Posted By: Lily Bohlke
By Carrie Baker for Ms.
Four years ago, Dutch physician Rebecca Gomperts
founded Aid Access to
provide telemedicine abortion to people in the United States for a sliding
scale fee up to $150. The Austria-based organization serves people in all 50
states, including the 19 states that currently prohibit telemedicine abortion.
Gomperts has a long history of working to provide abortion pills to women in countries with barriers to abortion healthcare. She founded Women on Waves in 1999 to sail boats into international waters bordering countries where abortion was illegal to deliver abortion pills to women in those countries-a dramatic story recounted in the documentary film Vessel.
In 2005, Gomperts founded the organization Women on Web to provide medication abortion via the internet and mail to people living in countries without access to safe abortion services. After the election of Donald Trump, Women on Web received a growing number of requests for help from people in the U.S., so Gomperts founded Aid Access in March of 2018. According to their website, Aid Access seeks "to create social justice and improve the health status and human rights of women who do not have the possibility of accessing local abortion services."
In 2019, the Trump administration's FDA sent Dr. Gomperts a warning letter demanding that she stop mailing abortion pills to people in the U.S. She continued undaunted. Gomperts reports she has provided medication abortion to over 30,000 people in the U.S. since 2018.
In addition to delivering abortion pills by mail, Gomperts has continued to find creative ways to get pills into the hands of women. Over the last decade, Women on Waves has delivered abortion pills by ship to women in Morocco, Guatemala and Mexico; by drone in Poland and Ireland; and by robot in Northern Ireland, Poland and Mexico.
Ms. spoke to Gomperts about her work providing telehealth abortion services in the United States.
Carrie Baker: Why did you start Aid Access?
Rebecca Gomperts: I started Aid Access after we saw that there were a lot of requests coming in for help from women from the United States. Plan C had done research to see whether some of the websites that were offering mifepristone and misoprostol were reliable, which they were. So Women on Web started referring U.S. women to these websites. But women told us they couldn't afford the medications, so that's when I started Aid Access to serve women in the U.S.
Baker: Can you explain how Aid Access works?
Gomperts: We provide an online consultation, where pregnant people are asked about their health condition, how long they've been pregnant and any possible contraindications to the use of the abortion pills, which are very few. The online consultation also provides them information about what it entails to do a medical abortion by yourself. Then the consultations are reviewed by a team of doctors. We also ask for identification from the people that are requesting our help, which is mandatory as a doctor to know who you're seeing. And then I prescribe the medication and the prescriptions are filled by a pharmacist in India. He ships it to the U.S. Aid Access now has nine providers in the U.S. using the same platform to prescribe for their patients in their own states.
Baker: Do you have any other clinicians abroad? Or is it just you?
Gomperts: No, there's another clinician, but it's somebody who mostly reviews the consultations. I'm the only prescribing physician outside the U.S. at the moment.
Baker: Does the process happen all on the internet through online forms and messaging, or do you do video conferencing with your patients?
Gomperts: No, we don't generally do videoconferences, but we can. If it's a minor or somebody who's in an extremely vulnerable situation, we can do a video conference. We've used this same system with Women on Web for more than 17 years and all the data has been analyzed. It's very safe, and it's effective. And it's extremely acceptable for women to do it this way. I do sometimes do video conferences in the Netherlands when I see patients there, and it doesn't add any information to be honest to what you can obtain online.
Baker: How long does it take for a patient to get the prescription from when they first contact you?
Gomperts: The prescription is provided quite quickly after the online consultation and after receiving the payment, or if they cannot afford it, then it's donated. The pharmacy in India fills the prescription, but it takes some time before it arrives at the women's home address because mail needs time-between two and three weeks.
Baker: Why do you use a pharmacy in India?
Gomperts: Not all pharmacies can fill a prescription for mifepristone. Mifepristone is extremely restricted in many countries. India allows it. They provide good quality products. The medicines are produced under the supervision of the Indian government. They use exactly the same regulations that apply to pharmaceutical products made elsewhere in the world. Actually, most of the medication in the world is produced in India. There's also a lot of generic medication there, so it's much cheaper. We want to make the service available for women that have little to no money. One of the main obstacles to abortion care in the U.S. that we found is actually the cost. So many people live under the poverty threshold. They just cannot afford to pay the $600 or whatever it's costing at a clinic. So in order to meet the demand, we need to use the most cost-effective medications.
Baker: Have the medications, to your knowledge, ever been blocked in the mail coming to a patient in the U.S.?
Gomperts: Well, it's not clear. It seems like some packages were stopped a few years ago, after the FDA letter that was requesting me to stop providing care to women in the U.S. There were very few packages stopped. It might have been that these were actions done by the local mail centers themselves. We don't know. But we haven't seen any problems since then. Of course, the problem has been COVID. With COVID, a lot of the local mail services in the U.S. stopped working well. Fortunately, the World Health Organization recently submitted an advice that women can safely self-manage medical abortion until 13 weeks of pregnancy. We prescribe medications until 10 weeks, so there is time to receive the pills before then. More and more research shows it's safe to use abortion pills in the early second trimester. But of course, the process is a little bit more intense. The earlier the better. Always.
Baker: You prescribe medication abortion through 10 weeks or 70 days from the last menstrual period?
Baker: What do you charge for this service?
Gomperts: I'm charging about 95 euros, which is about 110 U.S. dollars. That includes everything-the consultation, the prescription medicines, the shipping. It's the all-inclusive cost.
Baker: And how does your sliding scale work?
Gomperts: It's very simple. When people say that they cannot afford to pay, we just ask how much they can afford to pay. If they say that they can pay $80, then that's fine. If they cannot afford that, then we ask if they can afford $55-the cost of the pills-because I try to cover my expenses. But sometimes even that's not possible. So it depends on what people can pay, to be honest.
Baker: How many of your patients use your sliding scale fee?
Gomperts: About 30 percent of the people who contact us cannot even afford $100. About 10 to 15 percent get a full donated service.
Baker: How can you afford to do that? Do you have funders that help support patients who can't pay?
Gomperts: Well, we do get donations because people support the service, even though I'm officially not a nonprofit. The good thing about this system is that you can keep it quite low cost. Especially if you don't need to invest the time to do video calls and all the organization around that. These things make services unnecessarily expensive. That makes it easier to keep the cost down.
Baker: How many misoprostol pills do you provide with the mifepristone?
Gomperts: I always prescribe 12 misoprostol pills. The reason is that we know from research that it's always better to have more so that you can repeat doses if you're a little bit longer in pregnancy. Before, we used to do eight, which is also okay, eight or 12. U.S. doctors usually do eight. Extra misoprostol helps in case there is too much bleeding. Misoprostol is like a miracle drug.
Baker: What kind of follow up care do you provide?
Gomperts: We have a help desk-a team of people that are specially trained to answer the questions posed by anybody reaching out to the service. There's an intense training program and there's medical supervision for them as well. They work in shifts so that they can go for 24 hours answering emails. All the emails are answered within 12 hours. And then we refer people to the M+A Hotline, which has doctors that answer any questions or concerns by phone or text. We also do a follow up email about three weeks afterwards or five weeks after the package has been sent so that we know exactly what was the outcome.
Baker: Do you do any sort of survey to gauge patient satisfaction?
Gomperts: Yes, we do that. That's part of the follow up email that we send at five weeks. We ask if it was acceptable for them, if they would recommend it to other people in their situation. The satisfaction is incredibly high. It's 98 percent. We have a very lenient reimbursement policy, so we refund people if there's any problems or any reason they aren't happy.
Baker: How many people have received care through Aid Access since you founded it in 2018?
Gomperts: More than 30,000 for sure.
Baker: Was there an uptick after S.B. 8 went into effect in Texas on September 1 last year?
Gomperts: Yes, absolutely. There was an increase in requests. But also with COVID, there were increased requests for telemedicine services.
Baker: Where are your patients coming from in the U.S.?
Gomperts: There's a lot from Texas. But also New York and California, which are now served by U.S. providers. They have a lot of requests. These are not restrictive states, but many services are still expensive, and there's a huge preference for telemedical abortions because it's very convenient and people can stay at home, they don't have to travel anywhere, they don't have to organize childcare.
Baker: How many people work for Aid Access?
Gomperts: Together with me and the U.S. providers, it's about 12 doctors that are using the system and at the moment about 10 help desk members. Then there's a technical team to make sure that the website is always very secure, and well protected. That is another three people.
Baker: Do you provide advanced provision pills?
Gomperts: Yes. I think this is a medicine that should be available over the counter. It has the safety profile for that. It's safer than many of the painkillers that you can buy in any pharmacy or drugstore. The reason why it's not there has to do with politics and not medical science. Especially in states where abortion is getting harder and harder to access, it really benefits women's health if they already have the medicines available when they find out they're pregnant. What we know now is that so many people are using apps to track their menstruation-almost all young people are doing that-so they know the moment that they miss their period that they are probably pregnant. They do a pregnancy test, it's positive and then the ordeal of finding an abortion service starts. The delays that are caused by that is really a shame because if they can use medications the moment they find out or think they're pregnant, the medicines don't have any side effects. It's much better for somebody to take abortion pills really early in pregnancy. Then it's like delayed menstruation, instead of when it's later and becomes like a miscarriage with more bleeding and more pain and more stress.
Baker: Taking abortion pills in early in pregnancy feels like the normal cramping of menstruation?
Gomperts: Exactly. Yes. The misoprostol causes cramping of the womb, but if you use good painkillers like naproxen, it's very doable. And it's very comparable to menstrual cramps.
Baker: Have you received many requests for advanced provision pills?
Gomperts: Yeah, there's definitely huge interest. I think one of the problems is that you would want it to be cheaper because it's quite a lot of money to invest upfront on something you might not need. In an ideal world, they should be like the morning after pill-$30 perhaps.
Baker: Do you think we'll get there someday?
Gomperts: Yes, absolutely. Of course. There's no doubt about it. I don't know how quickly the U.S. is going to get there because I think some things have to change. It seems the Supreme Court that is there now is not going to be very supportive of these kinds of ideas.
Baker: Recent research in the U.S. shows that people here want over the counter access to abortion pills. Are abortion pills available over the counter anywhere else in the world?
Gomperts: In Nepal, it's quite easy to buy them from any pharmacy. You can buy most prescription medicines at pharmacies in Nepal. In India it's the same. You can buy most prescription medication without a prescription. But it hasn't been registered as an over-the-counter medication anywhere as far as I know.
Baker: Do you offer missed period pills?
Gomperts: Yes. I think that's an area in between the advanced provision and the regular provision. I don't see the benefit of not doing a pregnancy test to be honest. It just helps to confirm the pregnancy so as not to use them when you don't really need them. But I'm totally open to having that conversation.
Baker: Is it legal for Americans to order abortion pills through Aid Access?
Baker: Is it legal for pharmacies in India to send abortion pills to people in the U.S.?
Gomperts: Yes. And is it legal for me to prescribe them.
Baker: Five states prohibit self-managed abortion, but your service is physician managed so it wouldn't fall under those laws, would it?
Gomperts: Right. Aid Access provides physician-supervised abortion. It's not self-managed in that sense. But let me say this: All medical abortions are self-managed, period. People take the pills themselves, they have the cramps themselves, they have the bleeding themselves. So what is self-managed abortion? Everything is self-managed. So I don't understand how they could ban that.
Baker: Could a woman's order be detected by legal authorities in the U.S.?
Gomperts: In the U.S., there's very strong protection of mail. Even if they track it down, there's no way to prove that anybody took the pills. And to buy the medicines is not against any law. It's not against any regulation to get medicines for your own use. I think one of the main problems with these laws is they are causing so much self-censorship. People become really scared of something that they don't have to be scared of, according to the law. But of course, one of the problems in the U.S. is that there's so much legal injustice anyway. Many people are in jail despite their innocence because they are forced to admit to something they never did because they know they don't have a chance to win a court case. So all these things are intertwined with each other. Aid Access is about providing information so that people know what their rights are. It's a human right to get abortion pills. Also, if they need to go to the hospital, they can say that they had a miscarriage. It's the same treatment as when you have a medical abortion. And it's nobody's business whether you took the pills or not. What kind of medical care you get doesn't depend on that. This is really about empowering women and pregnant people who do their own abortions, which they have a right to do with medicines, and empowering them so they understand that they shouldn't be intimidated by police or anybody else. I think that is where we have a real big problem with the laws that are on the books. The intimidation is huge. That's where you lose the power.
Baker: Why are you so passionate about offering abortion pills to people who don't have access?
Gomperts: When somebody can't get abortion pills on their own terms, that is a human rights violation. It doesn't matter what kind of obstacles there are, whether it's legal, financial, logistical, personal, private, preference-it doesn't matter. Abortion should be available on your own terms, however you need it, whenever you need it, and in whatever way you need it.
Baker: When the Trump administration sent you that cease and desist letter in 2019, what was your reaction?
Gomperts: I stayed in my bed for three days, researching and reading everything that existed on the FDA regulations, calling all the people I could call in the U.S., trying to find a good lawyer. I just needed to understand whether I had overlooked anything when I started Aid Access. I came to the conclusion that it's okay, I can do this.
Baker: What do you think of the recent FDA decision to lift some of its restrictions on the abortion pill mifepristone and allow telemedicine abortion?
Gomperts: It's so encouraging that now telemedicine is accepted as a safe form of abortion provision. But the remaining restrictions suck. This control system is in place to dissuade people because it makes every pill traceable, which is not the case with any other medication. That is why the restrictions are still in place-it's a form of dissuasion-with a finger, we will watch you. That is the only reason why the restrictions are in place, so they can trace back every pill and the person who buys it.
Baker: Why do your patients come to Aid Access?
Gomperts: It's a mix. You have poverty-people who can't afford a clinic-and preference-I just want to do it by myself, in my home, on my own terms.
Baker: What is your goal in providing this service to U.S. women?
Gomperts: To make sure that everybody has access who needs it, including people who don't have any money at all. In the U.S., that's really where there's always been a problem with abortion services. There's really a problem with financial obstacles to access any healthcare service if you're poor and you're not insured. I think our sliding scale system should be adopted by all the abortion services. It's possible. If you let some people pay a little bit more than what it costs you, you can always cover the cost of the people that can't afford it. There's always this fear of abuse. But the systems that you put in place to control it are much more expensive. And most people, almost all people, are well meaning.
Baker: How does it feel to be able to help people in this way?
Gomperts: It's really a privilege to be able to do it. It's empowering for me, as well as for the people using the service. And it's also empowering for the doctors to join the service. I think everybody really feels very excited about it.
Baker: Have you experienced any threats or harassment for providing this care in the U.S.?
Gomperts: Besides the FDA letter? No.
Baker: You have a long history of using art to raise awareness about medication abortion and to find creative ways to overcome legal restrictions. Are you still doing things like that today?
Gomperts: Yes, we are. The last campaign that we did was with robots in Mexico, where we had 10 robots delivering abortion pills in 10 states. The robots can deliver the abortion pills because they are controlled from a distance. They have the abortion pills in them and can deliver them from all over the world. I think it would be really nice to do an abortion robots campaign in the U.S. It's very funny. Actually, it's a robot that's produced in Texas!
Baker: I love it! That would be really funny.
Gomperts: We were approached by quite a lot of people that are thinking about the abortion boats. I see the symbolic advantage of it in the U.S. Let's see if people are going to do that.
Baker: What other projects are you working on?
Gomperts: My main project in the coming 10 years is to develop mifepristone as a weekly contraceptive. Fifty milligrams, which is a lower dose, is very good as a morning after pill. It's safer and more effective than any of the existing morning after pills. If you use it weekly, it's very effective as a contraceptive as well. If you take 50 milligrams of mifepristone every week, it prevents pregnancy. If you use it after you have unprotected sex, it also prevents pregnancy. And if you are already pregnant, you can use four tablets to end the pregnancy. We are trying to get research done that is needed to prove the safety and effectiveness of long-term use.
Baker: Is mifepristone effective for treating fibroids or endometriosis?
Gomperts: Yes, it is. It's approved for that treatment in some countries-in Russia, India, and some other countries.
Baker: How do you make sense of what's happening in the U.S. with regard to the rollback of abortion rights while many other countries are expanding abortion rights, such as Ireland, Argentina and Mexico?
Gomperts: I think it says something about the state of democracy in these countries. In the U.S., the democratic rule of law has been undermined for decades, not only with abortion rights but with voting rights. It's part of a bigger trend.
Baker: Why do you think abortion is so controversial in the U.S.?
Gomperts: Because if you can prevent abortion, you can keep people poor. And when you keep people poor, you can control them. Poor people have no voice in most places. In any normal-thinking democratic country, you would think, I can decide that for myself and somebody else can decide that for themselves as well. But the reality is with the way that religion in the U.S., it has been used to restrict people's rights.
Carrie Baker wrote this article for Ms. Magazine.
Content for this Post is provided by Florida News Connection, a Bureau of Public News Service. Public News Service is a member of the The Trust Project.
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