A Road Map for Restoring Abortion Access in the US

The overthrow of Roe v. Wade in June 2022 was not a surprise, but it was a gut punch. Three Trump-appointed justices joined three vehemently anti-abortion justices to form a majority that showed little regard for precedent, privacy rights, or women’s health and well-being. Fifty years of established constitutional rights — rights generations of activists fought hard to obtain and grow — were thrown out with one bang of the gavel.

Today, access to reproductive health care is unpredictable and inequitable in half of U.S. states. The nearly four years since have been challenging, and particularly devastating for marginalized communities, who are increasingly denied access to basic reproductive health care. Not only have clinics closed in abortion-hostile states, but a new report from Guttmacher shows closures and disruptive “churn” in the number of clinics even in supportive states, causing additional delays for those needing care.

What we need is an innovative strategy for restoring and expanding our rights — a plan to build a brighter future that recognizes reproductive rights as human rights.

I lived and worked in Ireland during a time when all abortion was illegal, and brought a legal challenge before the European Court of Human Rights to significantly advance legalization. Ultimately, Irish activists created a political environment where they could successfully pressure a reluctant government to hold a referendum which resulted in liberalizing their laws. I took away three lessons from that effort which now form the pillars of my work to help create a better landscape here in the United States.

First, the “Irish Journey” — where tens of thousands of women traveled to England and beyond for abortion services each year — was a voyage filled with shame and stigma, expense and exhaustion. Similarly, in the U.S. today tens of thousands of women and pregnant people journey from abortion-restrictive or under-resourced states to places where they can access care, in doing so often facing great expense, travel distance, and stress. Travel cannot be the only option we offer pregnant people in the U.S.

Second, when abortion is criminalized, all reproductive health care is compromised — often with deadly consequences. Six years before abortion was legalized in Ireland, Savita Halappanavar tragically died of sepsis after miscarriage treatment was delayed too long by a hospital in Galway. Her doctors were uncertain about the parameters for providing legal life-saving care to a pregnant patient and feared severe sanctions if they got it wrong. Today, we are seeing similar appalling scenarios play out in abortion-restrictive states. Even before the Supreme Court ruled in Dobbs v. Jackson Women’s Health to end federal abortion rights, the United States already had a horrifying maternal mortality rate, with Black women suffering disproportionately. That situation has only deteriorated further. We must make sure clinicians have clear legal guidance that enables them to provide patient-centered care without fear of criminal or civil liability or loss of license.

And third, and inspiringly, we know that the decision whether, when, and with whom to have a child is a fundamental human right, and that when we stand together, we are unstoppable. We have seen mass movements led by feminist groups challenge and change abortion laws in Ireland and through the Green Wave that liberalized Argentina, Mexico, and Colombia.

With these lessons in mind, I launched my organization, Reproductive Futures, last year to serve as the legal frontline protecting access to telemedicine, emergency, and post-abortion care. Telemedicine abortion is the bright spot we need in the post-Roe world.

Think of telemedicine as the “modern house call.” It enables licensed practitioners to safely and affordably prescribe medication abortion through the first trimester of pregnancy. After a screening by a licensed clinician, the medication arrives at the patient’s home within three to five days. Over the course of 48 hours a patient takes a series of two medications — mifepristone and misoprostol — and experiences what the clinicians I work with frequently describe as a heavy period with some flu-like symptoms.

For tens of thousands of women each month, telemedicine means there is no need to travel to a clinic just to pick up pills, which could involve missing school or work, covering child care or transportation costs, facing fears around immigration status, unexplained absences from home, or walking past clinic protestors.

Today nearly 30% of all abortions in the U.S. are done by telemedicine.

From San Francisco to Savannah, and everywhere in between, more people are choosing telemedicine as the method that is right for them. They embrace the bodily autonomy of self-managed care. In abortion-restrictive communities, telemedicine offers patients a safe and affordable option. When abortion is criminalized, it is the providers and other supporters who face the risks. It is not a crime for a person to take medication abortion herself anywhere in the U.S., although some anti-abortion officials have tried to make it so. Thankfully, it remains politically unpopular to criminalize self-managed abortion care, and so the main focus of anti-abortion policies has been on criminalizing providers and helpers, for now at least.

To protect providers and other supporters, eight states now have telemedicine shield laws that provide protection for clinicians and others who serve patients nationwide. This year, Reproductive Futures’ legislative program has been successfully working with state legislators and activists to safeguard and expand that number of states by enacting new or improved shield laws. Simultaneously, we are helping to engage and support additional medical providers to offer telemedicine abortion nationwide, for example by providing them access to pro bono representation from major law firms and technical support. Our work makes sure clinicians can access the services, expert advice, and legal protections they need to be able to offer telemedicine care to patients.

However, the anti-abortion movement is well aware of the power of telemedicine abortion, and they are working hard to derail it. State- and federal-level lawsuits have been filed against providers and supporters of access to telemedicine abortion. On an almost weekly basis, the FDA takes actions that threaten to impose unnecessary restrictions that would undo decades of policies well grounded in science supporting the safety and efficacy of mifepristone. But telemedicine shield laws are standing strong. Governors Gavin Newsom of California and Kathy Hochul of New York have denied attempts to extradite telemedicine abortion providers who were indicted by anti-abortion prosecutors from Louisiana. A New York court upheld a county clerk’s reliance on the state’s shield law to block a Texas lawsuit aimed at stopping telemedicine practice in New York. It is vital that we support elected officials who show leadership for abortion rights as human rights.

We have seen globally that when women organize, when movements stay steady, we gain and expand our rights. While this federal administration lobs everything it can at the most vulnerable among us, it is easy to feel demoralized. But we will not accept injustice as inevitable.

We will build forward. Reproductive Futures will continue to use our global lessons, legal skills, and policy power to ensure access to abortion and emergency care regardless of where a person lives. We will work with allies — activists and advocates, doctors and lawyers, state and federal officials, and more — to meet this moment in the U.S. And together, we will build a reproductive future worthy of the next generation.