Updated on July 16.
When Olivia Garcia found out she was pregnant in mid-April, it was a shock. The 28-year-old was “very, very nervous” — mostly because she was pregnant in a pandemic. But she was also excited. Garcia, a behavioral aide living in Texas, says it didn’t take her long to realize that she wanted to have the child with her partner.
Garcia hadn’t been planning to have an abortion. But when she went to a doctor’s appointment at nine weeks and learned she wasn’t producing enough progesterone for the baby, it was the first sign something might be wrong. A week later, when she went back for a check-up, she found out that she’d had a missed miscarriage. Her baby wasn’t alive, but her body hadn’t expelled the pregnancy tissue.
To remove the tissue, her doctor explained that she could have an in-person abortion surgery; receive the abortion pill and pass the embryonic tissue at home; or wait for it to pass naturally, which could take weeks and cause intermittent bleeding.
Garcia took a day to think over the options, considering the pros and cons with her partner. Ultimately, she landed on the one she believed was the safest, given the risks of in-person visits as the pandemic continued to rage. She decided on the abortion pill.
Nearly two months after Garcia’s decision, medical abortion is making headlines. On Monday, a federal judge in Maryland ruled that during the pandemic, women are not required to obtain an abortion pill in person. Previously, a Trump administration rule had required women to visit a hospital, clinic or medical office before receiving the drug, mifepristone, which is taken at home along with another pill, misoprostol. As the Associated Press reports, U.S. District Judge Theodore Chuang wrote that in-person requirements impose a “substantial obstacle” and are likely unconstitutional under the circumstances of the pandemic.
Reproductive justice advocates agree that Chuang’s Monday ruling represented a win, particularly for women of color, who face systemic barriers to accessing reproductive health care, pandemic or not. But many experts say that this is a small piece of the puzzle when it comes to expanding access to medication abortion. The Maryland court said the ruling will not impact state laws regarding access abortion, meaning that the real-life application of the ruling will vary state by state. What’s more, the ruling is specific to covid-19; it only extends to patients during the public health emergency declared by the Department of Health and Human Services.
The lawsuit was brought by the American College of Obstetricians and Gynecologists (ACOG), along with other groups, in May. American Civil Liberties Union lawyers argued for the plaintiffs, who were suing HHS and the U.S. Food and Drug Administration, which approved the abortion pill but imposed the in-person requirement. “The pill” actually consists of two medications: Mifepristone is approved to use in combination with mosoprostol to end an early pregnancy or manage a miscarriage.
As Skye Perryman, chief legal officer of the ACOG, explains, the case sought to lift a restriction on the drug that the medical community has agreed is not medically necessary. “In the covid-19 pandemic, [the restriction] was having a negative and disproportionate effect on vulnerable patient populations in communities that already experience systemic barriers to access,” she says.
Katherine Kraschel, an instructor at Yale Law School’s Reproductive Rights and Justice Project, says the Maryland case is an example of how the administration took “an exceptional stance when it comes to reproductive justice and access to reproductive care,” pointing out that the FDA had waived in-person requirements for other drugs during the pandemic.
Antiabortion activists decried the decision, arguing that in-person visits are necessary for safe medication abortions. Marjorie Dannenfelser, president of the antiabortion group the Susan B. Anthony List, said in a statement: “The current FDA regulations are reasonable and necessary to protect women from serious and potentially life-threatening complications of abortion drugs including intense pain, heavy bleeding, infection, and even death.”
Medical abortion was first approved by the FDA in 2000, and is considered safe and effective up to 10 weeks. As the AP reports, more than 4 million people in the United States have used mifepristone and misoprostol to end a first-trimester pregnancy. In 2017, according to the lawsuit, the combination accounted for 39 percent of all U.S. abortions.
Growing up Catholic, Garcia had never planned to have an abortion. But she knew that if she was put in a position where she “had to do it,” she would. “It just so happens that it did come down to it,” Garcia says. (The ACOG classifies Garcia’s experience a miscarriage management rather than medication abortion.)
A self-described “planner,” Garcia felt that she would have the most control with medication abortion; she could do it without the increased risk of going into surgery during covid-19. She’d already had to go through numerous precautions for her in-person visits when she was pregnant: getting her temperature taken before entering the clinic, wearing masks throughout the appointment.
If she didn’t have the option to take the abortion pill, she would be “so worried,” she says:
In 2018, an organization that provided medication abortions to women who live in countries where abortion is illegal started shipping to the United States. For $90, the company, Aid Access, screens women for their eligibility to take the pills and fills prescriptions at an Indian pharmacy, then ships the pills to the United States. But the company has recently had difficulty getting the pills through U.S. Customs, as Vice reports.
Garcia says her medication abortion cost $15 with health insurance. She doesn’t know what she would do if she had to pay out of pocket, which can cost several hundred dollars.
Cost is a major barrier for women when it comes to abortion, according to Monica Simpson, executive director of SisterSong, a group that fights abortion restrictions on behalf of black women and women of color. She points to the Hyde Amendment, which still does not allow poorer Americans reliant on Medicaid to access abortion via federal assistance.
Experts say accessibility to reproductive health care has only been further limited during the pandemic, as it’s dependent on where one lives, the availability of physicians and clinicians, work schedules, other family obligations and travel distances in rural areas. In the covid-19 pandemic, vulnerable patient populations are having the most trouble accessing the care they need.
This is only compounded for black women and women of color, according to Simpson. “Unfortunately, the health care system isn’t this separate thing that’s not impacted by racism,” she says. The coronavirus pandemic has highlighted these disparities, with black communities being hit hardest by covid-19.
Before the pandemic, black women faced a maternal mortality rate that was 2.5 times higher than that of white women. The Maryland ruling “helps to alleviate” some of the systemic inequities that women of color face when it comes to reproductive health care, Simpson says.
The larger landscape of reproductive health continues to to be contentious: Even as the Supreme Court in June blocked a Louisiana law that would have required all abortion providers in the state to obtain hospital admitting privileges, it also said employers and universities could deny birth control coverage over religious and moral objections.
Simpson says that her organization is focusing on emphasizing community care, in which women are given the educational tools and resources to care for themselves — mutual aid funds during the pandemic have been a great example of this, she says. And as the 2020 election looms, they are trying to “find out who our champions are: the legislators at the state and federal levels who are willing to fight with us and create legislation that will make it better for folks in our communities.”
Even though Garcia believed medication abortion was the right thing to do for her own health, it was still difficult for her to “come to terms with the reality” of ingesting the pill. She cried when she did it.
“It’s heartbreaking knowing you have a life in you and it’s gone,” Garcia says.
Despite the emotional turmoil and the physical pain — Garcia says she had terrible cramps for two days — she doesn’t regret taking the abortion pill. She knows it was necessary for her own health.
“If another woman has a missed miscarriage and has that option to just get the pill through the mail and not risk herself, then that’s amazing,” she says. “I don’t understand how we can tell people they can’t have access to things like this when it’s potentially so beneficial.”