti-abortion federal judge presiding over Alliance for Hippocratic Medicine v. FDA could, at least temporarily, ban abortion drugs any day now. But if he does, reproductive-health care experts say it will be based on deeply flawed evidence that largely rests on cherry-picked studies and a handful of anecdotes from a handful of anti-abortion doctors. And it will have immediate consequences for pregnant people in America, many of whom have begun to rely on this method to terminate pregnancies early and safely, especially in states that banned abortion after the U.S. Supreme Court overturned Roe v. Wade last year.?

“The attempt to reverse the FDA’s approval of mifepristone has absolutely nothing to do with the safety of this drug,” Dr. Kristyn Brandi, a family-planning subspecialist and fellow with the American College of Obstetricians and Gynecologists, said in an email. “This is a highly safe and effective medication that should be available to patients. The use of mifepristone for medication abortion improves patient outcomes. We know this based on evidence from numerous medical studies and data from millions of uses in the twenty-three years since the FDA first approved the use of mifepristone for medication abortion.”

Many of the doctors who brought this case are with the American Association of Pro-Life Obstetricians and Gynecologists, which represents about 7,000 members compared to ACOG’s 60,000 members. Despite its small stature, AAPLOG wields an enormous amount of power when it comes to reproductive-health policy. The group has spent decades in the courts and legislatures selling a narrative unsupported by the predominating medical consensus: Abortion is not only immoral, but should be banned because it’s dangerous.??

That strategy helped codify hundreds of state anti-abortion laws and paved the legal pathway for the reversal of federal abortion rights. Now, AAPLOG is back in court as part of the Alliance for Hippocratic Medicine, a consortium of medical associations that practice Christian-right beliefs when it comes to reproductive-health care, health care for trans people, and end-of-life care. They are represented by the nonprofit Christian-right legal shop Alliance Defending Freedom, which also represented plaintiffs in Dobbs v. Jackson Women’s Health Organization. ADF has? previously leaned on shaky science in the courts to defend anti-abortion and anti-LGBTQ policy, including the widely discredited practice of conversion therapy to change people’s sexual orientation and gender identity.??

One of conversion therapy’s biggest advocates, Dr. Quentin Van Meter, also testifies in this lawsuit: arguing that long-term effects of mifepristone on minors have not been adequately studied (HHS disagrees).

And the evidence in this case couldn’t be shakier. The data footnoted in the 113-page complaint don’t actually support plaintiffs’ horrifying scenario. At most, plaintiffs show there are sometimes complications associated with medication abortion, which sometimes require medical attention – but they don’t present convincing data to show high rates of life-threatening incidences.

Instead, plaintiffs cast doubt on the safety data collected and monitored by the FDA since it approved mifepristone under the brand-name Mifeprex in 2000, and then approved an abortion-drug regimen of mifepristone and an ulcer medicine called misoprostol. In more than two decades, there have been 28 reported deaths associated with mifepristone and a generally low rate of adverse events, according to the FDA.

Plaintiffs conjecture about high levels of under-reporting of adverse events. And they speculate that with increased availability of abortion drugs – especially as more people have begun self-managing their abortions – health issues will skyrocket.?

“We represent OBs, emergency-room doctors, medical associations, the doctors who every day care for women and see the harms of these dangerous chemical abortion drugs in their practice,” ADF senior counsel Julie Blake said last month on Washington Watch with Tony Perkins, produced by the conservative Christian Family Research Council. “And we are confident that once we get our claims in front of a judge, that he’ll say, ‘Hey you didn’t follow the law, you didn’t follow the science. And it’s time to withdraw these drugs from the marketplace.’”

In addition to relying on flawed research manufactured by the anti-abortion movement, the plaintiffs mix religion with their science.?

For example, California family doctor George Delgado, who practices medicine based on “teachings of the Catholic Church,” invented a controversial protocol to “reverse” an abortion, which has raised safety flags. Another plaintiff is Republican Indiana Sen. Tyler Johnson, an emergency room doctor, who last year campaigned as “a pro-life physician, not a politician.” He’s spoken out against the COVID-19 vaccine and against exceptions to Indiana’s legally challenged abortion ban.

This is the second time group-plaintiff Christian Medical & Dental Associations tapped the Detroit-based Dr. Regina Frost-Clark to be a party in an abortion-related lawsuit. She considers God to be the ultimate authority in her medical practice and works for a Catholic hospital system whose guidelines deny access to miscarriage management in the absence of life-threatening infection.

Like CMDA, AAPLOG is always scouting for new expert witnesses to lend credibility to their lawsuits and has been regularly hosting expert-witness trainings around the country, including this Sunday in Tucson, Arizona. Upcoming trainings are scheduled in Georgia, Kentucky, Florida, Wisconsin, Iowa, Michigan, and North Carolina.

“The voices of medical professionals carry great weight in the public square,” reads a recent AAPLOG member email advertising this training program. “We want to provide you with the training and confidence you need to give the evidence-based rationale for prolife medical practice to the media, to your state legislators, and in court.”

So, what are some of the most serious medical claims plaintiffs are making, and will their medical degrees be able to sell them in the absence of robust evidence?

?CLAIM: Abortion drugs are dangerous.

The FDA-approved medication abortion regimen involves taking mifepristone, which blocks the hormone progesterone, needed for the pregnancy to grow and develop normally. That’s followed a day or two later by misoprostol, which stimulates the uterus to empty the pregnancy, essentially inducing a miscarriage. The FDA approves this regimen for early abortion and miscarriage management through 10 weeks of pregnancy, while the World Health Organization says the drug regimen can be safely taken through 12 weeks.

Cramping and bleeding are expected symptoms after taking medication abortion. Just as with menstruation and pregnancy and childbirth, women report various experiences after taking medication abortion. Some report horrifying pain, while others compare the experience to a heavy period. Other potential side effects, which the FDA says are reportedly rare, are incomplete abortion (which then requires surgical intervention) and life-threatening bleeding and infection. The drug’s warning label instructs patients to seek medical attention if their blood soaks two thick full-size sanitary pads per hour for two consecutive hours, or if they experience fever, vomiting, or diarrhea in the days after taking the medicine.

In their opposing brief, general counsel for the U.S. Department of Health and Human Services cites the FDA’s 2016 scientific review of mifepristone, which was based on a dozen studies and on data from more than 30,000 patients, and found low rates of “serious adverse events”: 0-0.1 percent for needed blood transfusions; less than 0.01 percent for sepsis; 0-0.7 percent for hospitalization; 0.1 percent for hemorrhage.

But according to AAPLOG CEO-Elect Dr. Christina Francis in a recent Newsmax interview, “These drugs are extremely dangerous.”

To bolster this assertion, the main statistic plaintiffs cite in their complaint is that 1 in 5 women “will have an adverse event after taking chemical abortion drugs. … This includes over fifteen percent (15%) of females experiencing hemorrhaging and two percent (2%) having an infection during or after taking chemical abortion drugs.”

It comes from a 2009 Finnish study comparing adverse events associated with medication abortion compared with surgical abortion. As if they haven’t spent decades trying to ban surgical abortion on the premise that it’s also dangerous to women, plaintiffs have also glommed onto another statistic from the Finnish study: that the complication rate for medication abortions is four times higher than surgical abortions.

The HHS attorneys claim the plaintiffs have misconstrued the Finnish study’s findings, noting that that percentage encapsulates instances of expected and necessary bleeding. The Finnish researchers ultimately conclude that “both methods of abortion are generally safe,” but that counseling should address all the risks.

“Plaintiffs do not even attempt to allege facts supporting the chain of causation,” the government’s legal team argues. “They do not corroborate any of the pecuniary harms that they purport to fear, nor any of the intangible concerns that they raise. That omission is particularly telling given the more than two decades that mifepristone has been in use. If Plaintiffs’ injuries had an evidentiary basis, then Plaintiffs would be able to marshal allegations grounded in fact rather than conjecture.”

CLAIM: Medication abortion is riskier than full-term pregnancy and childbirth

Plaintiffs in their complaint boldly claim, “Pregnancy rarely leads to complications that threaten the life of the mother or the child.”?

Their source that medication abortion is deadlier than pregnancy and childbirth is a 2013 research paper published in a journal produced by one of the plaintiff groups, the Catholic Medical Association.?

The paper’s author, Dr. Byron Calhoun, is a longtime anti-abortion activist and a high-risk OB-GYN in West Virginia who says abortion is never necessary to save a life. He’s also made false claims to the West Virginia attorney general about high rates of abortion complications in his state for which he never produced evidence. Calhoun tries to take down the often-cited statistic that the risk of death associated with childbirth is approximately 14 times higher than with abortion. But his evidence boils down to assumptions that abortion-related deaths are vastly under-reported. The bulk of his argument relies on discredited studies showing links between abortion and suicide and cancer.

The footnote that abortion is deadlier than pregnancy also links to a National Review Online article by James Studnicki and Tessa Longbons, who work for the anti-abortion research group the Charlotte Lozier Institute. They also assume vast under-reporting of abortion-related complications. But their main evidence is a red herring.??

“Depending on the assumptions in estimating and accounting for miscarriages and the simple recognition that abortion is a death, abortion could be as much as 4,500 times more likely to result in a human death than giving birth,” Studnicki and Longbons write.

Arguing that abortion is more dangerous than giving birth because it ends a pregnancy omits the well-documented evidence that maternal mortality in the U.S. is the highest among developed countries and is three times higher for non-Hispanic Black women (about 55 maternal deaths per 100,000 live births in 2020) compared with non-Hispanic White women. There were 861 total reported maternal deaths in 2020, but the rate was three times higher for non-Hispanic Black women (about 55 maternal deaths per 100,000 live births in 2020) compared with non-Hispanic White women.?

CLAIM: ERs are flooded with medication abortion cases that are overwhelming the blood supply.

?To argue that they have legal standing in this case and are directly impacted by its outcome, plaintiffs speculate that the FDA’s most recent rule changes – allowing for patients to obtain medication abortion via telemedicine and allowing retail pharmacies to dispense the drugs directly to patients – will lead to a burdensome increase in workload in emergency rooms.?

“The increased occurrence of complications related to chemical abortions also multiplies the workload of healthcare providers, including AHM and AAPLOG members, in some cases by astronomical amounts,” writes outgoing CEO Dr. Donna Harrison in a legal declaration. “This is especially true in maternity care ‘deserts.’”

She argues that some of the FDA’s previously relaxed regulations resulted in “the explosion of Mifeprex complications including hemorrhage, adding to the current shortage of blood and blood products across the United States.”

?These claims are baseless, says Dr. Nikki Zite, a board-certified OB-GYN and complex-family-planning specialist at the University of Tennessee Graduate School in Knoxville, who submitted a legal declaration on behalf of the federal government.

?“Given the demonstrably low rate of complications from the Mifepristone/Misoprostol regimen, it is inconceivable to me that medication abortion could have a measurable impact on the blood supply in any location,” Zite writes, noting that ACOG has been monitoring a nationwide problem of hemorrhage following childbirth. “If hemorrhage or transfusions from medication abortion was a significant issue, ACOG would be addressing it as well.”

?The plaintiffs also offer anecdotes.

?Dr. George Delgado, who spearheaded a network of anti-abortion doctors willing to perform his experimental abortion-pill reversal protocol, claims he has “treated women suffering complications from chemical abortion and seeking to reverse the effects of chemical abortion,” but he gives no details.?

?The one attempt at a controlled study of Delgado’s protocol – which amounts to instructing women who have taken mifepristone to throw away their misoprostol and receive progesterone injections – stopped prematurely because the OB-GYN and mifepristone expert leading the study determined it was unsafe after three patients hemorrhaged. Neither in his declaration, nor in response to a media inquiry does Delgado explain if these complications were from the FDA’s approved regimen, or from women only taking the mifepristone.??

?Dr. Regina Frost-Clark of Michigan said she has “treated several women who have suffered complications from chemical abortions,” which she clarifies amounts to about dozen women who were suffering “significant bleeding,” which is inherent in a medication abortion.

?Dr. Shaun Jester, an OB-GYN from Dumas, Texas, recounts one example to back up his claim that unsupervised medication abortion is dangerous and “potentially life-threatening.” He says he treated a Texas woman, where abortion is currently banned, who obtained the medication abortion regimen in New Mexico but was still heavily bleeding two weeks later and had developed an infection. “IF she had waited a few more days before receiving care, she could have been septic and died,” Jester writes, noting that he reported the adverse event to the FDA.

?Similarly, Indiana state Sen. Tyler Johnson gives a concerning example: an Indiana woman who obtained abortion drugs in Chicago and bled heavily on the drive home, needed a blood transfusion. “I have seen multiple cases similar to this one,” he writes.

But their testimony does not contradict the medication abortion’s reported safety record, which does account for some incidences of serious adverse events. Neither of the doctor-plaintiffs or their attorneys responded to requests for comment.

Outside of the lawsuit, plaintiffs have simultaneously claimed abortion bans haven’t and won’t lead to denial of emergency medical care in the case of pregnancies that need to be terminated for health reasons – despite ample evidence to the contrary.

?What’s next

?Family physician Dr. Linda Prine, who co-founded the Miscarriage and Abortion Hotline to help pregnant people navigate self-managing medication abortions post-Roe, said it’s the anti-abortion movement putting women in riskier, more traumatizing abortion situations. She said her hotline has been hearing more from people taking abortions drugs later than 12 weeks – because it’s the earliest they could get them.

?“What leads to using abortion drugs past the first trimester are the abortion bans and the difficulties in getting the medications,” Prine said in an email. “It is medically less risky to use the medications earlier, and it is medically less risky to have an abortion rather than an ongoing pregnancy. The bottom line is that people should be able to get the medical care they need, whenever it is that they determine that they need it.”

There are other ongoing legal cases aimed at preserving access to abortion drugs, even in states that have passed abortion bans. But as early as this month, U.S. District Judge Matthew Kacsmaryk could rule that the FDA must ban the drugs, or resume its old protocols. From there the case would go to the conservative Fifth Circuit Court of Appeals. And if it goes to the U.S. Supreme Court, the scale is tipped by anti-abortion hard-liners.

?As the decision date for Alliance v. FDA has gotten closer, more providers have begun discussing how to help pregnant people terminate pregnancies using only misoprostol, which is used in other countries, but not as effective and more risky than the current regimen. Abortion-rights advocates and health professionals are scared for patients and frustrated.

?“The scenario of people being scared and traumatized by a later abortion could be prevented by giving people access to the pills early and legally, not by forcing them to continue an unwanted pregnancy,” Prine said.