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This story is an accompaniment to a three-part podcast series released by ReadNOW’s Embedded and Futuro Media. You can listen to the full series here or wherever you listen to podcasts.

For nearly four years, Dr. Maya Bass’s commute included a monthly plane ride from Philadelphia to Oklahoma to provide abortions at a clinic there. Starting in 2018, she took these trips even though flying made her nauseous and she had to use vacation time from her regular job. Bass was motivated to fill a gap: Oklahoma — like all parts of the U.S. outside of a fraction of metropolitan areas — has long had a shortage of abortion providers.

Bass trained in abortion care the year before in medical school, during a rotation at a Planned Parenthood.

There, she realized the connection between an abortion provider and patient can be deep. “I want to be that provider who lets people feel heard and helps break that stigma,” she says.

Since the 1970s, legal abortions in the U.S. have taken place at brick-and-mortar facilities across the country, like the one where Bass practiced in Oklahoma. But that began to change in the early 2020s. Between the COVID pandemic and the 2022 Supreme Court decision overturning Roe v. Wade, doctors had to rethink what a safe abortion looked like. The evidence for how to have safe and effective abortions outside the clinical setting was waiting for them.

A Medication Revolution, Despite Barriers 

If what you picture when you think of an abortion is a woman in a medical gown, undergoing a procedure, that’s far from the norm today. Medication abortion — taking pills to end a pregnancy — now makes up 63 percent of all abortions in the country. The first time Bass counseled someone through a medication abortion, she remembers how simple and straightforward it was.

“Being able to just tell someone how to take pills and then know that the issue they were dealing with would be resolved just felt like such a great contribution to health care,” she recalls.

To perform a medication abortion, which is approved in the U.S. through the first 10 weeks of pregnancy, Bass gave patients two drugs: misoprostol and mifepristone.

The medications each play a different role in an abortion and have different histories. Misoprostol, which causes contractions that empty the uterus, has multiple medical uses, including treating ulcers. Starting in the mid-1980s, women in Latin America — a region that had widespread abortion restrictions — noticed that miscarriage was a side effect of misoprostol. Underground networks emerged there to help women use the drug for abortion. In the U.S., misoprostol is prescribed off-label for abortion and other gynecological purposes.

Mifepristone, in contrast, stops the pregnancy from progressing by blocking an important hormone. It was developed in a French laboratory with the express purpose of causing abortions.

The Food and Drug Administration approved mifepristone in 2000 but with a caveat: doctors had to follow stringent guidelines when they prescribed medication abortion. Those came to be known as Risk Evaluation and Mitigation Strategies (or REMS), which are typically reserved for drugs that are highly addictive, like fentanyl, or dangerous, like cancer drugs. Mifepristone is neither.

Bass says she found some of these rules unnecessarily burdensome.

For instance, because of the REMS, patients had to schedule an appointment and come to the clinic to get the mifepristone; they couldn’t pick up the pills from a pharmacy at their convenience.

On top of the federal regulations, Bass had to follow state-level requirements from Oklahoma. One of them, which was the case for several states at the time, required patients to swallow the mifepristone in front of her.

“I have to watch you take this specific pill,” she says. “It is a little silly.”

But Bass supported some of the rules she had to follow. Clinics created exhaustive standards of care to comply with the REMS and to reduce their legal risk. They included a mandatory ultrasound to date the pregnancy and bloodwork to check for medical risk factors.

Bass followed up these physical exams with counseling that helped patients understand what to expect and what signs indicated something might be going wrong.

After attending all of these appointments, undergoing tests, and paying for the pills, patients went home to manage the abortion — a process that involves cramping and bleeding that can take more than 24 hours. For Bass, this introduced risk and uncertainty.

“I think a lot of our protocols are created so that we don’t have to trust that our patients know when to advocate for themselves. We can just confirm, at every state of the process, that this is fine,” she says.

Despite finding aspects of the REMS unnecessary, overall Bass considered the protocol to be good doctoring — until she encountered an alternative.

Out of the Clinic, Onto the Internet

Throughout the 2010s, American women started to lose access to doctors who could give them an abortion. During this period, states passed hundreds of new restrictions that closed clinics and shortened the time frame women had to get an abortion.

Abortion rights advocates started looking for an alternative. Elisa Wells, a public health researcher and one of the founders of the organization Plan C, had worked in international settings and had seen how freely available abortion pills were in some other countries.

Wells and her team started looking into access in the U.S. They discovered one place where you could purchase pills without a prescription: the internet.

“There were people in chat rooms that were asking, ‘How can I get abortion pills?’ And people were desperate to know this information. They couldn’t afford the cost of a clinic… the $500-$600 it was going to take to get these pills,” she says. “And so they saw these other pills online and wondered ‘Were they real? Would they arrive? Am I going to be scammed?’”

Wells and her colleagues set out to answer these questions. She found 18 websites selling pills. She recalls that the sites looked “a little sketchy,” but she decided to test-purchase pills anyway. She entered her credit card information and waited, doubtful that they would arrive.

But a couple weeks later a package appeared at her door. Inside were the abortion pills. “It was amazing to me that these pills actually came,” Wells says.

Wells had them tested at a lab to check if they were real and presented her findings at the National Abortion Federation meeting in 2017.

“There was a bit of buzz ahead of time,” she recalls. “People were pretty convinced that the research was gonna show that these pills were fake.” Then Wells and her team revealed the results of the lab tests: the pills were real.

“There was an audible gasp in the room,” Wells says. “People realized how transformative that could be to abortion access in the United States.” She even remembers some applause.

But as news spread throughout the abortion rights community, not everyone was celebrating.

At medical conferences across the country, clinicians who supported abortion rights began having heated debates about self-managed medication abortion — getting abortion pills without a prescription and taking them without a doctor’s oversight. Jen Karlin, a professor of family and community medicine at the University of California, San Francisco, became interested in the disagreement.

Self-managed medication abortion “was starting to make some people uncomfortable… People felt it was really unsafe,” she says. “I wanted to talk with clinicians about this to find out what is at stake here? Are you really worried about the safety of this? And if you are, what aspect of the safety of this are you worried about?”

In 2019, Karlin turned these questions into a study. First, she surveyed 40 clinicians who provide abortion and asked what they thought about self-managing.

Half of these doctors believed self-managed abortions were safe, effective and empowering. Nearly half were ambivalent.

Bass, the abortion provider who regularly flew to Oklahoma, participated in the study, and she fell into this latter category. She pictured worst-case scenarios for women who self-managed. “What if they have a septic abortion? What if they take the medication wrong and they hurt themselves?” she says.

After the survey, Karlin gave participants a fact-sheet. It summarizes nearly two dozen peer-reviewed articles on the safety and effectiveness of people managing a medication abortion without going to a clinic or seeing a doctor.

The studies on that sheet spanned decades and the globe.

Bass later read through every article footnoted in the fact sheet, all 23 of them.

“Wow, this is real,” she remembers thinking.

Some of the studies directly challenged the multi-step protocol Bass adhered to when prescribing abortion medication. For instance, one study found that an ultrasound wasn’t necessary to determine patients’ gestational age in early pregnancy; patients’ reported last period was usually accurate enough. Other studies found that an in-person follow-up appointment to make sure the abortion was complete also wasn’t essential. Together, the studies suggested that the extensive safety measures doctors followed weren’t necessary for all patients.

Though many of the participants in Karlin’s study were struck by the fact-sheet’s overwhelming evidence, another exercise in the study is what tended to change their minds: Karlin asked them to reflect on their values, in light of what they’d just learned.

One doctor realized that her discomfort with self-managed abortion wasn’t really about safety. She felt that supporting her patients in person was the best part of her job, and self-managed abortion would take that away from her.

Karlin recalls the abortion provider saying, “I went into this trying to provide quality care, evidence-based care… But then I realized that it’s not about me, it’s actually about centering the patient.”

Several participants, including Bass, realized that requiring a doctor to be involved actually limited abortion access.

The Pandemic Greases the Wheels 

The evidence summarized in Karlin’s fact sheet had been around for decades. But it took a global pandemic for that research to translate into policy.

COVID-19 made in-person contact risky, so, Karlin says, “All of a sudden, the health care profession is saying… ‘Do we really need that person to come in and do that test… that ultrasound?’ And lo and behold, there’s all this evidence already out there that no, they don’t.”

In 2020, the  American College of Obstetricians and Gynecologists, with help from the American Civil Liberties Union, sued the FDA for putting doctors and abortion patients at risk. In response, the FDA walked back its regulations.

In 2021, the FDA announced that it would stop enforcing the REMS for mifepristone — more than two decades after the regulations had been introduced. Patients were no longer federally required to go to a clinic to get abortion pills. They could simply fill out a form online or attend a virtual appointment and then get the pills mailed to them.

During the pandemic, Karlin returned to the doctors she had surveyed in 2019 to see if their views about self-managed abortion had shifted. Some told her they were now even more convinced it was safe for patients to have abortions with less medical oversight because they’d seen the evidence through their patients’ experiences.

Half of the people she had surveyed who had thought it was necessary to do an ultrasound to determine gestational age no longer did. The fraction of clinicians who believed patients needed an ultrasound to make sure the abortion was complete also dropped, down to 5 percent.

Even after the FDA revised its policies, only about two-thirds of states allow telehealth for medication abortion. But it was still a dramatic shift.

Although some doctors would prefer to see patients in person, the shift to telehealth got many clinicians thinking outside of the box on how to create access to abortion despite barriers. It’s an approach they would use again when abortion seekers faced another barrier to clinic access.

The Fall of Roe

After participating in Karlin’s study and changing her mind about self-managed medication abortion, Bass looked for ways to support people who took pills on their own.

In the fall of 2019, she joined a group of clinicians who were establishing the Miscarriage and Abortion Hotline, or the M+A Hotline.

Bass took an 18-hour shift, two to four times a month. In some ways the calls on the hotline were similar to the counseling she’d been doing in a clinic.

“Most of what we do is reassure,” Bass says “I would say the vast majority of the calls I’m dealing with are people just being like, ‘Hey, can you tell me if it worked? Or can you tell me if this is too much bleeding?’”

Bass was surprised to find that the conversations on the hotline could feel more intimate than those in the clinic. She thinks patients open up more because both they and the doctor are anonymous.

Bass remembers one woman who called in the middle of the night confiding in her, saying: “I haven’t told anybody. I feel so alone. I don’t know anybody else to talk to.”

“Those experiences are why I kept doing it,” Bass says. “Because it’s very infrequent that you feel like you can make that much of an impact on a person.”

After Roe was overturned in 2022, Oklahoma banned abortion, and the clinic there where Bass worked stopped providing abortions. Her monthly trips stopped. Unable to practice in person, the hotline gave her a sense of purpose.

It also changed her understanding of why someone would self-manage their abortion. Before joining the hotline, she assumed self-managing was an act of desperation, a last resort. But that wasn’t always the case.

She got calls from women in states with abortion protections, who opted to self-manage because they found it more convenient or affordable.

Bass knows that self-managed abortion can’t replace all abortions – for instance, emergency cases or certain medical risk factors still require a clinician. And sometimes people just want a doctor involved. But the hotline led her to appreciate doctoring in a de-medicalized setting without unnecessary ultrasounds or bloodwork. For the first time, she was able to care for people having an abortion without politics shaping the process.

“It feels like I’m just on the cutting edge of medicine,” she says. “I’m practicing evidence-based medicine that is the leading edge of what reproductive healthcare might look like.”

In the last few years, the broader medical community, including the World Health Organization, has declared self-managed abortion to be a safe and effective method in the first trimester.

Many American doctors agree. In 2024, the American College of Obstetricians and Gynecologists put out a statement in support of self-managed abortion. It called on doctors to educate themselves and provide support for patients who do it.

Since the Supreme Court overturned Roe, the hotline has only grown. It now has dozens of volunteers, including clinicians as well as people who provide logistical support. The hotline gets thousands of calls and texts every month.

Other doctors contributed to a demedicalized model in another way — using telehealth to prescribe pills from states with abortion protections, called shield laws, to people in states with restrictions or bans.

Doctors’ embrace of telehealth has led to an increase in the number of abortions in the U.S. In fact, research has shown that telehealth is one of the main reasons for this rise.

But access to these demedicalized options may be more fragile than it seems.

In her study, Karlin found that some clinicians weren’t swayed to support self-managed abortion. It wasn’t because they thought self-managed or telehealth abortion was dangerous – they worried about the political consequences.

“When and if something goes wrong — which it will, because with medicine, something goes wrong eventually — they were worried that that would be used by politicians to try to limit reproductive autonomy further,” Karlin says.

That prediction has borne out. In 2022, the sister of Louisiana state Sen. Thomas Pressly was secretly drugged with abortion pills by her husband. Sen. Pressly then introduced a bill in Louisiana to make mifepristone and misoprostol “controlled, banned substances.” The bill passed in 2024, making the drugs much harder to get, even for doctors. And possession of them without a prescription can result in jail time.

States have also sued shield law providers — doctors who prescribe abortion pills to states with abortion restrictions.

In May, Secretary of Health and Human Services Robert F. Kennedy Jr. ordered the FDA to review regulations on mifepristone, citing a paper from a conservative think tank that calls for restoring earlier restrictions on the drug and reconsidering the FDA’s approval of mifepristone altogether. Medical experts have criticized the analysis in the paper, which hasn’t been peer reviewed and reports higher serious adverse effects of the pill than was found in dozens of prior studies.

Despite these efforts to increase restrictions, ReadNOW’s reporting indicates that self-managed abortion, and the means to get support, is spreading in an informal, person-to-person way that might be outside government control. Sources shared stories of older sisters who had self-managed before helping their little sister through it, people getting pills and advice from their hairdresser, and several examples of people who had been supported by abortion doulas — someone who supports people through the process of self-managing — training to become doulas themselves.

Dee Redwine, an American who worked for 30 years in Latin America for Planned Parenthood Global, sees a pattern unfolding that she’d witnessed abroad. She learned about self-managed medication abortions in the 1990s and saw the use of misoprostol sweep across Latin America. She says when it comes to self-managed medication abortions in the U.S., “There’s no putting that genie back in the bottle.” 

“That wave is coming. It’s here. It’s like crashing over the shores of the United States. It was… moved along much faster because of the Dobbs decision. And it is going to change entirely the landscape of abortion, just like it did globally,” she says.

As Redwine sees it, the Dobbs decision matters for abortion access, but not in a straightforward way.

“The irony of this post-Dobbs world is that if it goes the way that I think it will, which is what I saw in Latin America, in some ways abortion ironically will become more accessible, but less legal.”

Zazil Davis-Vazquez fact-checked this story. Reporters Marta Martinez and Victoria Estrada and editor Rhaina Cohen also contributed to the reporting and writing for this article.