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.

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 won re-election; challenger Republican Attorney General Daniel Cameron had also made abortion a huge focus of his campaign and gave voters varying answers on whether he would support exceptions to Kentucky’s near-total abortion ban 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.”

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.

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 lots of 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-streamed their 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 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 (he said his opinions are his own and do not reflect the opinions or positions of South University). 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.”

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. The physician who pioneered this work, Dr. George Tiller, was villainized by Fox News years before an anti-abortion advocate 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 this clinic as the “end of the line,” the last place 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.”

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