Ending a pregnancy in 14 states leaves few options. Some are looking to Europe and India for help.

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.