Women turn to at-home abortions, as unregulated pill sites expand operations

Jane was living in rural New Mexico when she discovered she was pregnant. She never wanted to have children or carry a pregnancy and knew immediately she wanted an abortion.

But while abortion remains legal in the state, she says she also didn't want to take her chances with long waitlists at a clinic or a sudden change in the law that would put her in limbo. She had volunteered at an abortion hotline years ago and knew that even before the Supreme Court decision to overturn Roe v. Wade, waiting periods and mandated ultrasounds can cost extra time and money.

So, instead she turned to her closet, where she kept a package of abortion pills purchased online for $150 after an earlier pregnancy scare.

Rather than a doctor, she relied on the counsel of a few close friends and called the M+A Hotline, an anonymous help line that counsels women experiencing miscarriages and abortions.

"I was not in a place where I could call a bunch of (clinics), and get 'no's,'" said Jane, who agreed to tell her story on condition that ABC not use her real name -- or identify the online pharmacy she used -- because of privacy concerns and fear of criminal prosecution.

"I wanted certainty," she added. "And I didn't want to be pregnant."

Less than five months after the fall of Roe v. Wade, the impact on women across the country has become almost impossible to measure. Abortion access has become considerably more restricted on paper – at least 14 states have ceased nearly all legal abortion services, including prescriptions for medication abortions. Data released this week estimated there were 10,670 fewer legal abortions since the Supreme Court decision.

But advocates say those numbers aren't telling the whole story. They estimate that demand for abortion pills has exploded, even in states where abortion remains accessible because of the legal uncertainty.

Stepping in to fill that demand are online pill brokers that are buying generic versions of the drugs in bulk from pharmacies in India, Russia and Vietnam. The drugs are then shipped illegally to U.S. consumers at a significant markup -- as much as 10 times the original cost or higher -- but still a fraction of the $400 to $500 price tag charged by many abortion clinics, advocates say.

The result in many cases is that online abortion medication is emerging as a cheaper, easier option, if also unregulated in many cases.

"We have known for a long time -- even when people have access to clinics -- that some people may prefer other routes of access because of privacy, convenience or cost reasons," said Elisa Wells, founder of the online abortion site Plan C, which helps people find services that will deliver abortion medication.

While a precise accounting of self-managed abortions is nearly impossible, there's no doubt it's growing dramatically, she said.

"There's a big market for these pills," Wells said.

Mifepristone, also sold under the brand name Mifeprex, has been available in the U.S. for 22 years. It works by blocking the hormone progesterone needed to continue a pregnancy. It is typically prescribed with a second drug, misoprostol, which causes cramping and bleeding to empty the uterus.

Under rules by the Food and Drug Administration, only certified providers can prescribe mifepristone to someone less than 10 weeks pregnant. The person must be screened for potential health complications like bleeding disorders. They also would would want to rule out an ectopic pregnancy, which requires immediate life-saving treatment.

While state rules can be stricter, or might ban the drug outright, the FDA says mifepristone is safe enough to be offered via telehealth and mailed to a person's house without seeing a doctor in person -- so long as it comes from one of two government-inspected manufacturers -- Danco Laboratories and GenBioPro.

"You should not buy Mifeprex or its approved generic over the Internet because you will bypass important safeguards designed to protect your health," the FDA warns online.

Still, as Americans in recent decades have crossed the U.S.-Canadian border for cheaper insulin or flown to India for more affordable medical procedures, many women post-Roe appear to be bypassing these warnings and state laws to get the abortion pill delivered to their doorstep.

One site, Medside24, said it's based in Kazakhstan and ships medication into the U.S. from overseas. The company said it began operations three years ago as an anonymous "no questions asked" way for people to access the drug.

In answers to questions emailed by ABC, the company said its suppliers can change based on availability but generally come from Vietnam, Thailand, China and Russia. It said it takes about a 30% profit margin -- down this year from 50% as manufacturers raise their prices to supply the drug.

Medside24 said its abortion medication is "genuine because we use them in our family planning clinics in Kazakhstan" and have never had a problem.

When asked about the FDA's warning not to use unregulated medications procured from overseas, the company said it's not surprising a U.S. regulatory agency would discourage use of any product it can't control.

"If the kits are used according to instructions then it would be fine," the company wrote in a statement.

A research paper published Tuesday in the medical journal JAMA found another online site Aid Access -- which offers women telehealth appointments and writes abortion prescriptions filled by a pharmacy in India and shipped to their home -- saw a spike in requests for pills from the U.S. following the Supreme Court decision. Requests increased the most in states with near-total bans, including Louisiana, Mississippi, Arkansas, Alabama and Oklahoma.

"The evidence that we've seen shows us that when you ban or severely restrict abortion, you don't do anything to change the need for abortion. But what you seem to do is change how and where people access care," said Dr. Abigail Aiken, a professor of public affairs at the University of Texas at Austin and one of the co-authors on the study, in an interview with FiveThirtyEight.

Other online pharmacies appear to offer little or no medical evaluation, shipping the medication directly with few questions asked.

That leaves many people getting abortions with medical concerns that they can't always take to their doctor due to fears of prosecution. April Lockley, the medical director of the M+A Hotline, which answers medical questions about miscarriages and abortions but does not provide access to abortion medication, said the line saw an uptick in calls after Texas passed its abortion ban and again after the Supreme Court decision last summer. She said the hotline is currently averaging about 25 to 50 contacts per day.

It's not immediately clear whether the FDA has any of these online pharmacies on its radar, or if the agency has the bandwidth or appetite to go after them. While the agency has written stern warning letters to Aid Access, no other enforcement actions have been made public.

Online medication abortion is an option that Texas resident Jessica Garza wished was on her radar last year when she found out she was six-weeks pregnant.

Garza said she was struggling with severe depression following the traumatic birth of her daughter six months prior. A stay-at-home mom, she arranged to travel to Louisiana, which at the time allowed surgical abortions.

At the clinic, Garza faced a lengthy wait list and state-mandated restrictions that meant she had to make the trip multiple times. She was 15 weeks along before she could get the abortion – a wait she described as agonizing and traumatic.

"I believe if I was forced to carry that pregnancy to term – I don't think I would have survived it. I was in such a bad place," said Garza.

For Jane, she said she has no regrets working outside the system.

"As much as I worried about what I Googled and who I texted – going to a clinic physically in some ways felt more visible and legally risky," she said.

With clinics, she said, "you've got to cross borders and you've got to cross picket lines. No thank you."