New research demonstrates the importance of online pharmacies in direct-to-patient care and provision of medication abortion in the United States. These pharmacies have a strong link to virtual-only prescribers. This model for delivery of medication abortion spiked after the U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization. But the future role of these pharmacies is jeopardized by the election of Donald Trump to the presidency.1
“We found that the overall provision of medication abortion by online pharmacy was higher following the Dobbs decision, and most was driven by prescriptions from virtual-only providers,” says Terri-Ann Thompson, PhD, a senior research scientist with Ibis Reproductive Health in Cambridge, MA.
“This points to an increasingly critical role that online pharmacies are providing,” she adds. “The reason this is important is because it demonstrates a growing role of online pharmacies in direct-to-patient care abortion provision, and there are strong linkages between virtual-only providers and online pharmacists.”
The U.S. Food and Drug Administration (FDA) removed in-person and clinician-only dispensing requirements for mifepristone in 2020. This opened the door for online pharmacies to work with prescribers and send pills directly to patients. The use of telehealth for abortion medication jumped after the Dobbs decision and resulted in an overall increase in medication abortions from 53% of all abortions in 2020 to 63% of all abortions in 2023.1
“The biggest spikes were in the year following Dobbs. We saw that there was a daily mean of 200 prescriptions in March 2023, vs. 88 in March 2022,” Thompson says. “That’s a pretty large increase in prescriptions,” she adds.
“In this paper, the pharmacy we worked with only sends abortion medication to states where abortion provision is allowed and where telehealth for abortion provision is allowed,” Thompson says. “There are providers who operate under a shield law, and they are able to send medications into banned states.”
Research has shown that the integration of telemedicine services can result in people presenting at earlier stages of pregnancy, she notes. “Virtual providers and the pharmacies they use play an important role in responding to spikes in demand, and that could logically reduce wait time at abortion clinics,” Thompson says.
If the incoming presidential administration decides to enforce the Comstock Act and interpret it to mean that mailing or shipping any abortion medication or materials is illegal, then this could have a big impact on abortion access and the use of online pharmacies. “This would be a misuse of the Comstock Act because it’s about illegal distribution of abortion drugs, and that would not be the case here,” Thompson says.
“While Comstock might ban shipment of medication abortions, it wouldn’t ban provision of abortion. People could still go to a clinic, and we could have a resurgence of allowing people to go into an actual office and get medication there,” she adds.
“Abortion is a desired service and has been used for decades, and it’s a service that will continue to be desired and used regardless of the abortion landscape,” she says. “We can look at studies in Texas to see what happens after an abortion ban, and these saw a marked increase in self-management abortion services and requests for self-managed abortion services from services like Aid Access.”
There also are displays of innovation in abortion-ban states. “I imagine we’ll see similar outcomes if a national ban is instituted in the U.S.,” Thompson says. “We may see similar actions of people going to the borders [to obtain abortion medication] and increased requests for self-managed abortions.”
A take-home message from the study about online pharmacies and medication abortion is that it is a response to a rapidly evolving abortion landscape, and it is safe for patients. Even without action by Trump’s administration, there are barriers that need to be lifted, such as the FDA’s use of Risk Evaluation and Mitigation Strategies (REMS) to govern mifepristone provision.
“Pharmacists are ready and available to be integrated into patient care through virtual telehealth, and removing REMS restrictions would allow more people to get this care because we would remove restrictions around pharmacy dispensing,” Thompson says.
The goal in improving abortion access is to use as many formats as people want. “Telemedicine is not for everybody. In-person care is not for everybody,” she says. “Maybe someone has very good feelings about getting care directly from a pharmacist, so we should make medication abortion available in a number of different formats.”
One hopeful part of living in the information age is that it is much more difficult to block access to abortion care now that people know about the medication and have become accustomed to the convenience of medication abortion, Thompson says. But it does not mean that easy access to accurate abortion information is guaranteed in the future. In Texas, for example, House Bill 2690, which was referred to the state affairs committee on March 13, 2023, would make it a crime to fund abortion care, and it references the Comstock Act’s 18 U.S.C. Section 1461. It also would allow citizens to sue websites for providing abortion medication and services, and it specifically names aidaccess.org, heyjane.co, plancpills.org, and several other sites.2,3
If the Texas legislature returns to this bill, it could severely hamper women from obtaining fact-based abortion information in that state. “We’ve had a hard time; litigation has been nonstop,” Thompson says. “How do we ensure people are not blocked from accessing that information?”
State shield laws could protect abortion funds, online pharmacies, and information sources, as well as abortion providers. But state attorneys general anticipate legal challenges to their shield laws and are preparing for nationwide restrictions on mifepristone, including state laws — like the recently passed law in Louisiana — that classify mifepristone and misoprostol as controlled substances.4
Regardless of new state laws and national restrictions or a ban on abortion medication, people will continue to desire abortion care and will obtain it outside the formal healthcare system, if necessary, Thompson says. International abortion funds display innovation in getting people the care they desire. “I imagine we will see similar outcomes if a national abortion ban is instituted in the United States,” she adds.
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
References
- Brander C, Nouhavandi J, Thompson TA. Online medication abortion direct-to-patient fulfillment before and after the Dobbs v. Jackson decision. JAMA Netw Open. 2024;7(10):e2434675.
- Texas H.B. No. 2690. A Bill To Be Entitled. https://capitol.texas.gov/tlodocs/88R/billtext/pdf/HB02690I.pdf#navpanes=0
- Texas House Bill 2690. Last Action: March 13, 2023. https://fastdemocracy.com/bill-search/tx/88/bills/TXB00062276/
- Vollers AC. Expecting challenges, blue states vow to create ‘firewall’ of abortion protections. Stateline. Nov. 21, 2024. https://stateline.org/2024/11/21/expecting-challenges-blue-states-vow-to-create-firewall-of-abortion-protections/#:~:text=Bolstering%20shield%20laws&text=But%20just%20eight%20states%20%E2%80%94%20California,where%20their%20patient%20is%20located
