A Dutch doctor and the internet are making sure Americans have access to abortion pills

A little-known European medical team is poised to become one of the most important groups in the shifting landscape of US abortion bans.

Aid Access, an online-only service run by a Dutch physician, Dr. Rebecca Gomperts, began shipping abortion pills to Americans from abroad four years ago. The organization’s team consists of about four doctors supervising about 10 medical staff members, and they’re difficult for US authorities to reach because all are outside the country and they ship pills from a pharmacy in India.

Opponents of abortion rights have so far largely found themselves powerless to stop Aid Access from mailing abortion pills even to the most conservative corners of the country, at least while the organization’s opponents don’t control the White House. That has transformed Aid Access nearly overnight from an obscure overseas group into an essential part of the effort to keep abortion accessible nationwide.

“It’s the only clinically supported service that mails to states where telehealth for abortion is banned,” said Ushma Upadhyay, an associate professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco.

Gomperts, who founded Aid Access in 2018, said she has no intention of changing her work now that the Supreme Court has overruled Roe v. Wade. Aid Access has been receiving 4,000 requests a day since Roe v. Wade was overturned, she said, up from 600 to 700 a day previously.

Last year, after Texas banned abortions after about six weeks of pregnancy, orders from the state tripled in the weeks after the law took effect, according to a study published in JAMA Network Open.

“We will continue to serve women who need it. We’re not going to stop,” Gomperts said in a phone interview, adding, “We are expanding again our capacity, so we can help with all the requests that we get.”

The steps are relatively straightforward: Potential patients visit the Aid Access website and answer a series of questions, including how long they’ve been pregnant and whether anyone is forcing them to seek abortions. The medical team reviews the answers and may write prescriptions that get sent to pharmacies. For pills coming from India, the process may take a couple of weeks. Gomperts said the organization is prioritizing people who are pregnant over those who want to stock pills for the future.

Around 25 people work on a help desk to answer questions from patients, with three people on at any given time, Gomperts said. Aid Access charges $110 to $150 depending on where the patient is.

The ease of the process makes Aid Access yet another example of how a global internet can frustrate and subvert local law enforcement — at least so far.

James Bopp, the general counsel of the National Right to Life Committee, said that without control of the presidency or a new federal law, there’s little his organization or its allies who oppose abortion rights could do against a group based outside the US

“The reality is state laws have limited extraterritorial effects,” he said. “There’s no question that the federal government has much more authority, and we hope to get them on our side to make these state laws much more effective.”

A medication abortion generally involves five pills of two different drugs. Women take one pill of mifepristone, followed a day or two later by four pills of misoprostol.

The pills became easier to obtain during the pandemic, when first a federal judge and then the Biden administration allowed patients to get them without visiting clinics in person. Medication abortions accounted for 54% of US abortions in 2020, according to the Guttmacher Institute, a research institute that supports abortion rights. In 2011, the share was 24%.

But even before Roe was overturned, 19 states had banned the use of telemedicine for medication abortions or required the physical presence of the prescribing physician, according to KFF, a nonprofit organization for health information.

Now, more than 20 states have banned or restricted abortions, according to an NBC News tracker of state laws.

Gomperts said Aid Access is hearing confusion and fear from women in the US

“The people who are affected are poor women in red states that have these trigger laws,” she said. “There’s so much social injustice being done — again and again and again, to the most vulnerable part of the population.”

Other online pharmacies will ship abortion pills to states where abortion is banned, according to the website of Plan C, an advocacy group, but experts said Aid Access is different because it’s based outside the US, has staff members available to answer questions and has cooperated with outside researchers.

“We know it’s safe, because it’s one of the options for self-managed abortion that we’ve been able to study,” said Dr. Abigail Aiken, a physician who is an associate professor of public affairs at the University of Texas at Austin , who has done research on Aid Access.

About 96% of those who used abortion pills from Aid Access reported successfully ending their pregnancies without surgical intervention, according to research Aiken published this year. About 1% reported they received treatment such as antibiotics or blood transfusions, and there were no reported deaths.

“They really are a humanitarian nonprofit, not a business the way an online pharmacy is,” Aiken said.

Gomperts founded Aid Access in response to tightening US laws around abortion access. She had already been running a similar service, called Women on Web, in other countries, and Aid Access received 57,506 requests from people in the US in its first two years.

“It was clear in the last few years that access in the US was getting harder and harder and harder. We started off mostly with helping service women in the military in Iraq and Afghanistan, in South Korea and Japan,” she said, because US service members in those countries had limited access.

Gomperts’ resume has made her a hero within the abortion rights movement; she has performed abortions in international waters off Portugal and other countries where abortion was restricted, and she has used drones to deliver pills in Northern Ireland in defiance of authorities there.

Time magazine named Gomperts one of its 100 most influential people of 2020, and in a tribute in the magazine, Cecile Richards, the former president of Planned Parenthood, called her “one of the bravest people I know.”

“She is living her ethical and moral duty as a physician to ‘do no harm,’” said Dr. Emily Godfrey, an associate professor of family medicine and of obstetrics and gynecology with the University of Washington’s health system. “The problem is when nonmedical people restrict access to medical care, to licensed qualified medical care, people are more prone to seek unsafe abortion — and that’s what kills, unsafe abortion.”

Aid Access already faced down one hostile US presidency. In March 2019, under then-President Donald Trump, the Food and Drug Administration sent a warning letter asking Aid Access to cease operations. Aid Access refused and sued the FDA to block any potential action. The agency never followed through on its request. Last week, an FDA spokesperson had no immediate comment on what plans the agency has, if any, with regard to Aid Access.

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The agency’s stance could change if an opponent of abortion rights were to become president. But on the state level, said Dr. Richard Hearn, a physician and lawyer in Idaho who has represented Aid Access, regulators and prosecutors might have as difficult a time barring the organization as their counterparts did stopping the import of alcohol during Prohibition in the 1920s .

“No state like Texas or Idaho is going to be able to do anything to Aid Access in Amsterdam or Austria. They’re not going to have jurisdiction, and the Netherlands isn’t going to extradite,” he said, emphasizing that he was speaking for himself, not the organization.

Complicating state-level legal efforts is the fact that Attorney General Merrick Garland has said states can’t enforce bans on abortion pills because the FDA has approved the regimen, which pre-empts state action. The issue is already being litigated in federal court in Mississippi, where a generic maker of mifepristone is suing to block state restrictions.

It’s not clear whether any state or federal prosecutor plans to pursue action against Aid Access directly. The Mississippi attorney general’s office, which argued the case that led to last month’s Supreme Court ruling, didn’t respond to a request for comment.

“It’s just futile to try to stop mifepristone and misoprostol. They’re perfectly safe, especially early on,” Hearn said.

Nonetheless, abortion rights opponents have proposed even harsher penalties aimed at online prescriptions of abortion pills. The National Right to Life Committee published a model state law on its website that would, if states adopt it, make it a felony to maintain a website giving instructions for self-managed abortions, but enforcement would remain a challenge.

One of the few things limiting the reach of Aid Access is that it’s still not well known. Gomperts criticized social media apps such as Instagram and Facebook for removing posts about abortion services.

“The freedom of speech is one of the key constitutional rights in the US, but because of these laws, even that right is under stress because people are so afraid,” she said.

The lack of awareness is something that abortion rights advocates and some physicians hope will change, even if Aid Access becomes a lightning rod similar to Planned Parenthood.

Gomperts said her goal is for Aid Access to eventually become unnecessary.

“It shouldn’t have to be a foreign organization,” she said. “What should happen in the end is that the states like New York and California, liberal states, they should just make it possible for the doctors and providers there to ship the pills to the other states.”