In Aid Access' first year of operation, 21,000 U.S. women reached out to the online organization launched in March 2018 that offers abortion pills internationally. Requests came from all over the country ⁠– especially states where abortion is tightly restricted.

After a string of states passed bans or limits in recent weeks, pushing the abortion debate in the USA to a fever pitch, abortion rights advocates said those numbers could climb.

In 2019, more than a dozen states have either passed or tried to pass more restrictive abortion legislation. Alabama, Georgia, Kentucky and others moved to ban abortion when a fetal heartbeat is detected, which is within six weeks of a pregnancy. Georgia's bill allows exceptions for rape and incest, but Alabama's does not.

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Francine Coeytaux, co-director and co-founder of Plan C, a website geared to helping women understand abortion pills, said views on her site skyrocketed after the Alabama Senate passed its bill in May. Plan C has a report card ranking online abortion pill providers based on shipping time, physician oversight and product quality.

"When the law was passed in May, the Alabama law,the next day we had a 1,600% increase on our report card," Coeytaux said. "We have reason to believe that sales in the U.S. last year of abortion pills were probably in the hundreds of thousands."

What are abortion pills?

Medication abortion, also known as abortion with pills, was approved by the Food and Drug Administration for use in the USA in 2000. The two pills used are mifepristone and misoprostol; the first stops the pregnancy's growth, and the second empties the uterus.

Medication abortion before eight weeks' gestation accounted for 24.6% of all abortions in the USA in 2015, according to the latest figures from the Centers for Disease Control and Prevention. The FDA said taking the combination of pills in the first trimester has a success rate of 95% to 99%.

Abortion pills are different from birth control pills, which are a form of contraception. They're also different from Plan B, an emergency contraception that works to prevent pregnancy when taken within 72 hours of having unprotected sex.

Abortion with pills has proved to be a relatively safe, easy option during the early stages of pregnancy, according to the FDA. Still, the agency imposed restrictions by limiting distribution to providers with specific certifications. Certain states require in-person administration of the pills, which hinders access within more rural communities.

"Medication abortion has an extensive safety record, and the evidence suggests that the restrictions placed on it by the FDA are unwarranted," said Megan Donovan, senior policy manager at the Guttmacher Institute. "Medical organizations have called for lifting the federal restrictions on medication abortion."

Ingrid Skop, an OB-GYN based in San Antonio and chairman-elect of the American Association of Pro-Life Obstetricians & Gynecologists, expressed concerns about women with ectopic pregnancies obtaining abortion pills from providers not meeting the FDA's criteria.

"The first pill does nothing to end a tubal pregnancy, and tubal pregnancies rupture the tube," Skop said. "A woman who orders it online without the provision of a doctor is going to have no idea if she has an ectopic pregnancy."

Elisa Wells, co-founder and co-director of Plan C, said the reasoning behind restrictions of this method of abortion is political, not medical.

"This is a very safe procedure that could be helping people," Wells said. "There’s no medical reason for why it can’t be more widely available than it is outside. It's purely political at this point. People need to know that these pills are so safe."

What are the downsides?

Traffic on Plan C's website has grown significantly in recent years, Wells said.

It's not just the surge of restrictive abortion bills causing women to pursue other options but a steady legislative effort to limit access, she said.

"The more people are restricted, the more likely that they are going to try to manage an abortion on their own," said Gretchen Ely, an associate professor at the University at Buffalo specializing in access to abortion and contraception. "So instead of it being a pre-Roe situation with objects, they’re going to be looking to manage it with medication. More often, it will be unsupervised."

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Ely said more women turning to unsupervised means of managing their own abortions is a concerning trend. It's far preferable, she said, for women to get abortions with the advice of medical professionals.

Online medication abortions may put women's lives at risk, particularly those in rural areas with limited medical facilities, Skop said.

"We consider this is a human rights issue, because the fetus is a living human being," Skop said. "Rural women who are being primarily targeted by this, they’re not close to a good hospital. We’re running the risk with these mail-order abortions of increasing the mortality rate of the procedure."

The FDA advises against buying abortion pills off the internet because that would bypass FDA requirements.

In March, the FDA issued a warning letter to Aid Access for shipping drugs the agency deemed "misbranded and unapproved." Aid Access founder Rebecca Gomperts, a physician based in Austria, fought back, saying the services she provides are needed by people who face barriers to clinical abortions.

There are other barriers, experts said: lack of internet access and payment and shipping issues.

"You have to figure out how to pay for it online," reproductive law expert Carol Sanger said. "There are details that might make it not as smooth as you think it is. And then where are you going to have it delivered? You have to figure out where are you going to have it sent. Might your husband open it?"

What are the implications?

Wells and Coeytaux conducted a study testing the reliability of online abortion pill providers. They received the pills from 18 websites and concluded that ordering abortion pills online is feasible. Most of these sites are unsupervised. Plan C's report card lists only one online provider ⁠– Aid Access ⁠– that has physician oversight.

People need accurate, comprehensive information to ensure a safe medication abortion, said Donovan of the Guttmacher Institute.

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"What's important is that people still have access to the information they need to pursue medication abortion and self-managed abortion safely and effectively," Donovan said.

The legal consequences of self-managing an abortion with pills are unclear, Sanger said. It's unclear, too, how prosecutors would know a woman took the pill – they would have to be able to track the mail order.

The ability to purchase abortion pills online, Sanger said, gives women more power to make their own choices on abortion.

"The existence of the pills and the fact that you can order them just shows how much power has moved into the hands of women themselves," Sanger said. "And that’s a huge and kind of frightening shift for those who oppose abortion."