By Carrie Baker for Ms. Magazine.
Broadcast version by Lily Böhlke for Florida News Connection reporting for the Ms. Magazine-Public News Service Collaboration
Dr. Razel Remen has been an independent abortion provider in the Detroit Metro area of Michigan since 2016. Last year, Remen launched Pills By Post, a telemedicine abortion service for people in Colorado, Illinois, Minnesota and most recently New York. She offers medication abortion pills to people 14 and older through 11 weeks of pregnancy and charges a fee of $150 with sliding scale available to those who are unable to pay the full cost.
Ms. spoke to Remen about her telehealth abortion practice, including how why she started offering this service.
Carrie Baker: Can you tell me about your medical background?
Razel Remen: My medical background is a little unusual. I actually studied medicine at the Latin American School of Medicine in Havana, Cuba, and completed my residency in Alabama. I’m originally from New York City where, growing up, the first seven pages of the yellow pages were dedicated to abortion clinics. I didn’t fully understand how bad lack of access to abortion was for most of the United States was until I lived in Alabama. I always say that if I had not done my residency in Alabama, I would not have become an abortion provider.
In Alabama, there’s such a severe lack of access to reproductive health services. Undocumented immigrants make up a large part of the state’s population, often working as migrant farm workers. The only time they have any access to reproductive health services is when they’re pregnant. I had an interaction with one undocumented immigrant who’d just given birth. When I went in to congratulate her on the birth of her child, she was sobbing and upset. She didn’t want to have another child and expressed concern over the fact that she could barely provide for the ones she already had and worried about how another mouth to feed would impact them.
The experiences I had during residency made me realize that lack of access to abortion not only negatively impacted individual people, but also their families and communities. I received very little training in contraceptive care and no training in options counseling or abortion. Sadly, this is typical for a majority of family medicine programs across the country.
After I finished residency, I went on to pursue a fellowship with the Reproductive Health Access Project and Dr. Linda Prine in New York City. After the fellowship, I knew I wanted to work in a diverse community that needed providers so I moved out to Michigan with my son, who was 7 at the time, and I have been working here as an abortion provider ever since.
Carrie Baker: How did you first become interested in telemedicine abortion?
Razel Remen: During fellowship, I came across Women on Web and Women on Waves, and I thought that it was one of the most awesome things I had ever heard of. When Aid Access started in 2018, I followed them and their founder and medical director Rebecca Gomperts almost like a groupie. I thought she was and still think she is so amazing. I was one of the first people to contact Plan C about providing telemedicine abortion. I hit all kinds of roadblocks mostly because I didn’t have my own brick-and-mortar clinic and could not receive wholesale shipments of medications. The FDA requires a physical business address in order for pharmacies or distributors to ship wholesale bulk medications. It was only when the pharmacy Honeybee Health started offering to ship mifepristone and misoprostol directly to patients that I was able to join Aid Access and start providing telemedicine services in October of 2021.
Carrie Baker: Can you tell me how the telemedicine abortion service you offer works?
Razel Remen: People can schedule an appointment with me on my website pillsbypost.com. Then I do a phone consultation with them to make sure that they are eligible to take the medication-where I go through a series of screening questions to ensure they don’t have any allergies or any contraindicatory health problems or risk for ectopic pregnancy.
Once the intake is done, I have them electronically sign informed consents and send the payment. Once the intake and consultation are completed, I send their prescriptions to the pharmacy.
Carrie Baker: How does the sliding scale work?
Razel Remen: Most people pay the full amount, but some people can’t so we talk about it. I don’t grill them. Usually, people are pretty up front. One woman said, “I’m homeless, I can’t pay anything,” so I just sent the medication to her free of charge. There’s currently funding to cover the cost of the medications for anyone paying $75 or less. The U.S.-based Aid Access providers are in conversation with an organization to see if we can get additional funding to cover the costs of anyone who pays less than $150.
I’m also trying to work out independent funding with the Chicago Abortion Fund and another fund in Colorado which has mentioned they might be able to cover Colorado minors seeking judicial bypass. I wish we just had universal healthcare like Cuba.
Carrie Baker: Since you offer telemedicine abortion in Colorado, are you getting women from Texas?
Razel Remen: Yes. I’ve noticed patient with IDs from outside of the states I serve are asking for medication. I don’t inquire as to where they are as long as their shipping address is in a state where I’m licensed.
Carrie Baker: How does it work with minors?
Razel Remen: llinois recently eliminated their parental consent requirement for minors, but Minnesota and Colorado still require parental notification. They don’t require consent. Parents just have to be notified. I’m in contact with a lawyer in Colorado, who said that she would help with judicial bypass if a patient needs it. And then I’m going to also get in contact with someone in Minnesota to see if they can help people with judicial bypass if they need it.
Carrie Baker: Do you do same day consults?
Razel Remen: Yes. I put in a six-hour window so I don’t get surprised last minute.
Carrie Baker: Do you offer evening and weekend appointments?
Razel Remen: Most of my appointments are in the evenings and on weekends.
Carrie Baker: How long do the calls normally take?
Razel Remen: Usually they take about 15 to 20 minutes. It really depends on how many questions people have. Some people are very anxious about it, understandably because the service is very new. Maybe they’re not familiar with medication abortion, so they’re afraid of what the pain will be like, or will this actually work and is this dangerous? People who need more reassurance require longer visits.
Carrie Baker: What kind of patient education do you offer?
Razel Remen: I have materials that I email to them. I also go over how to take the medication and then also encourage them to call or email if they have any questions.
Carrie Baker: How far into pregnancy do you prescribe abortion pills?
Razel Remen: 11 weeks. I was tempted to do 12 weeks because the World Health Organization endorses it through 12 weeks. Studies from overseas show abortion pills are effective up to 20 weeks. There’s currently a study underway in the United States showing the pills are effective through 13 weeks. The FDA recommendation is currently up to 77 days from the first day of the last menstrual period, but the FDA guidelines are always behind the evidence because of money-it takes about a million dollars to change an FDA recommendation.
Carrie Baker: Once you submit the prescription to Honeybee, how long does it take for patients to get the pills?
Razel Remen: Usually three to five business days. There have been people who wanted the medication sooner so I can overnight it to them. The pharmacy charges an extra $25 for overnight delivery.
Carrie Baker: What kind of follow-up care do you provide to the patient? Do you have a helpline for patients to call?
Razel Remen: If they need assistance, I recommend that they call the Miscarriage and Abortion Hotline during the day because I’m in clinic and I might not be able to answer the phone. But if it’s after business hours, then they can just call me directly with any questions they might have. Two days after they receive their medications, I call or email them asking how things went. I had one person who was very anxious and they weren’t sure as to whether or not the medication worked. So we worked through that to try to figure out where they could get an ultrasound if they needed it. I think it’s really essential for the entire movement to compile a database of pro-choice, friendly, inexpensive places where people can go to get ultrasounds.
Carrie Baker: How has telemedicine abortion worked for your patients?
Razel Remen: They seem to really like it and appreciate the service. Aid Access does a patient satisfaction survey and the feedback is positive. Medication abortion has a very, very high success rate. I send eight misoprostol pills if someone is below nine weeks and 12 if they’re above nine weeks, so if they have an issue, they have it if they need it.
Carrie Baker: How many patients have you seen so far since you opened in October?
Razel Remen: I see about 90 a month.
Carrie Baker: Do you take insurance?
Razel Remen: I don’t take insurance. We do a sliding scale. If I did insurance, that would just increase the cost because it’s very time consuming. A lot of states have regulations that make it difficult for insurance to cover abortion. In New York and California, Medicaid does cover abortion. I might eventually look into signing up for Medicaid in New York. I’ll have to see if it would be time and cost effective.
Carrie Baker: How do you afford the sliding scale?
Razel Remen: Someone has donated money to Honeybee to cover the cost of the medication for those who need assistance.
Carrie Baker: Do you know why your patients are choosing telemedicine abortion?
Razel Remen: I haven’t asked them specifically why they choose telemedicine. I do know from dealing with patients in clinic that it’s often very burdensome to go to the clinic if someone has children, or work, or other people that they have to take care of. Sometimes it’s the issue of travel. At the clinic I work at in Michigan, people sometimes are coming from the Upper Peninsula, which is an eight-hour drive! It can be quite a burden for somebody to get to a clinic. The TRAP laws also make things difficult. People have to take time off of work or school to show up to clinic only to find out because of some absurdity in the TRAP laws they can’t be seen. It’s really heartbreaking.
Carrie Baker: Can you tell me about who your patients are?
Razel Remen: It’s a mix. I get a higher concentration from the bigger cities like Chicago, Denver and Minneapolis because there are more people there, but I do also get people from rural areas. They are in their late teens all the way up to their 40s. Some people have had children and for some this is their first pregnancy. It’s all over the place.
Carrie Baker: Does anybody in Michigan offer telemedicine?
Razel Remen: Not that I’m aware of. I do know that there’s a provider that’s working on getting their Michigan license to start offering the service.
Carrie Baker: What motivated you to start offering telemedicine?
Razel Remen: I think it’s really important in terms of increasing access. I see how people really struggle. They have a really hard time accessing services.
Carrie Baker: Was it difficult to meet the FDA requirement that physicians distributing mifepristone must be certified with a distributor?
Razel Remen: No, it’s not difficult. It’s just paperwork. They ask you for your medical license and your business entity, if you have one. And now that the pharmacy Honeybee Health exists, you don’t have to worry about having a brick-and-mortar location.
Carrie Baker: Have you experienced any harassment for offering telemedicine abortion?
Razel Remen: No. I don’t think many people know about it. I expect that I may get some kickback. I hope not.
Carrie Baker: Have you experienced harassment working at your brick-and-mortar clinic?
Razel Remen: Yes. I was living in an urban apartment complex and antis mailed my neighbors. One neighbor knocked on my door and she was really concerned. She handed me a piece of anti-abortion “fan mail” that’d been delivered to her and told me to be careful. At the clinic where I work, we get protestors every week. People sometimes come in sobbing because of the protesters. I mean, they’re literally crying. This makes me really angry. The one that upsets me the most as a woman of color is when they start saying “Black Babies Matter.” The hypocrisy of that statement especially bothers me considering Flint. Flint is a Michigan city that is predominantly Black and still has dirty lead filled water. Lead crosses that placental barrier and can cause miscarriages as well as severe brain damage to infants and children. If they want to protect Black babies, then why don’t they go protest the dirty water in Flint? I’ve had quite a few Black women come in feeling horrible after they see those signs. I ask these women, “Do you really believe those protestors think that Black babies matter?” They all get it and say, “No.”
Carrie Baker: What do you think is the future of abortion rights in light of what’s happening at the Supreme Court?
Razel Remen: First of all, I am not as optimistic as some about what the Supreme Court will do. I think they’re going to say the fetus is a person and therefore abortion should be universally illegal. I don’t think it’ll fall back to the states. But if that doesn’t happen, then it will go to the states. In Michigan, it’ll become illegal. We’re currently in the process of trying to amend our Constitution to protect abortion rights. It looks like we have a pretty good chance of that passing in November. We have a lot of conservative people who are against vaccine mandates. They really get the concept of “my body, my choice.” Those people are often Trump supporters, very conservative, but they get the idea that the government should not interfere in somebody’s bodily autonomy and personal choices. I think we have a very good chance of amending the Michigan Constitution to protect abortion rights.
Carrie Baker: Any final thoughts?
Razel Remen: I want people to know that telemedicine abortion is safe and reliable. If you want to find a good service, go to Plan C because all of the providers they list have been vetted so you can feel confident.
Carrie Baker wrote this article for Ms. Magazine.
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By Carrie Baker for Ms. Magazine.
Broadcast version by Lily Böhlke for Florida News Connection reporting for the Ms. Magazine-Public News Service Collaboration
Four years ago, Dutch physician Rebecca Gomperts founded Aid Access to provide telemedicine abortion to people in the United States for a sliding scale fee up to $150. The Austria-based organization serves people in all 50 states, including the 19 states that currently prohibit telemedicine abortion.
Gomperts has a long history of working to provide abortion pills to women in countries with barriers to abortion healthcare. She founded Women on Waves in 1999 to sail boats into international waters bordering countries where abortion was illegal to deliver abortion pills to women in those countries-a dramatic story recounted in the documentary film Vessel.
In 2005, Gomperts founded the organization Women on Web to provide medication abortion via the internet and mail to people living in countries without access to safe abortion services. After the election of Donald Trump, Women on Web received a growing number of requests for help from people in the U.S., so Gomperts founded Aid Access in March of 2018. According to their website, Aid Access seeks “to create social justice and improve the health status and human rights of women who do not have the possibility of accessing local abortion services.”
In 2019, the Trump administration’s FDA sent Dr. Gomperts a warning letter demanding that she stop mailing abortion pills to people in the U.S. She continued undaunted. Gomperts reports she has provided medication abortion to over 30,000 people in the U.S. since 2018.
In addition to delivering abortion pills by mail, Gomperts has continued to find creative ways to get pills into the hands of women. Over the last decade, Women on Waves has delivered abortion pills by ship to women in Morocco, Guatemala and Mexico; by drone in Poland and Ireland; and by robot in Northern Ireland, Poland and Mexico.
Ms. spoke to Gomperts about her work providing telehealth abortion services in the United States.
Carrie Baker: Why did you start Aid Access?
Rebecca Gomperts: I started Aid Access after we saw that there were a lot of requests coming in for help from women from the United States. Plan C had done research to see whether some of the websites that were offering mifepristone and misoprostol were reliable, which they were. So Women on Web started referring U.S. women to these websites. But women told us they couldn’t afford the medications, so that’s when I started Aid Access to serve women in the U.S.
Baker: Can you explain how Aid Access works?
Gomperts: We provide an online consultation, where pregnant people are asked about their health condition, how long they’ve been pregnant and any possible contraindications to the use of the abortion pills, which are very few. The online consultation also provides them information about what it entails to do a medical abortion by yourself. Then the consultations are reviewed by a team of doctors. We also ask for identification from the people that are requesting our help, which is mandatory as a doctor to know who you’re seeing. And then I prescribe the medication and the prescriptions are filled by a pharmacist in India. He ships it to the U.S. Aid Access now has nine providers in the U.S. using the same platform to prescribe for their patients in their own states.
Baker: Do you have any other clinicians abroad? Or is it just you?
Gomperts: No, there’s another clinician, but it’s somebody who mostly reviews the consultations. I’m the only prescribing physician outside the U.S. at the moment.
Baker: Does the process happen all on the internet through online forms and messaging, or do you do video conferencing with your patients?
Gomperts: No, we don’t generally do videoconferences, but we can. If it’s a minor or somebody who’s in an extremely vulnerable situation, we can do a video conference. We’ve used this same system with Women on Web for more than 17 years and all the data has been analyzed. It’s very safe, and it’s effective. And it’s extremely acceptable for women to do it this way. I do sometimes do video conferences in the Netherlands when I see patients there, and it doesn’t add any information to be honest to what you can obtain online.
Baker: How long does it take for a patient to get the prescription from when they first contact you?
Gomperts: The prescription is provided quite quickly after the online consultation and after receiving the payment, or if they cannot afford it, then it’s donated. The pharmacy in India fills the prescription, but it takes some time before it arrives at the women’s home address because mail needs time-between two and three weeks.
Baker: Why do you use a pharmacy in India?
Gomperts: Not all pharmacies can fill a prescription for mifepristone. Mifepristone is extremely restricted in many countries. India allows it. They provide good quality products. The medicines are produced under the supervision of the Indian government. They use exactly the same regulations that apply to pharmaceutical products made elsewhere in the world. Actually, most of the medication in the world is produced in India. There’s also a lot of generic medication there, so it’s much cheaper. We want to make the service available for women that have little to no money. One of the main obstacles to abortion care in the U.S. that we found is actually the cost. So many people live under the poverty threshold. They just cannot afford to pay the $600 or whatever it’s costing at a clinic. So in order to meet the demand, we need to use the most cost-effective medications.
Baker: Have the medications, to your knowledge, ever been blocked in the mail coming to a patient in the U.S.?
Gomperts: Well, it’s not clear. It seems like some packages were stopped a few years ago, after the FDA letter that was requesting me to stop providing care to women in the U.S. There were very few packages stopped. It might have been that these were actions done by the local mail centers themselves. We don’t know. But we haven’t seen any problems since then. Of course, the problem has been COVID. With COVID, a lot of the local mail services in the U.S. stopped working well. Fortunately, the World Health Organization recently submitted an advice that women can safely self-manage medical abortion until 13 weeks of pregnancy. We prescribe medications until 10 weeks, so there is time to receive the pills before then. More and more research shows it’s safe to use abortion pills in the early second trimester. But of course, the process is a little bit more intense. The earlier the better. Always.
Baker: You prescribe medication abortion through 10 weeks or 70 days from the last menstrual period?
Gomperts: Yes.
Baker: What do you charge for this service?
Gomperts: I’m charging about 95 euros, which is about 110 U.S. dollars. That includes everything-the consultation, the prescription medicines, the shipping. It’s the all-inclusive cost.
Baker: And how does your sliding scale work?
Gomperts: It’s very simple. When people say that they cannot afford to pay, we just ask how much they can afford to pay. If they say that they can pay $80, then that’s fine. If they cannot afford that, then we ask if they can afford $55-the cost of the pills-because I try to cover my expenses. But sometimes even that’s not possible. So it depends on what people can pay, to be honest.
Baker: How many of your patients use your sliding scale fee?
Gomperts: About 30 percent of the people who contact us cannot even afford $100. About 10 to 15 percent get a full donated service.
Baker: How can you afford to do that? Do you have funders that help support patients who can’t pay?
Gomperts: Well, we do get donations because people support the service, even though I’m officially not a nonprofit. The good thing about this system is that you can keep it quite low cost. Especially if you don’t need to invest the time to do video calls and all the organization around that. These things make services unnecessarily expensive. That makes it easier to keep the cost down.
Baker: How many misoprostol pills do you provide with the mifepristone?
Gomperts: I always prescribe 12 misoprostol pills. The reason is that we know from research that it’s always better to have more so that you can repeat doses if you’re a little bit longer in pregnancy. Before, we used to do eight, which is also okay, eight or 12. U.S. doctors usually do eight. Extra misoprostol helps in case there is too much bleeding. Misoprostol is like a miracle drug.
Baker: What kind of follow up care do you provide?
Gomperts: We have a help desk-a team of people that are specially trained to answer the questions posed by anybody reaching out to the service. There’s an intense training program and there’s medical supervision for them as well. They work in shifts so that they can go for 24 hours answering emails. All the emails are answered within 12 hours. And then we refer people to the M+A Hotline, which has doctors that answer any questions or concerns by phone or text. We also do a follow up email about three weeks afterwards or five weeks after the package has been sent so that we know exactly what was the outcome.
Baker: Do you do any sort of survey to gauge patient satisfaction?
Gomperts: Yes, we do that. That’s part of the follow up email that we send at five weeks. We ask if it was acceptable for them, if they would recommend it to other people in their situation. The satisfaction is incredibly high. It’s 98 percent. We have a very lenient reimbursement policy, so we refund people if there’s any problems or any reason they aren’t happy.
Baker: How many people have received care through Aid Access since you founded it in 2018?
Gomperts: More than 30,000 for sure.
Baker: Was there an uptick after S.B. 8 went into effect in Texas on September 1 last year?
Gomperts: Yes, absolutely. There was an increase in requests. But also with COVID, there were increased requests for telemedicine services.
Baker: Where are your patients coming from in the U.S.?
Gomperts: There’s a lot from Texas. But also New York and California, which are now served by U.S. providers. They have a lot of requests. These are not restrictive states, but many services are still expensive, and there’s a huge preference for telemedical abortions because it’s very convenient and people can stay at home, they don’t have to travel anywhere, they don’t have to organize childcare.
Baker: How many people work for Aid Access?
Gomperts: Together with me and the U.S. providers, it’s about 12 doctors that are using the system and at the moment about 10 help desk members. Then there’s a technical team to make sure that the website is always very secure, and well protected. That is another three people.
Baker: Do you provide advanced provision pills?
Gomperts: Yes. I think this is a medicine that should be available over the counter. It has the safety profile for that. It’s safer than many of the painkillers that you can buy in any pharmacy or drugstore. The reason why it’s not there has to do with politics and not medical science. Especially in states where abortion is getting harder and harder to access, it really benefits women’s health if they already have the medicines available when they find out they’re pregnant. What we know now is that so many people are using apps to track their menstruation-almost all young people are doing that-so they know the moment that they miss their period that they are probably pregnant. They do a pregnancy test, it’s positive and then the ordeal of finding an abortion service starts. The delays that are caused by that is really a shame because if they can use medications the moment they find out or think they’re pregnant, the medicines don’t have any side effects. It’s much better for somebody to take abortion pills really early in pregnancy. Then it’s like delayed menstruation, instead of when it’s later and becomes like a miscarriage with more bleeding and more pain and more stress.
Baker: Taking abortion pills in early in pregnancy feels like the normal cramping of menstruation?
Gomperts: Exactly. Yes. The misoprostol causes cramping of the womb, but if you use good painkillers like naproxen, it’s very doable. And it’s very comparable to menstrual cramps.
Baker: Have you received many requests for advanced provision pills?
Gomperts: Yeah, there’s definitely huge interest. I think one of the problems is that you would want it to be cheaper because it’s quite a lot of money to invest upfront on something you might not need. In an ideal world, they should be like the morning after pill-$30 perhaps.
Baker: Do you think we’ll get there someday?
Gomperts: Yes, absolutely. Of course. There’s no doubt about it. I don’t know how quickly the U.S. is going to get there because I think some things have to change. It seems the Supreme Court that is there now is not going to be very supportive of these kinds of ideas.
Baker: Recent research in the U.S. shows that people here want over the counter access to abortion pills. Are abortion pills available over the counter anywhere else in the world?
Gomperts: In Nepal, it’s quite easy to buy them from any pharmacy. You can buy most prescription medicines at pharmacies in Nepal. In India it’s the same. You can buy most prescription medication without a prescription. But it hasn’t been registered as an over-the-counter medication anywhere as far as I know.
Baker: Do you offer missed period pills?
Gomperts: Yes. I think that’s an area in between the advanced provision and the regular provision. I don’t see the benefit of not doing a pregnancy test to be honest. It just helps to confirm the pregnancy so as not to use them when you don’t really need them. But I’m totally open to having that conversation.
Baker: Is it legal for Americans to order abortion pills through Aid Access?
Gomperts: Yes.
Baker: Is it legal for pharmacies in India to send abortion pills to people in the U.S.?
Gomperts: Yes. And is it legal for me to prescribe them.
Baker: Five states prohibit self-managed abortion, but your service is physician managed so it wouldn’t fall under those laws, would it?
Gomperts: Right. Aid Access provides physician-supervised abortion. It’s not self-managed in that sense. But let me say this: All medical abortions are self-managed, period. People take the pills themselves, they have the cramps themselves, they have the bleeding themselves. So what is self-managed abortion? Everything is self-managed. So I don’t understand how they could ban that.
Baker: Could a woman’s order be detected by legal authorities in the U.S.?
Gomperts: In the U.S., there’s very strong protection of mail. Even if they track it down, there’s no way to prove that anybody took the pills. And to buy the medicines is not against any law. It’s not against any regulation to get medicines for your own use. I think one of the main problems with these laws is they are causing so much self-censorship. People become really scared of something that they don’t have to be scared of, according to the law. But of course, one of the problems in the U.S. is that there’s so much legal injustice anyway. Many people are in jail despite their innocence because they are forced to admit to something they never did because they know they don’t have a chance to win a court case. So all these things are intertwined with each other. Aid Access is about providing information so that people know what their rights are. It’s a human right to get abortion pills. Also, if they need to go to the hospital, they can say that they had a miscarriage. It’s the same treatment as when you have a medical abortion. And it’s nobody’s business whether you took the pills or not. What kind of medical care you get doesn’t depend on that. This is really about empowering women and pregnant people who do their own abortions, which they have a right to do with medicines, and empowering them so they understand that they shouldn’t be intimidated by police or anybody else. I think that is where we have a real big problem with the laws that are on the books. The intimidation is huge. That’s where you lose the power.
Baker: Why are you so passionate about offering abortion pills to people who don’t have access?
Gomperts: When somebody can’t get abortion pills on their own terms, that is a human rights violation. It doesn’t matter what kind of obstacles there are, whether it’s legal, financial, logistical, personal, private, preference-it doesn’t matter. Abortion should be available on your own terms, however you need it, whenever you need it, and in whatever way you need it.
Baker: When the Trump administration sent you that cease and desist letter in 2019, what was your reaction?
Gomperts: I stayed in my bed for three days, researching and reading everything that existed on the FDA regulations, calling all the people I could call in the U.S., trying to find a good lawyer. I just needed to understand whether I had overlooked anything when I started Aid Access. I came to the conclusion that it’s okay, I can do this.
Baker: What do you think of the recent FDA decision to lift some of its restrictions on the abortion pill mifepristone and allow telemedicine abortion?
Gomperts: It’s so encouraging that now telemedicine is accepted as a safe form of abortion provision. But the remaining restrictions suck. This control system is in place to dissuade people because it makes every pill traceable, which is not the case with any other medication. That is why the restrictions are still in place-it’s a form of dissuasion-with a finger, we will watch you. That is the only reason why the restrictions are in place, so they can trace back every pill and the person who buys it.
Baker: Why do your patients come to Aid Access?
Gomperts: It’s a mix. You have poverty-people who can’t afford a clinic-and preference-I just want to do it by myself, in my home, on my own terms.
Baker: What is your goal in providing this service to U.S. women?
Gomperts: To make sure that everybody has access who needs it, including people who don’t have any money at all. In the U.S., that’s really where there’s always been a problem with abortion services. There’s really a problem with financial obstacles to access any healthcare service if you’re poor and you’re not insured. I think our sliding scale system should be adopted by all the abortion services. It’s possible. If you let some people pay a little bit more than what it costs you, you can always cover the cost of the people that can’t afford it. There’s always this fear of abuse. But the systems that you put in place to control it are much more expensive. And most people, almost all people, are well meaning.
Baker: How does it feel to be able to help people in this way?
Gomperts: It’s really a privilege to be able to do it. It’s empowering for me, as well as for the people using the service. And it’s also empowering for the doctors to join the service. I think everybody really feels very excited about it.
Baker: Have you experienced any threats or harassment for providing this care in the U.S.?
Gomperts: Besides the FDA letter? No.
Baker: You have a long history of using art to raise awareness about medication abortion and to find creative ways to overcome legal restrictions. Are you still doing things like that today?
Gomperts: Yes, we are. The last campaign that we did was with robots in Mexico, where we had 10 robots delivering abortion pills in 10 states. The robots can deliver the abortion pills because they are controlled from a distance. They have the abortion pills in them and can deliver them from all over the world. I think it would be really nice to do an abortion robots campaign in the U.S. It’s very funny. Actually, it’s a robot that’s produced in Texas!
Baker: I love it! That would be really funny.
Gomperts: We were approached by quite a lot of people that are thinking about the abortion boats. I see the symbolic advantage of it in the U.S. Let’s see if people are going to do that.
Baker: What other projects are you working on?
Gomperts: My main project in the coming 10 years is to develop mifepristone as a weekly contraceptive. Fifty milligrams, which is a lower dose, is very good as a morning after pill. It’s safer and more effective than any of the existing morning after pills. If you use it weekly, it’s very effective as a contraceptive as well. If you take 50 milligrams of mifepristone every week, it prevents pregnancy. If you use it after you have unprotected sex, it also prevents pregnancy. And if you are already pregnant, you can use four tablets to end the pregnancy. We are trying to get research done that is needed to prove the safety and effectiveness of long-term use.
Baker: Is mifepristone effective for treating fibroids or endometriosis?
Gomperts: Yes, it is. It’s approved for that treatment in some countries-in Russia, India, and some other countries.
Baker: How do you make sense of what’s happening in the U.S. with regard to the rollback of abortion rights while many other countries are expanding abortion rights, such as Ireland, Argentina and Mexico?
Gomperts: I think it says something about the state of democracy in these countries. In the U.S., the democratic rule of law has been undermined for decades, not only with abortion rights but with voting rights. It’s part of a bigger trend.
Baker: Why do you think abortion is so controversial in the U.S.?
Gomperts: Because if you can prevent abortion, you can keep people poor. And when you keep people poor, you can control them. Poor people have no voice in most places. In any normal-thinking democratic country, you would think, I can decide that for myself and somebody else can decide that for themselves as well. But the reality is with the way that religion in the U.S., it has been used to restrict people’s rights.
Carrie Baker wrote this article for Ms. Magazine.
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This story was produced with original reporting from Carrie N. Baker for Ms. Magazine
Broadcast version by Lily Böhlke for Texas News Service/Public News Service
As the Supreme Court has allowed the Texas abortion ban to stand and is now poised to overturn Roe v. Wade this summer, people in states with restrictive abortion laws are finding creative ways to obtain abortion pills online, made easier by a recent increase in telemedicine abortion providers in many states.
In December, the FDA permanently lifted a longstanding in-person distribution requirement for the abortion pill mifepristone. In many states, this opened the door to telemedicine abortion, where providers screen patients online or by phone then mail them abortion pills. People in 24 states and DC can now access telemedicine abortion legally from providers within their states for as little as $150, with some services discounting the price to zero, if needed.
But 19 states have laws prohibiting telemedicine abortion. In these states, evidence suggests that people are finding new ways to access abortion pills, says Elisa Wells, co-director of Plan C, an organization that conducts research and publicly shares information about how people are accessing abortion pills in the U.S.
“As politicians continue to pass unjust laws that restrict access to these safe and effective medications, we know that people are finding alternate ways to access them,” said Wells. “We have a section on our website about creative ways people are accessing pills when they live in restricted areas to help people understand what we know people are doing and how to do it. There is absolutely no reason why modern telehealth abortion care should be restricted based on your zip code, and these folks are finding effective workarounds to get the care they need.”
Many people are getting abortion pills from outside of the U.S. by ordering them directly from online pharmacies. Researchers at Plan C have vetted many of these online pharmacies by ordering abortion pills from them and testing the pills for quality. On their website, Plan C lists websites that send quality medication, along with cost and shipping time, including Secure Abortion Pills (for $200, delivery in 14 days), Abortion Rx ($239, eight days), Generic Abortion Pills ($291, six days), Buy MTP Kits ($301, six days), Abortion Privacy ($380, five days) and Online Abortion Pills ($480, four days). These pharmacies do not require a prescription to obtain abortion pills.
Another option many people are using is ordering abortion pills through the Austria-based health care provider Aid Access, run by Dr. Rebecca Gomperts. Aid Access offers physician-supervised telemedicine appointments using online forms and then ships abortion pills to patients in the U.S. In states that restrict telemedicine abortion, the pills are shipped from India, which can take several weeks. In these states, Gomperts charges a sliding scale fee of up to $110.
A third option people in restrictive states are using is mail forwarding services to access telemedicine abortion care from health care providers located in U.S. states that allow it. Because providers are only allowed to mail pills to patients who have an address in the states where the provider is licensed to practice, people are renting a mailing address from mail forwarding services such as iPostal1.com or Anytime Mailbox to use for the telemedicine consultation. Then, they request the service to forward the pills to them in their home states.
“We actually did our own investigation to see if mail forwarding was possible, you know, in the same way that we order and test pills from online pharmacies to see what’s involved in that,” said Wells. They found mail forwarding did work.
On their website, Plan C details the process of how people are using mail forwarding to order abortion pills. People are renting an “address” in a state that has legal online abortion services for about $8-10 for one month plus a $25 online notary fee to get set up. They then do an online consultation with a provider in the state where they’ve rented the mailbox and list the forwarding service address as their shipping address.
Since clinicians are only allowed to serve people in the states where they are licensed, if asked, patients say that they are in the state where the clinic is located when doing the online, video or telephone consultation. Those who use a credit card for payment state needing to list the correct billing address associated with their credit card. This did not affect their ability to have the pills shipped to the forwarding service address.
When the mail forwarding service tells them that a package has arrived at their “address,” they ask for it to be forwarded to them at their home address. Sometimes there is a small fee for this, about $5. The rental is only needed for one delivery, so can be canceled after one month.
Using this method, people who live in states with restrictions on abortion health care have been able to access abortion pills by mail through U.S.-licensed clinicians.
“You have to jump through a few hoops to get a mailing address,” said Wells. “You have to provide two forms of ID and you have to have an electronic notarization done. It’s all online so you don’t have to go anywhere. You just have to upload some documents, and you have to pay some fees, about $40 total to get it set up and rent the address for a month. It does add a little bit of a delay-about four to five days.”
As an alternative, some people ask friends who live in a state that has telemedicine abortion access if they can have the pills shipped to the friend’s address and then pick it up from them. People who do this list their name followed by “c/o friend’s name” and then the full address. This helps prevent the package from being marked “addressee unknown” or “return to sender.”
Others use “general delivery” at a U.S. Post Office on the state border to reduce the distance they have to travel. “General delivery” means that mail is sent to a person at a specific U.S. office and the person receiving the mail goes there in person to pick it up with an ID that matches the name on the package. There is no need to set up a post office box and no charge for this service.
To use general delivery, people identify a nearby state that offers pills by mail. For instance, if they live in Tennessee, they could order from a service that is located in Georgia, Virginia or Illinois, depending on which state is closest to their location. Then, they look at a map to find the closest border town in the other state. For instance, someone living in Chattanooga, Tenn., might identify Rossville, Ga., as the closest town with a U.S. post office. Not all post offices offer general delivery, but many do. People can check to see if general delivery service is offered at a particular post office by searching for the town name on the U.S. Postal Service website.
After verifying that a post office will accept a general delivery package, they then contact a provider in the state that provides telehealth abortion and schedules a consultation. If asked, they say they are located in the same state as the provider at the time of the consultation. They provide the “general delivery” address to the clinic. They track the delivery using information provided by the clinic and go to the post office in person when the package has arrived. They make sure to take identification that matches the name on the package.
Wells warns that using creative ways to access pills without having to travel to another state may open people up to unjust prosecution.
“Lawyers have told us that a person is doing nothing wrong when they access pills in some of these creative ways, yet we know that some people have been criminalized for obtaining and taking pills on their own, and we know that criminalization in general falls heaviest on people who are already marginalized by our systems,” said Wells. “We always advise people to check with the free Repro Legal Helpline if they have questions about their legal risk. We want people to have as much information as possible so they can make the best decision for their situation.”
While people are finding creative ways to access abortion pills in states that restrict access, reproductive health advocates express frustration that they have to do so.
“Our whole system is broken,” said Wells. “Our medical system is broken. Our justice system is broken. We have modern medical health care available to us in the form of these pills and telemedicine. There is absolutely no reason why they shouldn’t be available to people across borders from doctors who are knowledgeable and willing to provide the service.”
Carrie N. Baker wrote this story for Ms. Magazine.
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Nearly 300,000 Kentucky women live in counties lacking a health center providing contraceptive methods such as the birth-control pill.
Advocates in eastern Kentucky say proposed legislation would boost access to the full variety of birth-control methods in rural counties and help lower the number of unintended pregnancies.
Mimi Pickering, team leader for All Access EKY, a project working to increase the availability of comprehensive reproductive-health services in Appalachia, said cost and the need to make frequent trips to health clinics or pharmacies to get and refill prescriptions are major barriers.
“And this can mean having to leave work or having to find and pay for child care,” Pickering explained. “Or, for many, locating transportation. So these are real obstacles to getting long-term and consistent access to birth control.”
Rep. Josie Raymond, D-Louisville, Rep. Attica Scott, D-Louisville, Rep. Kelly Flood, D-Lexington, and Rep. Susan Westrom, D-Lexington, sponsored House Bill 300, which would require insurance coverage of all FDA-approved contraceptive methods, with no cost-sharing and without the requirement for a prescription. Under the legislation, insurance companies also would have to cover a 12-month supply of contraceptives at one time.
Pickering pointed out when contraceptives are widely available and easier to acquire, pregnancy rates go down.
“It should be the goal of all Kentuckians, including members of the General Assembly, to reduce the number of unintended pregnancies in Kentucky,” Pickering asserted. “And the best way to do that is to increase access and affordability of birth control for all who desire to use it. “
A study by researchers at Washington University found providing birth control to women at no cost substantially reduces unplanned pregnancies and cuts abortion rates by 62% to 78%.
Tamara Weider, state director of Planned Parenthood Alliance Advocates, said another bill known as House Bill 3, would add onerous requirements for abortion providers and patients.
“It’s going to require patients to complete an in-person visit, effectively prohibiting safe telemedicine abortion,” Weider noted. “So these restrictions that are in House Bill 3 fly in the face of the current medical, scientific guidance.”
The bill is currently being considered by the Veteran’s, Military Affairs, and Public Protection committee.
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