It can be difficult to find good news in women’s health these days, but here’s a sliver: Abortion, to some extent, is easier and cheaper to access than ever before.

To talk us through how that’s possible in a post-Dobbs world, we spoke to Angel Foster, a professor at the University of Ottawa who in 2023 co-founded the Massachusetts Medication Abortion Access Project, also known as the MAP. The MAP currently assists 2,500 patients a month, prescribing and sending abortion pills primarily to U.S. states where abortion is banned or restricted. 

Foster, a Rhodes scholar and Harvard-educated doctor, runs a global abortion research group and was prepared to strike back when the U.S. Supreme Court overturned Roe v. Wade in its 2022 landmark Dobbs decision. The landscape quickly changed as 50 years of settled law was upended and the constitutionally enshrined right to abortion was eliminated. Today, one-third of American women live in a state where abortion is banned or restricted in the first trimester.

But a few factors have offset what could have been an even more disastrous blow to women’s reproductive freedom. For starters, the Covid-19 pandemic ushered in a new era of telehealth, making it possible for women – especially those who live in rural areas – to consult with medical professionals via an Internet connection. Shield laws in progressive states (think Massachusetts, California, New York and others) have given rise to practices that can prescribe reproductive health care, regardless of the patient’s location. And medication abortion, over the course of several decades, has now become the most common form of abortion care in the U.S., allowing women and pregnancy-capable people to safely and effectively end pregnancies in their own homes.

We talked to Foster about how the MAP came to be, the relatively low cost of abortion ($75, although most MAP patients pay less), and what she worries about when it comes to the future. 

Responses are lightly edited for length and clarity.

Can you provide a quick description of the MAP, for those not familiar?

On International Safe Abortion Day of 2023, we launched the MAP. The MAP is an asynchronous telemedicine service. We provide FDA-approved mifepristone and misoprostol to abortion seekers in all 50 states, all U.S. territories, and to those who have a military or a State Department address. We provide care to patients who first contact us when they’re within 11 weeks from the first day of their last menstrual period. Our hope is that patients will have pills in their hands by 12 weeks and take the pills in the first trimester. 

How does the Massachusetts shield law, passed a few weeks after the Dobbs decision, make this possible for patients in abortion-restricted states? 

It effectively redefines the location of reproductive health care or gender-affirming care that’s provided by telemedicine. If the clinician is a resident of Massachusetts, is physically in Massachusetts, and is licensed in Massachusetts, then for the purpose of that care, the care is taking place in Massachusetts. So it is as if the patient was in Massachusetts.

The service is asynchronous, meaning the patient and the clinician communicate at different times. Is that typical with telemed? 

We’re seeing it more and more. Often when people think about telemedicine, they think about having a video conversation with a clinician. We don’t do that. We are available to our patients by secure phone, by text, and email. We can and do have live interactions when patients need those. But it’s basically going online, filling out forms. Then one of our clinicians – our doc of the day – reviews those forms, makes a determination about eligibility and either prescribes pills or follows up with a patient for additional information. That can be things like trying to rule out an ectopic pregnancy or getting more information about a patient’s history. 

How much does abortion care cost through the MAP?

For the first year, we operated as a practice where we charged $250 for our service, but we used a sliding fee scale, so it was really a pay-as-much-as-you-can model. On Oct. 1 of last year, we launched a new financing model for our service, and so now we effectively charge $5 or more. We ask patients to make a minimum payment of $5 but invite them to pay what they can, and we’re able to do that because we have philanthropic support that covers our core operational costs.

The package that we send to patients costs $75, and that’s the medications, the postage, the package inserts, and it takes into account that about 3% of our packages don’t make it to patients because of snafus with the postal system, so we have to resend the packages.

How many people are involved in the MAP?

We have five prescribing clinicians. We have office personnel and community engagement personnel. We have folks who are doing work on the research side, and then we have a lot of volunteers who are helping us with packing parties, who help us get the packages to the post office every day, and who do fundraisers or fundraiser events. 

When I hear $75 – or less if it’s subsidized – it seems like an amazingly inexpensive solution, for many women.

Yes, it really is.

Are the costs that low because the process can be managed through telehealth and also through abortion pills? 

Right. We don’t have all of the things that one would have with a brick-and-mortar clinic in terms of labs and ultrasound machines, all of the things that you would need if you’re doing instrumentation or procedural abortion care. We can be a really streamlined service. We’re also a nonprofit. That’s informed our model as well.

Do you have a sense of your success rates?

Sure, we do. We take that very seriously. Medication abortion in general is about 98% effective. What we see from the outcomes from our patients are very comparable to that. We’ve had very few serious adverse events, and we track those very carefully. In 2024, we served a little less than 11,000 patients. We had about 12 serious adverse events. By that, I mean a patient with bleeding that required a transfusion, so a patient who went to the hospital and actually had an intervention. I want to say we had five patients who needed transfusions, and we had maybe six or seven patients who had retained products of conception and needed an instrumentation procedure.

We also had a handful of patients who had either ectopic or molar pregnancies. We worked very carefully with those patients to get the care that they needed because mifepristone and misoprostol don’t work in those cases. 

Then we had a couple of patients who had continuing pregnancies. We worked with them to find in-clinic providers, getting them linked into, for example, the National Abortion Federation‘s hotline so that they could get subsidies to travel across state lines to get typically hospital-based care.

Can you tell me a bit about your typical patient?

About a third of our patients are from Texas. Our demographics are similar to patients who obtained abortion care in clinics prior to Dobbs. About 40% or 42% of our patients are white. A little bit more than half of our patients identify as Black or Latino. Then we’ve got a small number of folks who identify as Middle Eastern, Asian, Pacific Islander. 

We seem to be serving more rural white women than what we’ve historically seen. Being able to get pills in the mail might be a particularly attractive strategy for them. Before Dobbs, they weren’t able to get abortion pills in the mail. About 7% of our patients have four or more children. That’s actually a pretty high number. Maybe this is a population that didn’t have access to abortion care before. 

Then the other thing that’s different is that more of our patients are getting subsidized care than what we saw prior to Dobbs. Subsidies come from local and national abortion funds, and then also individual donations. A full two-thirds of our patients are getting subsidies and a third of our patients pay $5 or less.

We’re living in a time where there’s so many more restrictions, yet at the same time, there’s greater access.

There’s a deep irony. Multiple things that can be true at the same time. Dobbs is a human rights travesty. It’s awful and we need to continue to fight for legal reform. Abortion with pills is more accessible today than prior to Dobbs because of telemedicine in general and because shield laws now allow telemedicine in places where abortion was restricted before.

And of course, Dobbs had perhaps unintended consequences for women suffering miscarriages, who need medical procedures and can’t get them.

Again, it’s this irony where Dobbs has been terrible for pregnancy-related care. It has been devastating for people with pregnancies that have complications, for example, and [yet] it has opened up medication abortion tremendously.

What are you worried about in terms of what the future holds? We know a New York doctor [Margaret Carpenter] is facing legal challenges in both Texas and Louisiana for prescribing abortion pills to patients in those states.

So let me just start by saying, obviously it’s really disappointing. It’s scary. The fact that the Texas lawsuit against Dr. Carpenter published her home address in multiple places, it creates security concerns. It’s clearly about creating a chilling effect and fear, and inviting people to dox her.

I don’t think anybody in the shield law space was surprised that there was going to be legal action. The question for all of us has been – Is it going to be against a practice? An individual provider? A patient?

With what’s happened with Maggie, we now have the opening salvo. I think there’s going to be more of these. [But] the reality is that, if the anti-abortion rights movement wants to stop abortion in the United States, that is going to be very challenging because of the way that pills can move. With the shield laws, FDA-approved medications and community networks, we can provide excellent, safe, effective abortion services. 

It’s really hard to put that genie back in the bottle. Medication abortion is here to stay, but I think that the anti-abortion rights movement is really doubling down. We’re starting to see, at least being introduced in state legislatures, the idea of criminal penalties for pregnant people who seek abortion care. Some of these folks are discussing the death penalty for women who have abortions or really long criminal prison terms. 

The anti-abortion rights movement is really struggling with – you finally get the thing that you’ve been fighting for, for decades – and actually the number of abortions goes up.

They’ll come after us. I’m sure. I don’t know exactly what it’ll look like. We’ve got really wonderful legal representation. We feel really confident in what we’re doing and the fact that our service is legal and that the state backs us up.

I have to think what you’re doing comes at a great personal cost. Does it? Do you stress out?

A little bit. I think everybody who’s involved with the MAP did their own individual assessment of risk and risk tolerance. Some people are public-facing and some people aren’t. 

As someone who’s public-facing, I don’t travel to or through banned-or-restricted states. I don’t drive a car outside of Massachusetts. I enter the country through Canada. The hardest thing for me is my mom and stepdad live in South Carolina. I can’t visit them. We had a situation where my mother-in-law in the Netherlands just died, and my husband was able to be with his mom for the last 10 days and say goodbye. It’s hard to think about how that wouldn’t be possible if it was my own mom.

When we created the MAP, we created what we call a distributed risk model. The person who orders the pills is different from the person who prescribes the pills, is different from the person who packages the pills, is different from the person who processes the payments, is different from the person who takes the packages to the post office. 

It sounds like a CIA operation. 

The idea is that it’s really hard to tie an individual person to a specific patient. That was an intentional strategy.

We continue to be really hopeful that this pilot project might inspire others, that we can have a shield law practice in every state with a comprehensive shield law. [Currently, 8 states have shield laws protecting telehealth abortion providers.]

What do you hear from the patients?

Mostly, it’s just gratitude for being unpregnant.

People are often scared this is a scam. “Is somebody going to send me something dangerous?” It seems too good to be true. We send a follow-up form, two weeks and six weeks after we send the pills. They’ll say, “Oh my God, thank you so much. You made this process so easy. I didn’t know if this was real.” 

That must keep you in this, right?

It really does. It really keeps our whole team in it. We mine those comments once a week, and we’ll share them out with the team so people can just remember that these are the folks that we’re helping,

Last question, how can a person fight extremism and support an abortion network?

First, help get the word out that abortion with pills is available in all 50 states, and that medication abortion is safe and effective, and clinician-supported abortion is available in all 50 states to all abortion seekers.

We’ve got these attempts that are coming down the pike that are meant to really restrict speech and our ability to communicate about what’s available. The more people that can just amplify that abortion pills are available, the harder it will be to do that.

The other thing, at this moment, is that our mantra is “no anticipatory obedience.” We are going to continue to operate until we are no longer able to legally operate. Then we might pivot and do something else, but the MAP is part of the formal health care system. We’re not going to preemptively change our practice because of some vague or imagined risk. 

Right now, that’s my feeling about all of this. Do not comply in advance. Push back on all kinds of things. ◼️

People can find information on abortion from various resources, including Plan C, I Need An A and AbortionFinder.