The number of abortions in the United States has skyrocketed in recent years despite the Supreme Court overturning constitutional abortion rights in 2022 and 18 states banning first-trimester abortions. Spurred by restrictions, abortion rights advocates have pioneered new abortion pill delivery routes both inside and outside of the medical system that have revolutionized abortion access in the U.S. in ways anti-abortion policy makers will likely not be able to stop.
While 930,160 women obtained abortions through the medical system in 2020, that number grew to 1,033,740 in 2023, the first time in more than a decade that the number of abortions exceeded 1 million. In 2024, the number rose to 1,038,090, a .4 percent increase over 2023. In Mississippi—the state that brought us Dobbs, the case overturning Roe v. Wade—the number of those obtaining abortions from inside the medical system climbed from 2,850 in 2020 to 3,305 in 2023—a 16 percent increase in just three years. These numbers do not include abortions occurring outside of the medical system—estimated to be more than 100,000 since 2022.
There are many reasons for the rise in abortions: more unwanted pregnancies because states with abortion bans have also reduced access to contraception; the deterioration of social safety net programs that enable women to afford to bring pregnancies to term, such as child care, Medicaid expansion, food programs, and income supports; the medical dangers of carrying a pregnancy to term in states with abortion bans because of higher obstacles to obtaining emergency care if they experience complications later in pregnancy; and increased criminalization of pregnancy post-Dobbs that may disincentivize carrying a pregnancy to term. However, none of these factors explain how patients are accessing abortion in the more restrictive legal environment.
In my new book, Abortion Pills: U.S. History and Politics, I explain that the primary reasons for the expansion of abortion access despite state bans are the advent of telehealth abortion during the pandemic and the development of community support networks that provide free abortion pills to individuals living in restrictive states.
Inside the medical system, women in states with bans are accessing telehealth abortion from providers in eight states—California, Colorado, Maine, Massachusetts, New York, Rhode Island, Vermont, and Washington—that have telehealth provider shield laws allowing clinicians to serve those seeking abortions no matter where in the U.S. they reside. Six shield state providers—Abuzz, Aid Access, Choice Rising, The MAP, A Safe Choice, and We Take Care of Us with dozens of clinicians—are now mailing abortion pills to more than 10,000 patients each month. In addition, two international telehealth providers—Abortion Pills in Private and Women on Web—serve individuals seeking abortions throughout the United States.
Telehealth abortion care is more convenient, private, prompt, and affordable than in-clinic abortion services, which cost an average of $550. Telehealth abortion is available for $150 or less. For example, one provider—The Massachusetts Medication Abortion Access Project (The MAP), located in Cambridge, Massachusetts, and serving patients in all 50 states—charges $5 and up. Telehealth abortion has expanded access for those who live in rural areas and those who can’t afford to take time off from work to travel to cities, where most abortion clinics are located. Telehealth has also significantly increased the number of abortion providers. In Massachusetts, for example, the addition of 17 new telehealth clinics has more than doubled the number of abortion providers in the state. Telehealth providers offer prompt consultations, often asynchronously, and quick delivery of abortion pills by mail, compared to possible delays of a week or more for in-person appointments at brick-and-mortar abortion clinics. Telehealth abortion also means that patients do not have to walk through groups of aggressive—and often violent—anti-abortion protestors.
Many seeking abortions are now obtaining pills outside of the medical system from community support networks. Red State Access shares information about networks providing free abortion pills in every U.S. state and territory that bans or restricts abortion. A new community network called DASH is now providing abortion pills to people in restrictive states as well. Another widely used avenue for obtaining abortion medication is through websites such as Private Emma, Pill Pulse, Medside 24, Privacy Pill Rx, Life Easy on Pills, and ybycmeds.com, which sell pills for much less than what it costs to obtain them from medical providers in the U.S.
Multiple free and confidential resources are available to those seeking abortions, including the Miscarriage and Abortion Hotline, which provides caring and accurate information and support from experienced healthcare professionals; the Reprocare Healthline, offering anonymous peer-based support, medical information, and referrals; Self-Managed Abortion; Safe & Supported (SASS), a secure digital resource for accessing information and support; the Online Abortion Resource Squad (OARS), which moderates an abortion subreddit answering questions about abortion and providing support; and the Repro Legal Helpline, offering legal support. There’s even a chatbot, Charley, that can guide you through your options based on where you live and how far along your pregnancy is. The organization Plan C has a website that provides details on how to obtain abortion pills in all 50 states as well as U.S. territories and includes a vetted list of websites selling pills.
The convenience and affordability of abortion pills are critical because half of those seeking abortions in the U.S. live in poverty, and another one-quarter have a low income. Sixty percent already have children. Telehealth abortion, community networks, and websites selling pills enable those who lack transportation or who can’t take time off from work or afford child care to obtain abortion services.
These new avenues to abortion, both inside and outside of the medical system, work so well because the two medications used for abortion—mifepristone and misoprostol—are 97.4 percent effective and safer than Tylenol. Mifepristone blocks progesterone, which stops a pregnancy from developing. Then, 24 to 48 hours later, the patient takes misoprostol, which causes uterine contractions to expel the pregnancy tissue, usually within several hours.
This abortion access revolution has been hard fought and a long time coming, as I document in my book. The French pharmaceutical company Roussel Uclaf patented mifepristone in 1980 and the French government approved the medication in 1988, but American anti-abortion politics delayed FDA approval here for more than a decade. When the agency finally approved mifepristone in 2000, it slapped the drug with medically unnecessary and burdensome restrictions, mainly due to anti-abortion political pressure and threats of violence. The FDA limited who could prescribe mifepristone and required patients to make multiple in-person visits to obtain the medication. As a result, American use of the pills lagged far behind Europe’s.
Anti-abortion forces also blocked the development of mifepristone for treating fibroids, endometriosis, and postpartum depression, despite research showing its efficacy.
Finally, between 2016 and 2021, advocates convinced the FDA to lift some of its restrictions on mifepristone for abortion, such as in-person dispensing. That opened the door to increased access. Today, more than two-thirds of abortions occurring inside of the medical system are done with medications, and 20 percent of all abortions are done through telehealth services.
Anti-abortion activists and politicians are working on multiple fronts to restrict abortion pill access, including filing a federal lawsuit to reverse FDA approval of mifepristone to eliminate telehealth abortion or remove mifepristone from the market entirely; threatening to misuse an 1873 anti-obscenity law called the Comstock Act to prosecute anyone mailing abortion pills criminally; civilly suing and criminally indicting shield state telehealth abortion providers; criminalizing the possession of abortion pills by making them controlled substances; and criminalizing the use of abortion pills (which no state has yet done). Meanwhile, supporters of abortion rights have filed lawsuits to remove the remaining FDA restrictions on mifepristone, as well as challenging states’ limits on abortion pills, arguing that they are preempted by federal law. In addition, they’re defending, strengthening, and expanding shield laws for telehealth abortion providers.
In my book, I chronicle the creative, determined, and courageous activists who brought abortion pills to the country in the 1990s and who have recently revolutionized abortion pill access despite growing restrictions on abortion in many states. “Abortion pills are here to stay,” Elisa Wells, Plan C’s cofounder and codirector, said after Donald Trump was elected. “Community distribution networks and overseas providers will remain intact, and abortion pills will continue to come into the country.”
