A blanket given to Anne Angus at the Boulder Abortion Clinic in Colorado, one of the only clinics in the country that offers termination after the second trimester. Angus said a former patient makes the blankets, called Bananas for Annie, for others who had to terminate for medical reasons. (Courtesy of Anne Angus)

Editor’s note: This is the fifth installment of an occasional States Newsroom series called When and Where: Abortion Access in America, profiling individuals who have needed abortion care in the U.S. before and after Dobbs. The first installment can be found here, the second installment is here, the third is here, and the fourth ishere.

Anne Angus has been ready to start growing her family for years now.

She got pregnant on her first try and felt lucky to escape the morning sickness and extreme fatigue that often comes with the first trimester of pregnancy. She quit her job in anticipation of being a full-time mom.

“It was so exciting, I was so ready,” said Angus, who lives in Montana.

She’d bought a few items off Facebook Marketplace by the time she was close to the halfway point, including a bassinet, some toys, a bouncer — and the teddy bear onesie that she holds onto when she tells the story of her doomed pregnancy.

At her routine 19-week anatomy scan, Angus’ doctor said something didn’t look right with the abdomen. But that could mean any number of things with varying degrees of severity, according to her doctor, and they wouldn’t know more until further tests could be completed. And those tests would need to be done by a team of specialists almost 700 miles away, at a children’s hospital in Denver, Colorado. Her appointment was four weeks out from the anatomy scan.

At the end of a series of tests, she met with a team of doctors at the children’s hospital to discuss the diagnosis and next steps. It was called Eagle-Barrett Syndrome, a rare genetic defect that can cause the partial or complete absence of stomach muscles, urinary tract malformations and abnormalities of the testes.

“The little glands running from the kidney to the bladder — his were three times the size of an adult’s,” Angus said. “You’re not even supposed to be able to see them at an ultrasound, let alone have them be very obvious.”

There’s a 50-50 chance her future pregnancies would have the same mutation, which led her to decide in vitro fertilization was the safer way to get pregnant and be able to test embryos prior to implantation in the uterus. But like abortion, access to IVF treatments is becoming another political argument at the state and federal level, leaving Angus to worry that her remaining option for having a child is also at risk.

Following Dobbs decision, clinic was overrun with patients

Before arriving in Denver, Angus had told her husband that even if the diagnosis was severe, she didn’t want to terminate. He understood and supported whatever decision she wanted to make, she said.

But after determining the status of the fetus’ condition, the Denver doctors started to discuss dialysis, kidney transplants, and a variety of other courses of treatment that would be needed after birth.

“All of which sounded to me like they would just be experimenting on my baby, with the experiment being, ‘How long can we keep him alive?’” Angus said. “That did not feel loving and compassionate to me.”

While talking it over with her husband, Angus said they discussed a family member who had a terminal illness.

“It has been devastating to the family to watch this person’s pain increase as they slowly fall apart over the years,” she said. “We didn’t want that for our son.”

It was at that time that they made the decision to let him go without the medical interventions and the idea that he might just slowly slip away in a neonatal intensive care unit, she said.

By that time, it was mid-October 2022, four months after the Dobbs decision that allowed states to once again regulate access to abortion and the ensuing legal and legislative chaos. One of the only places in the country where Angus could terminate at her stage of pregnancy was a clinic in Boulder, Colorado. Montana has a gestational age limit of 21 weeks for termination, so she knew she couldn’t go back home.

“That clinic (in Boulder) was overrun because all of the states that used to have access now didn’t have it, or they were being pushed until much later,” Angus said. “We had a two-week wait from when we made the decision.”

By the time she got to the intake appointment, she was at 26 weeks. There were protesters outside of the clinic, so an escort with an umbrella covered Angus and her husband as they walked inside.

“I remember feeling so much anger and rage at them. You have no idea what’s going on,” she said. “You don’t care at all about my baby’s suffering if he’s born.”

The termination was a few days later. Angus said it was difficult to face the reality of letting go of any shred of hope she had left.

“That was probably the most scared I’ve ever been. Nobody talks about what it’s like to get an abortion at the end of your second trimester. What am I supposed to feel? What’s going to happen? Who do I talk to about this?” she said.

After the procedure, the doctor told her it was a difficult process because of the amount of water retention in the fetus’ body. Angus said she could tell just by looking at him.

“I didn’t see his whole body just because of how medically fragile he was, but you could just tell that it would’ve been a really ugly death for him earthside,” she said.

Insurance didn’t cover the costs. With the travel, lodging and the price of the procedure, Angus and her husband spent $10,000 of their savings.

Frustration continues for Angus as IVF becomes new political target

Throughout 2023, Angus had many appointments for egg retrievals, but she said the process has been emotionally and financially draining.

“We are extremely lucky that my husband has benefits through his work, but we’re also at the end of (those benefits), which is why this is our last IVF retrieval cycle,” she said.

She has a planned embryo transfer in September, but if it’s not successful, she worries about future political decisions around IVF limiting her options. There is only one clinic that offers IVF treatment in Montana.

The Alabama Supreme Court ruled in February that embryos are “children” and several IVF clinics in the state closed their doors over liability concerns. In the months since, some states have taken steps to ensure access to the treatment, but congressional bills to protect IVF federally have failed to advance and a politically influential religious sect came out against it for ethical reasons, potentially igniting more ideological battles.

The new political fight over IVF on top of her experience getting an abortion has made Angus fearful about not having explicit protection for the treatment in her state. It has also made her passionate about telling her story, including at the Montana Legislature in early 2023, when legislators did not advance a bill that would have eased some of the remaining restrictions to abortion access in the state.

Although access is still broadly available in Montana, Republicans have tried to change that since the Dobbs decision. Gov. Greg Gianforte signed several anti-abortion bills in 2023, including a 20-week ban, but they’ve so far been blocked in the courts. Gianforte continues to use executive authority to try to limit Medicaid funding and who can perform abortions.

Republicans in the legislature have also made it clear they don’t support a November ballot initiative to amend the state constitution with a right to abortion access, and at least one candidate endorsed by a national anti-abortion group is running for a congressional seat.

“I’m so angry that politicians are inserting themselves into an extremely intimate part of my life. I am trying to grow my family in a way that I can and in a way that is loving and sustainable, and they think they know better than me, and I am so insulted by that,” she said.

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After justices rejected the legal standing of anti-abortion doctors, activists search for plaintiffs that say they were harmed by the drug Mifepristone, an FDA-approved for pregnancy terminations. (Photo by Chris Coduto/Getty Images)  

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

Mifepristone is one of two drugs used to treat miscarriages and terminate a pregnancy during the first trimester, and is the most common method of abortion in the U.S.

Anti-abortion groups, in conjunction with conservative religious law firm Alliance Defending Freedom, sought to revert the FDA guidelines to 2016, when the prescribed gestational time frame was three weeks shorter and there were more requirements around who could prescribe it and where and when provider visits had to take place.

The case made its way to the nation’s highest court after outspoken anti-abortion U.S. District Judge Matthew Kacsmaryk in Texas ruled that mifepristone’s approval should be revoked, followed by a Fifth Circuit Court of Appeals opinion that agreed in part, saying the restrictions should revert to pre-2016 rules.

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

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

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

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

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

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

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

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

Three intervenor states expected to continue fight at district court level

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

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

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

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

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

Abortion opponents target abortion drugs from multiple angles 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Protesters gather outside the U.S. Supreme Court on Wednesday, April 24, 2024, while justices hear oral arguments about whether federal law protects emergency abortion care. (Sofia Resnick/States Newsroom)

U.S. Supreme Court justices spent two hours Wednesday morning debating whether a federal law about emergency treatment encompasses abortion care even in states with strict abortion bans, with no clear indication of how they may ultimately rule.

A decision could come as soon as the end of June whether Idaho’s near-total abortion ban means doctors who might need to terminate a pregnancy during a health emergency would be protected from prosecution under the Emergency Medical Treatment and Labor Act, or EMTALA, a federal law that requires hospitals to treat patients who come to an emergency room regardless of their ability to pay. That includes treatment to prevent serious damage to bodily functions.

If the court decides the law does not provide that protection, then hospitals and doctors in Idaho have said they will have to continue transferring patients out of state for that treatment. Since January, when the court decided to take the case and struck down an injunction that provided protection under EMTALA, transfers out of state for pregnancy complications that may require termination increased from one in 2023 to six over the course of four months.

The court’s liberal wing — Justices Sonia Sotomayor, Elena Kagan and Ketanji Brown Jackson — ​​questioned Idaho Deputy Attorney General Josh Turner about what EMTALA explicitly says about stabilizing treatment and whether abortion procedures fall into that definition when complications occur before a fetus can survive outside of the womb.

Turner argued that Idaho’s law should supersede federal law in the case of abortion procedures, even if it goes against commonly accepted medical care standards.

Sotomayor rejected that argument.

“There is no state licensing law that would permit the state to say, ‘Don’t treat diabetics with insulin. Treat them only with pills,’” Sotomayor said. “Federal law would say you can’t do that.”

She said federal law requires treatment of a person who is at risk of serious medical complications without that treatment, but Idaho’s law does not provide that much leeway.

“Idaho law says the doctor has to determine not that there’s really a serious medical condition, but that the person will die. That’s a huge difference, counsel,” she said.

Idaho’s abortion ban went into effect in August 2022, a few months after the U.S. Supreme Court issued its Dobbs v. Jackson Women’s Health Organization decision that overturned Roe v. Wade, ending federal protection for abortion access and allowing states to regulate it instead. Providers who are prosecuted for performing an abortion are subject to two to five years in prison plus the loss of their medical license, and they are also subject to civil enforcement laws by any family members related to the person who had the abortion.

Doctors are subject to prosecutorial discretion in Idaho, deputy AG says

The justices repeatedly asked Turner to identify situations where a doctor might provide an abortion as part of stabilizing care and it would not be allowed under Idaho law. He continued to point to the state’s exception to save a patient’s life and referred to a doctor’s “good faith medical judgment” being enough to avoid prosecution.

The government listed nine emergency medical conditions where termination of the pregnancy may be the recommended treatment to stabilize a patient’s condition, including when the water breaks before a fetus is viable or when a patient experiences uncontrolled high blood pressure or bleeding. Idaho doctors identified one recent “traumatic” case when a patient had to wait until advanced infection set in before the doctor felt secure enough to end the pregnancy. Others are sending patients out of state as soon as termination might be needed to avoid having to wait until they meet qualifications under Idaho’s exception to prevent death.

Justice Amy Coney Barrett, considered one of the court’s more conservative members, said Turner was hedging in his answers and asked what happens if another doctor or prosecutor reaches a contrary conclusion about what the appropriate medical treatment should have been.

“That, your honor, is the nature of prosecutorial discretion,” Turner said.

Barrett also asked if Idaho had released any legal guidance about its abortion laws, the way a federal health agency might issue guidance. Turner said the “guiding star” is the Idaho Supreme Court’s opinion from August 2022 interpreting the abortion statute, where it said the law does not require imminence of death or medical certainty for a physician to intervene. The Idaho court also said another doctor’s opinion would only be considered if they accused the doctor who performed the abortion of acting in bad faith.

U.S. Solicitor General Elizabeth Prelogar said for those reasons, women in Idaho are not getting the treatment they need, often in already-tragic situations where a wanted pregnancy is lost because of complications.

“They are getting airlifted to Salt Lake City and to neighboring states where there are health exceptions in their laws,” she said. “The doctors can’t provide the care until they can conclude that a prosecutor looking over their shoulder won’t second guess that maybe it wasn’t really necessary to prevent death.”

Conservatives ask about conscience objections, expansion of ‘emergency’ definition

The more conservative justices offered mixed questions to Prelogar, who argued on behalf of the government. Justice Neil Gorsuch posed questions related to the federal Supremacy Clause about when federal law can override state law in the context of medicine, while Barrett asked whether conscience exceptions exist for doctors who don’t feel comfortable terminating a pregnancy even in emergency situations. Or if a hospital did not want to provide the procedure, such as a Catholic hospital, would be exempt under EMTALA for conscience reasons. One of Idaho’s largest hospital systems, Saint Alphonsus, is a Catholic hospital.

Prelogar confirmed that yes, individual doctors and entire medical entities qualify for those conscience objections and are therefore not required to perform an abortion under EMTALA. But at a hospital that did not have a blanket objection, they would take individual objections into consideration for appropriate staffing so that there is always someone available to provide that care if necessary.

“If the question is, could you force an individual doctor to step in over a conscience objection, the answer is no, and I want to be really clear about that,” Prelogar said.

Justice Sam Alito also asked Prelogar if EMTALA could be understood to apply to other emergency situations such as a mental health emergency, if someone was expressing suicidal thoughts and wanted to end their pregnancy to resolve those thoughts. Idaho’s legal representation, conservative religious law firm Alliance Defending Freedom, argued in its brief to the court that a ruling in favor of EMTALA protection would allow such situations to occur. Prelogar said no, the proper treatment would be to administer medications to alleviate the suicidal thoughts.

“There can be grave mental health emergencies, but EMTALA could never require pregnancy termination as the stabilizing care … because that wouldn’t do anything to address the underlying brain chemistry issue that’s causing the mental health emergency in the first place,” Prelogar said. “If she happens to be pregnant, it would be incredibly unethical to terminate her pregnancy. She might not be in a position to give any informed consent.”

Demonstrators, legislators from Idaho comment on court case

Hundreds of abortion rights advocates, medical professionals and two Idaho legislators gathered outside the U.S. Supreme Court building in Washington, D.C., on Wednesday morning before the arguments advocating for the court to uphold EMTALA as a guiding principle regardless of state abortion laws. On the anti-abortion rights side, Idaho-based crisis pregnancy center Stanton Healthcare argued the case was about forcing states with abortion bans to perform them. Danielle Versluys, the organization’s chief operating officer, said women with complications should deliver a baby naturally, regardless of the circumstances.

“The outcome is the same — a dead baby — but the difference is one is natural, and the other is not,” she said. “And one allows the woman the natural process to give birth and to grieve, and the other one is unnatural.”

Rep. Ilana Rubel, a Democrat and the legislature’s minority leader, told States Newsroom the case is a waste of state taxpayer dollars.

“It is, frankly, stunning that leaders in our state think that this is something they want so badly they were willing to take it to the Supreme Court to deprive women of appropriate care in medical emergencies,” Rubel said. And with the Idaho Legislature adjourned for the year, she added, “If the Supreme Court does not give us EMTALA back, there will be no lifeline for women at least until 2025.”

States Newsroom reproductive rights reporter Sofia Resnick contributed to this report.

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Anti-abortion and abortion rights activists protest during the 50th annual March for Life rally in front of the U.S. Supreme Court on January 20, 2023, in Washington, DC. Anti-abortion activists attended the annual march to mark the first to occur in a “post-Roe nation” since the Supreme Court's Dobbs vs Jackson Women's Health ruling which overturned 50 years of federal protections for abortion healthcare. (Photo by Chip Somodevilla/Getty Images)

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WASHINGTON, DC - JANUARY 20: Anti-abortion and abortion rights activists protest during the 50th annual March for Life rally in front of the U.S. Supreme Court on January 20, 2023 in Washington, DC. Anti-abortion activists attended the annual march to mark the first to occur in a “post-Roe nation” since the Supreme Court's Dobbs vs Jackson Women's Health ruling which overturned 50 years of federal protections for abortion healthcare. (Photo by Chip Somodevilla/Getty Images)

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Anti-abortion protesters gather outside A Preferred Women’s Health Center of Atlanta in Forest Park. (Ross Williams/Georgia Recorder)

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Latin American obstetrician doing an ultrasound on a pregnant woman at the hospital - healthcare and medicine

A study from the University of Washington released Monday shows maternal mortality rates more than doubled in some states between 1999 and 2019, with sharp increases for some racial and ethnic groups.

Researchers touted it as the first study to provide such maternal mortality calculations for every state. Previous reports have not included rates for states with fewer than 20 maternal deaths, which is nearly half of all states, the report shows.

The study assembled information about people who died while pregnant or up to one year afterward. Causes often include hemorrhage, heart conditions, infections and high blood pressure, all of which can develop even months post-delivery, because of the ways the body changes and reacts to carrying and birthing a baby.

Dr. Greg Roth, a cardiologist and associate professor of medicine at the University of Washington, said the study did not evaluate potential causes of deaths, but the university intends to examine those subjects in follow-up studies. He said based on his own experience in medicine, the deaths often point to the conditions in which people live and work.

“The map of maternal mortality looks like the map of social determinants of health,” Roth said. “Regardless of what the political situation is in a particular state, social determinants of health are going to drive maternal health.”

Studies over the past decade or more have often revealed large disparities between Black and white populations in maternal mortality rates, particularly in the South, where poor access to health care, gaps in insurance coverage and other social supports have historically been associated with high mortality rates.

“One of the key messages here is that we have to focus on women’s health before, during, at the time of delivery, and after pregnancy,” Roth said. “That sounds a lot like easily accessed, universal, low-cost primary care along with high-quality obstetrician care.”

Recent data in Mississippi, where a near-total abortion ban is in place, shows those trends are worsening. Doctors are expressing concern and confusion about reproductive health care laws in states like Louisiana, which is limiting essential care.

More than 150% increase for Indigenous people in five states

Researchers compiled data on deaths and live births from the National Vital Statistics System and used a special modeling method to estimate maternal deaths over the 20-year timespan and calculate a maternal death risk for each racial and ethnic group by state, which takes into account population increases over that time.

The authors said there is incomplete data around causes of death that were unable to be analyzed for this study, and a checkbox indicating the person was recently pregnant was added at different times in various states over the course of a decade.

Despite those factors, Roth said even after every state included the checkbox on death certificates, the trends continued to go up. Roth said there is early data indicating the number of deaths increased even more throughout the pandemic.

“It’s very clear from our results that this is what’s actually happening,” Roth said.

The study, published in the Journal for the American Medical Association on Monday, showed five states with a 93% increase in Black maternal mortality rates: Louisiana, New Jersey, Georgia, Arkansas and Texas.

But researchers also noted large increases of more than 162% among Indigenous people in Florida, Kansas, Illinois, Rhode Island and Wisconsin, where those spikes have not been highlighted as often. The data showed both physical conditions like hemorrhages and mental health were major contributors to their pregnancy-related deaths.

In the Asian, Native Hawaiian or Other Pacific Islander category, five states saw an increase of over 83%: Kansas, Illinois, Missouri, Michigan and Georgia.

Pregnant Hispanic people or those who’d recently given birth in Indiana, Minnesota, Georgia, Tennessee and Illinois died more than twice as often in 2019 than two decades before.

Roth said the modeling process allowed researchers to create accurate and complete results even from small amounts of data while protecting individual privacy.

“One of the challenges looking at maternal mortality within states is that it is still a relatively rare event for a woman to die during or following pregnancy,” Roth told States Newsroom. “(The model) makes use of all that information to (calculate) a risk of maternal death occurring. In any given year, there may be no maternal deaths in smaller populations, but it still gives you a risk assessment.”

High-risk OB-GYN: Abortion bans could worsen maternal death rates

Dr. Allison Bryant, a high-risk obstetrician-gynecologist for Mass General Brigham in Massachusetts, is chair of the state’s maternal mortality review committee and acted as a content expert for the study.

Bryant said the data confirms much of what was already known about trends, but it is even more important now that 15 states have near-total bans on abortion. People who become pregnant unintentionally and can’t get an abortion may become more likely to overdose or die by suicide, particularly those with existing addiction or mental health issues.

Additionally, she said more pregnancies may be carried to term that aren’t healthy and could cause death rates to rise.

One state, Idaho, failed to renew its maternal mortality review committee during its 2023 legislative session. It will become the only state without a committee that examines each maternal death in detail in July, amid doubling maternal mortality rates, specialized obstetrician-gynecologists leaving the state and clinics shutting down after the state’s new abortion restrictions.

Maternal deaths can signal broader trends to monitor, researchers say

Nationally, the maternal mortality rate is two to four times higher for the non-Hispanic Black population than non-Hispanic whites, the research showed.

According to the study, the states of Oregon, Hawaii, Colorado, Illinois, Wisconsin, Delaware, Vermont and Rhode Island had lower 2019 maternal mortality rates across all racial and ethnic groups, “suggesting that either underlying risk factors that drive maternal deaths are lower in these states, or that prevention efforts have had some success in these locations.”

Populations with high maternal mortality related to cardiovascular conditions also tend to happen in areas with high rates of cardiovascular disease in general, according to Roth.

“We think in many ways, a maternal death is a canary in a coalmine, it’s a signal not only that there was a terrible tragedy, and we need to develop interventions, but also that we need to make sure that we are looking at the health of that population where the woman was living and understand why vascular risks are much more common there,” Roth said. “In many ways, this is not a problem of inventing new solutions, but rather making sure that the good, well-tested solutions that we know work actually get used.”

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ROCKVILLE, MARYLAND - APRIL 13: In this photo illustration, packages of Mifepristone tablets are displayed at a family planning clinic on April 13, 2023 in Rockville, Maryland. A Massachusetts appeals court temporarily blocked a Texas-based federal judge’s ruling that suspended the FDA’s approval of the abortion drug Mifepristone, which is part of a two-drug regimen to induce an abortion in the first trimester of pregnancy in combination with the drug Misoprostol. (Photo illustration by Anna Moneymaker/Getty Images)

America’s major medical institutions and drug policy scholars have roundly denounced as “pseudoscience” many of the claims brought by anti-abortion groups in a high-profile federal lawsuit asking the Food and Drug Administration to revoke its 23-year-old approval of mifepristone, one half of a two-drug regimen that has become the most common form of pregnancy termination post-Roe v. Wade.

But the appeals court’s three-judge panel that heard oral arguments Wednesday appeared to be persuaded not by the medical consensus in this case, but by some of the evidence brought forward by plaintiffs that consists largely of anecdotes, speculation, and cherry-picked studies brought by a handful of anti-abortion medical groups and doctors.

Medical and public health societies led by the American Medical Association submitted a “friend of the court” briefbefore the 5th U.S. Circuit Court of Appeals, stating that the lower court’s ruling “relies on pseudoscience and on speculation, and adopts wholesale and without appropriate judicial inquiry the assertions of a small group of declarants who are ideologically opposed to abortion care and at odds with the overwhelming majority of the medical community and the FDA.”

While asking a question of U.S. Deputy Assistant Attorney General Sarah Harrington, Judge Jennifer Walker Elrod referred to mifepristone cutting off “nutrition” to the fetus, which is a false claim cited in the initial ruling written by Texas federal Judge Matthew Kacsmaryk in April. Kacsmaryk referred to mifepristone as a “synthetic steroid that blocks the hormone progesterone, halts nutrition, and ultimately starves the unborn human until death.”

According to Johns Hopkins Medicine, the progesterone hormone is produced in early pregnancy to help thicken the lining of the uterus to support implantation of a fertilized egg. Without that hormone stimulation, which mifepristone blocks, the lining breaks down and the pregnancy cannot continue. It is then followed by doses of misoprostol to induce contractions and expel the pregnancy.

Former President George W. Bush appointee Elrod – like her fellow Donald Trump appointee Judges James C. Ho and Cory T. Wilson – shares ideological views on abortion with the plaintiffs’ anti-abortion coalition, which is represented by the Alliance Defending Freedom. So does Kacsmaryk, whose since-blocked decision to suspend FDA approval of mifepristone cites anecdotal evidence from plaintiffs.

Mifepristone remains legal and on the market as the case winds its way through the legal system, and data from the FDA since the drug’s initial approval in 2000 shows it is overwhelmingly safe to use. Out of an estimated 5.6 million people in 23 years, 28 deaths have been associated with the FDA’s abortion medication regimen, which is a markedly lower rate than many common FDA-approved drugs, like Tylenol and Viagra. And as the FDA has noted, that number includes fatal cases “regardless of causal attribution to mifepristone,” such as people who died from homicide, suicide, and pulmonary emphysema.

If the plaintiffs prevail, health care providers, medical institutions and pharmaceutical industry organizations have warned of its potentially catastrophic consequences. In addition to radically reducing access to abortion nationwide, removing mifepristone from the market would reduce access for miscarriage treatment, public health experts say, and have far-reaching consequences beyond abortion.

“The implications of this case are extraordinary, and they include the potential termination of access to mifepristone, a precedent for court interference in the FDA’s rigorous and science-based testing and approval process not just for mifepristone, but for any drug,” said Joanne Rosen, a senior lecturer in the departments of Health Policy and Management and Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health, during a media briefing hosted by the university Thursday. “This would be the first time in history that a court has abrogated the FDA’s approval of a drug over the objections of the FDA.”

Sympathetic, cynical and combative exchanges

The appeals court judges seemed sympathetic to the narrative brought by the plaintiffs that mifepristone is a dangerous drug, as they were in their previous opinion blocked by the Supreme Court, which would have restricted the use of mifepristone. A big question in this case has been whether the coalition of anti-abortion medical groups and four doctors, including Indiana state Sen. Dr. Tyler Johnson, have standing to sue. Plaintiffs have argued their doctors would suffer direct harm if mifepristone remains on the market.

Like medical and legal scholars following this case, Rosen said plaintiffs’ arguments for standing are weak, and if accepted would open the door to any group that wants to challenge the FDA’s approval of a drug for any reason.

Plaintiff groups argue that their member doctors could be overwhelmed with a potential future influx of emergency room visits from mifepristone patients, or forced to treat an abortion patient against their will. These claims are based not on robust data but largely on the testimony of handful of plaintiff doctors, three of whom give mostly non-specific anecdotes about treatment they performed for women who allegedly had taken some form of medication abortion, but it’s not clear when the procedures took place and whether it was the FDA’s regimen.

Harrington argued on behalf of the federal government that plaintiffs had not made claims of being forced to treat abortion patients against their will.

“They claim injury from speculative downstream effects of choices made by a chain of other people who are not parties to this lawsuit,” Harrington said.

But Wilson pushed back.

“The declarants here said they’ve seen these patients, they’ve cared for them,” he said. “I take that to mean that they treated them and that they expect to see more in the future. How’s that not enough for standing if the doctor also has a conscience objection to doing so?”

The judges made a series of sometimes snarky and combative comments and questions aimed at the attorneys for the U.S. Department of Justice, representing the FDA, and the mifepristone manufacturer Danco Laboratories, and called into question trust in the FDA’s expertise and judgment.

Echoing plaintiffs’ criticism of the FDA approving mifepristone as part of a particular category of drugs for serious illnesses, Ho said pregnancy is not a serious illness, quipping, “When we celebrated Mother’s Day, were we celebrating illness?”

A question of evidence

And they misstated non-scientific assertions by plaintiffs, such as claiming that non-fatal adverse reporting is no longer required by the FDA. Mifepristone manufacturers (but no longer medical providers) are still required to report non-fatal adverse reactions.

Much of the anti-abortion evidence submitted in this case was authored by researchers who work for the anti-abortion Charlotte Lozier Institute, whose role is to defend abortion bans and restrictions with research. Regarding mifepristone, Charlotte Lozier’s researchers have published articles that mostly speculate large amounts of under-reporting when it comes to abortion complications, and argue the true risk of mifepristone is unknown.

Another anti-abortion organization, the Family Research Council, also submitted a 125-page amicus brief with false claims that the drug approval was expedited by former President Bill Clinton. It also cites research from the Charlotte Lozier Institute to back claims that the drug is unsafe.

Judges echoed this sentiment and speculated on the safety of telemedicine abortion and questioned the FDA’s process of loosening restrictions over time. Elrod asked Harrington if a medical provider could examine someone via email rather than video, and if people could use telemedicine as an “intermediary” to send the medication to a state with an abortion ban. Elrod referenced amicus briefs that alleged individuals were engaging in those tactics to skirt state laws.

Harrington said the statements referenced by Elrod in the briefs are unsupported and irrelevant to the central issue.

“None of that is dictated by the FDA, and none of that is relevant to whether the FDA’s determination that this drug is safe and effective with these conditions in place,” Harrington said.

Elrod pushed back, asking if it was a relevant factor to consider in issuing an injunction that would limit access to the drug.

“If it’s violating other law, which we have to determine, perhaps, then we have to decide whether or not it’s appropriate to enter an injunction or not and that’s one of the factors we would consider,” Elrod said.

Public health experts say the appeals court’s attitudes toward the science in this case are deeply concerning.

“Judges and lawmakers should not be substituting their own opinion for the experience, expertise, and authority of the U.S. Food and Drug Administration. Nor should they ignore the substantial weight of scientific evidence from hundreds of studies and millions of patients confirming the safety and effectiveness of mifepristone, which has been used for decades in both medication abortion and miscarriage management,” said AMA President Dr. Jack Resneck Jr. in a recent statement.

Even if the appeals court rules to restrict or revoke approval of mifepristone, the federal government will most likely appeal the case to the U.S. Supreme Court. Regardless, the 5th Circuit Court judges’ reasoning could prove influential to the Supreme Court’s eventual decision.

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An ultrasound image of Jennifer Adkins’ 12-week-old fetus that was diagnosed with Turner syndrome and hydrops fetalis, two defects that are often fatal to the fetus and dangerous for the pregnant person to carry. Adkins had to seek an abortion in Oregon because, like 13 other states across the country, Idaho has a near-total ban on abortions without exceptions provided to preserve the health of the pregnant person. (Courtesy of Jennifer Adkins)

Jennifer Adkins’ first pregnancy was near-perfect.

She sailed through her appointments and screenings with no complications, ticking every box and making lists of all the right questions to ask her medical professionals. By the time her unmedicated labor was over and the nurses placed her newborn son on her chest, Adkins felt like a superhero.

So when she discovered she was pregnant again the day after Valentine’s Day, she was ready for another home run. The baby would be due on Halloween, and she and her husband affectionately referred to it as “Baby Spooky.” Maybe they’d find out the sex beforehand, maybe it would be a surprise. They hadn’t decided yet.

On April 21, Adkins saw her doctor for a routine screening by ultrasound to measure the collection of fluid behind the fetus’ neck. And even without a medical degree, she could tell by the picture on the ultrasound that something was wrong. Sitting in the genetic counselor’s office that afternoon, Adkins learned her 12-week-old developing fetus likely had Turner syndrome, a chromosomal abnormality that ends in miscarriage in 99% of cases. Turner’s occurs when one of two X-chromosomes for a female is deleted, often from all cells. The few babies that do survive still have deletions in some cells that cause significant heart defects, fertility issues, kidney abnormalities and a range of other disabilities.

The normal measurement is less than 3 millimeters, according to Dr. Maria Palmquist, a maternal-fetal medicine specialist at Saint Alphonsus Regional Medical Center in Boise, Idaho. Palmquist said Adkins’ fluid measured at 11.7 millimeters, with additional fluid accumulating under the skin and around the body of the fetus, known as edema. The combination of increased fluid and skin edema is a condition known as hydrops fetalis, a severe form of swelling that is often fatal.

“The doctor said basically, lightning struck this pregnancy, there’s nothing you can do,” Adkins said. “This just happens in 1% of all pregnancies.”

Following the U.S. Supreme Court’s decision in June 2022 to overturn Roe v. Wade and allow states to regulate abortion access, 14 states have enacted near-total or total abortion bans, while others continue to pass abortion ban laws that become tied up in state and federal court. The patchwork laws create reproductive health care deserts, sometimes as much as an eight-hour drive or a flight across the country, forcing pregnant people to travel at great financial and often emotional costs, even if the termination of the pregnancy would prevent devastating health effects.

There are no abortion bans yet that criminalize the pregnant person. Instead, criminal penalties are focused on medical providers or others who help someone obtain an abortion. The charges in most states are felonies, with punishment ranging between two years and life in prison, and physicians face suspension or revocation of their medical licenses.

Because Adkins lives in a state with an abortion ban, she faced one of two options: Either continue carrying the pregnancy knowing it would almost certainly end in miscarriage or stillbirth and jeopardize her own health in the process — or make a trip out of state for termination.

‘Do we try? But for what purpose?’

Idaho has a near-total ban on abortions that applies to any stage of pregnancy, with exceptions for cases of rape and incest with an accompanying police report during the first trimester or to save a patient’s life. Health care providers who violate the statute put their medical licenses at risk and face between two and five years in prison, along with civil penalties of $20,000 against individual providers if family members decide to sue.

Since Roe fell, residents in states with bans like Texas have to travel much farther to obtain an abortion. The Texas Observer reported the average number of miles a resident must travel increased from 44 miles to 497 miles. Texans often go to New Mexico, where some abortion providers fled and opened new clinics. Washington abortion providers have reported seeing patients from seven states around the country within one day.

In the Southeast, where nearly every state has a highly restrictive ban, states such as Louisiana and Mississippi are hours away from the nearest abortion clinic. For many, the closest state is Florida, and the outcome of a Florida Supreme Court case over a law banning abortion at 15 weeks could determine whether a six-week ban signed in April by Republican Gov. Ron DeSantis will go into effect. If it does, the distance to access abortion for many residents in that region of the country will become much greater.

A study released in April conducted by international reproductive health care journal Contraception found that women who were forced to travel for abortion care described it as emotionally burdensome, saying it caused distress, anxiety and shame.

“Because they had to travel, they were compelled to disclose their abortion to others and obtain care in an unfamiliar place and away from usual networks of support, which engendered emotional costs,” the study said. “Additionally, travel induced feelings of shame and exclusion because it stemmed from a law-based denial of in-state abortion care, which some experienced as marking them as deviant or abnormal.”

Adkins said seeking care in another state made her feel like a criminal and a medical refugee of sorts, and she worried about what others would think of her for terminating. Another physician she saw for a separate issue wanted to keep the pregnancy out of her record entirely as a precaution.

“They make this out to be like people that seek abortions are horrible, horrible people, and murderers, and all this stuff, and I’m like, that could not be further from the truth. This is a baby that we love with all of our heart and soul. And because we are loving parents, we are choosing this route, not only to be loving parents to that baby, but also to our living son, because I have to think about what’s in my best interest so that I can still be here and be healthy enough to take care of my son who needs me,” Adkins said.

Idaho physicians have also stopped making referrals for patients in situations similar to Adkins’ in the wake of a legal opinion sent by Attorney General Raúl Labrador at the end of March. Until there is a decision in a lawsuit over the opinion, physicians and Planned Parenthood facilities in Idaho have said they will not make any referrals for abortion-related care outside of the state.

Adkins said if she wasn’t as informed about the state’s laws, she wouldn’t have understood what doctors were saying about her options.

“They said that I was welcome to leave the state on my own accord and seek health care outside of the state,” Adkins said. “It was a very odd experience because we were talking basically in code. … I understood the nuance, and I understood what they were implying, but it was a very surreal experience.”

A brief filed in the lawsuit on behalf of a health system in Idaho detailed a scenario nearly identical to Adkins’ on the same day she was diagnosed at a different facility. Like the case outlined in the brief, Adkins would be at risk for developing a condition called mirror syndrome, which causes the pregnant person to experience similar symptoms to that of the fetus. Dr. Palmquist told States Newsroom that it can lead to preeclampsia, a life-threatening state of high blood pressure in pregnant people that can cause seizures and organ damage.

Knowing all of this, Adkins decided it was in the best interests of her family, including the nearly 2-year-old son she already had and the daughter she would never get to hold, to terminate the pregnancy.

She hoped to miscarry within the following week so they wouldn’t have to make the emotional three-day trip. So she scheduled another ultrasound, but there was still a heartbeat. She was desperate to fix it — desperate to stop being a walking coffin for a dying dream.

“It’s hard knowing that my body and the fetus are trying so hard to hang on,” Adkins said. “And we had to make a really hard decision. Do we try? But for what purpose? There’s no sense in bringing a child into this world that’s not going to survive anyway or have severe complications. And it’s not fair to any of us.”

Maternal-fetal medicine doctors continue fleeing to other states

Idaho legislators made minor changes to the state’s abortion law toward the end of the legislative session in March to clarify that certain instances where the fetus has already died or ectopic or molar pregnancies would not fall under Idaho’s abortion ban, declining to proceed with an earlier iteration of the bill that included a clause exempting medical professionals from criminal liability. In that version, providers had to determine if an abortion was necessary “to prevent the death of the pregnant woman or to treat a physical condition of the woman that, if left untreated, would be life-threatening.”

Dr. John Werdel, an obstetrician-gynecologist at St. Luke’s in Boise, said he wasn’t sure if Adkins’ situation would have qualified under the health language in the original bill. She likely would have had to wait until the health effects were more severe, he said.

Many reproductive care physicians in states where abortions are banned have left to practice in other states in recent months, including one maternal-fetal medicine doctor in Tennessee who moved to Colorado in January after starting what she described as a dream job in Tennessee in August.

Idaho’s abortion laws caused Palmquist, one of three maternal-fetal medicine physicians at Saint Alphonsus, to take a job at Desert Perinatal in Las Vegas, Nevada. She is one of several specialists in the state to leave over the new laws since January. She was packing her belongings on Thursday, hoping the laws change soon and allow her to return.

“Since June, it’s just become so complicated to take care of pregnancy complications. Things before that were so straightforward now make us take an extra four to six hours and multiple meetings,” Palmquist said. “Making sure we’re protected by EMTALA, making sure this is an emergency medical condition. Does the hospital administration agree, does legal counsel agree? All of that.”

A recent study published in the Journal of General Internal Medicine found from a survey of more than 2,000 current and future physicians on social media that 82% preferred to work or train in states with preserved abortion access. More than 76% of respondents said they wouldn’t even apply to states with legal consequences for providing abortion care.

“At least monthly, we are faced with caring for moms with significant complications, and there’s no chance of a viable outcome. But with Idaho’s restrictions, there’s a lot of anxiety about essentially practicing the standard of care,” Palmquist said. “A year ago, it would’ve been just so straightforward, and now there’s all this caution and hesitancy.”

The mounting costs

Adkins and her husband left their son with grandparents to make the trip to Oregon on a Thursday for her appointment the following morning. The Northwest Abortion Access Fund and Cascade Abortion Support Collective helped pay for a hotel room, a rental car and the surgical procedure, which was $850 by itself without insurance. Friends and family sent her Venmo donations for other expenses.

“I just started calling organizations because I was like, I don’t know what to do. And they said, ‘We’re here to help you.’ And it was so relieving but also absolutely heartbreaking to hear multiple times from multiple people, ‘You are not the only one. We get stories like yours all the time, every day,” Adkins said. “Every day.”

The Planned Parenthood clinic was supportive and professional, she said, and they honored her request to be deeply sedated for the procedure. When she told them why she needed to terminate the pregnancy, they offered to take ultrasound photos beforehand.

“Everybody was like, ‘Oh my god, I’m so sorry you had to come all this way for this,’” Adkins said. “And they’re right. I shouldn’t have had to leave my son and travel hundreds of miles to do this.”

Since the procedure was performed in another state and at a Planned Parenthood clinic, Adkins had to ask the doctor to collect the remains of the fetus, the pregnancy tissue and the placenta and package them properly to be sent to a genetic testing clinic. She was also faced with rushing the package of remains to FedEx herself that same day.

While she doesn’t regret the decision, Adkins said it was a painful experience that could have been much easier if she had been able to access care in her own state.

“I deserve better, and so does everybody else,” she said. “We can’t stop things from happening in pregnancy. That’s why we have modern medicine, to help guide us and protect the things we do have control over. So if we can’t stop those horrible things from happening … why make it even worse by making the worst experience someone has to go through — learning that they will not give birth to a happy, healthy baby — why do we make that even worse by saying, ‘We don’t value your life enough to try to save it or prevent something bad from happening to you in the meantime?’”

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Close-up Of A Woman's Hand Taking Medicine Over Wooden Desk (Getty Images)

The pills came in a dark salmon-colored envelope sealed with a plastic covering that traveled more than 7,000 miles, over a dozen time zones from Nagpur, India, in almost exactly one week.

They were placed partially under the doormat of a home in a state with one of the most restrictive abortion bans in the United States, where zero clinics or pharmacies dispense the medication and the closest option for an in-person procedure is at least an hour to four hours away.

It is, advocates say, one of the only options left for those seeking abortions in one of the 14 states with criminal penalties for health care providers who perform the procedure. 

The process of ordering the medication from Aid Access, a nonprofit organization founded by Dr. Rebecca Gomperts in 2018, is cobbled together in segments. From the organization’s headquarters in Austria, Gomperts acts as the prescribing gynecologist for the person ordering the pills on the Aid Access website. It’s one of the only services that allows people to order the medication as a “just in case” option, as the pills don’t expire for two years with proper storage.

Payment of $105 (about 98 euros) is made separately via PayPal, and once payment is complete, Gomperts sends her prescription to the pharmacy. There is also an option for financial assistance. 

Mifepristone and misoprostol are used in combination to end a pregnancy, typically before 12 weeks of gestation, and the drugs are used to help manage early miscarriages. Mifepristone is taken first to stop the production of the progesterone hormone, which is needed to continue a pregnancy. Misoprostol is then taken to induce contractions in the uterus to expel the pregnancy.

Mifepristone was approved by the U.S. Food and Drug Administration in 2000, but it is under legal challenges in court and legislatures across the country are attempting to restrict access to the drug. On Friday night, Wyoming’s governor signed into law a ban on medication-induced abortions.  A lawsuit challenging the FDA’s approval process for mifepristone is ongoing in Texas, where a federal judge could order the agency to revoke its approval after more than two decades. Other states are attempting to restrict access by threatening legal action against retail pharmacies and any other suppliers of the drug. 

An email notification is sent when the package ships, with detailed instructions about how to take the medication, the potential risks involved, side effects and pain management and when to seek medical attention. The email also includes resources for hotlines with people available for emotional support or to provide answers to medical questions.

The package itself includes a box with one mifepristone pill and four misoprostol pills, and a separate package contains 12 misoprostol pills. The combination box is enough for pregnancies that are less than 12 weeks’ gestation, while the 12 pills are designed for pregnancies of more than 12 weeks.

By email, Gomperts told States Newsroom her organization is receiving more than 1,000 emails per day from individuals looking for help. Many of them also cannot afford the full price of the drugs. In February, Gomperts said 57% of those who paid for the drugs were able to pay less than 50 euros, or about $53.

“It is important to continue this work because the people we help cannot travel to other states to get a safe abortion,” Gomperts said.

Alabama has already threatened prosecution under different law for taking abortion pills 

Gomperts grew up in the Netherlands and became passionate about providing abortion care during her work for Greenpeace, according to the New York Times. She has worked to provide abortions for women in countries around the world, including Spain, Morocco, Guatemala and Ireland, when the country still had a strict abortion ban.

Christine Ryan, legal director of the Global Justice Center, is from Ireland and told States Newsroom she still lived there when the abortion ban was in place. It was repealed in 2018 after the high-profile case of a woman who died from a septic infection after she was denied abortion care during a miscarriage.

Ryan said witnessing those events and following Gomperts’ work is what made her decide to get involved in reproductive rights.

“Rebecca Gomperts has been like a guardian angel to women worldwide for decades,” Ryan said.

Gomperts used the same “workaround” to send the drugs to Irish women when it was banned, Ryan said, since she is based in another country.

Fourteen states across U.S. have abortion bans in place, nine of which do not include exceptions for cases of rape or incest. The bans do not have criminal penalties in place for the pregnant person, and while Texas, Oklahoma and Idaho have civil enforcement laws that allow family members or the pregnant person to sue medical providers for their role in an abortion, the suits cannot be brought against the pregnant person.

That has not stopped some states from threatening to prosecute individuals for taking abortion pills under different existing statutes. In January, Alabama Attorney General Steve Marshall said the state could prosecute people under a chemical endangerment law that has been used to prosecute women who use illegal substances during pregnancy. It’s unclear if that law would apply to mifepristone and misoprostol, which are legal drugs approved by the FDA. The U.S. Department of Justice also issued an opinion in December stating the mailing of the drugs to a particular jurisdiction is not sufficient basis for “concluding that the sender intends them to be used unlawfully.” 

The Wyoming Legislature also passed a ban on medication abortion in March, which Gov. Mark Gordon signed Friday.

Although Politico and the New York Times reported this month that Walgreens confirmed it would not sell the medication in up to 20 states where attorneys general had threatened legal repercussions for doing so, a Walgreens spokesman told States Newsroom in a statement, “We want to be very clear about what our position has always been: Walgreens plans to dispense Mifepristone in any jurisdiction where it is legally permissible to do so. Once we are certified by the FDA, we will dispense this medication consistent with federal and state laws.‘’

While that will make it difficult for individuals to receive mifepristone from a pharmacy, Ryan said it won’t be as easy to enforce bans on mailed pills.

“The authorities in (states with abortion bans) — who are they going to try to prosecute in terms of the mailing of these pills?” Ryan said.

Idaho anti-abortion activist: We need penalties for sending ‘human pesticide’ to women

Brandi Swindell, founder and president of anti-abortion clinic Stanton Healthcare, told States Newsroom she thinks the mailing of abortion pills is a major problem that she called “creepy” and said reminds her of a drug cartel.

“We have these — not only out-of-state — but out of country groups that are pimping a human pesticide that could have very serious ramifications on a woman physically and emotionally, can impact her mental health, her physical well-being,” Swindell said. “And they are coming into states where we have clear abortion laws, where we have gone through the legal process, the legislative process. … And they’re going to try to sell and pimp these drugs preying on women that are in a potential crisis or unexpected pregnancy situation, a vulnerable situation.”

Idaho has a near-total ban on abortions at any stage of pregnancy, with affirmative court defenses to save the pregnant person’s life and for rape and incest if a police report is provided. Swindell said she is working with state lawmakers in Idaho, where Stanton Healthcare is based, to seek an opinion from Idaho Attorney General Raúl Labrador’s office about whether the state’s abortion ban includes medication abortion.

“There needs to be clarification and enforcement that any organization or individual that is involved in promoting, selling or profiting from attempting to skirt Idaho’s law to dispense and sell and profit from the abortion pill, that those entities need to be held accountable,” Swindell said.

If Labrador’s office concludes the method is not included in Idaho’s law, Swindell said there needs to be legislation introduced as soon as possible to strengthen the existing law before the Idaho Legislature adjourns for the year, which could happen in the next few weeks.

“We’re passionately working to make sure that chemical abortions are banned,” Swindell said. “We want to make this a major issue in the 2024 presidential race.” 

Self-managed abortions at home make pregnant people feel safer, legal advocate says 

The drug’s use has become much more common in abortions across the country in the past three years. According to the Guttmacher Institute, as of December, medication abortion made up about 54% of all abortions performed in the United States.

Part of that may be people taking advantage of those legal workarounds with the mail, but Ryan said some pregnant people find home management of an abortion to be empowering and it offers a stronger sense of safety.

“You’ve had clinics suffering so much violence in the clinic setting, and having to deal with protesters, and the difficulties in arranging transport and financing transport, whereas managing pregnancy in someone’s own home is a safe place,” Ryan said. “Also having access to a clinician over the phone and online is something that has shown to be quite powerful.”

While providers and patients across the United States wait on a ruling from a federal judge in Texas about the U.S. Food and Drug Administration’s approval of mifepristone, advocates want to stress that options like Aid Access will still be available no matter the outcome of the court case.

Dr. Jennifer Lincoln, an obstetrician-gynecologist who practices in Portland and the executive director of an advocacy organization called Mayday Health, said if state laws become more stringent around policing abortion medication, Aid Access and other internationally based options will become more important.

“The best thing you can do is inform yourself and pass the message along that you’ll still be able to get these medications,” Lincoln told States Newsroom. “It requires a few more hoops, but you’ll still be able to get it.”

Ryan doesn’t worry about organizations like Aid Access being affected by whatever happens in U.S. courts, but she is worried about state- and county-level prosecutors trying to target people who use the pills at home.

“What I do really see as a particularly challenging (fact) that activists and patients have to deal with in the U.S. that wasn’t as pertinent somewhere like Ireland, or even in Mexico and Argentina, is the level of surveillance that exists and the power and zeal of the criminal legal system,” Ryan said. “It is a phenomenon that is very much overlapping with the human rights crisis to create this extremely challenging environment for people to exist in.”

States Newsroom National Reproductive Rights Reporter Sofia Resnick contributed to this report.

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