Originally published in Vox on May 7, 2022.
In 2018, more than two decades after Dutch physician Rebecca Gomperts first became an activist to deliver abortion pills around the world, she turned to the United States. For years she had dedicated her life to working in countries where the procedure was illegal, and was firm in her refusal to avoid the US, where safe, legalized access was still available. “I think this is a problem the US has to solve itself,” she explained in 2014.
But following the election of President Donald Trump, the desperate requests she received from Americans went up, and the cost barriers in the US were glaring.
So Gomperts launched a new nonprofit organization based in Austria — Aid Access — with the goal of providing affordable and accessible abortion services to people in the US.
Over the past four years, Aid Access says it has delivered abortion medication — mifepristone and misoprostol — to more than 30,000 Americans across all 50 states, including the 19 conservative states that currently ban telemedicine abortion.
The organization plays a unique role in the US reproductive rights ecosystem by successfully exploiting legal loopholes that make it easier for an overseas doctor to care for American patients in restrictive states — a role that could become even more key if Roe v. Wade is struck down.
If the right to an abortion does get overturned, Aid Access staff say they feel confident their services could continue, in the same way they’ve been able to operate in red states that have barred other abortion groups.
So what’s the catch?
For now, the biggest one may be the big tech platforms. Aid Access needs to spread awareness about its services, and quickly. The pills, when shipped from overseas, can take two to three weeks to arrive, and Aid Access prescribes the two medications up to the first 10 weeks of pregnancy. But because it operates outside the formal US health care system, Aid Access says it has been penalized by search engines and social media giants that have tried to tackle the spread of Covid-19 misinformation.
Aid Access still pops up on Google if you search the organization’s name, but most users had come to the site while searching for terms like “abortion by mail” and “abortion pills.” Following a series of algorithm updates beginning in May 2020, Aid Access says it no longer shows up in top results for general medication abortion searches — and that ads from its sister organization, Women on Web, which serves countries all over the world, are frequently removed or rejected from Facebook and Instagram for dubious reasons, like “language … that is likely to offend users.”
Republicans might not be able to stop Aid Access right now, but it appears that Silicon Valley can.
How Aid Access works
The Aid Access model goes like this: If you need an abortion, you fill out an online consultation form. If you’re early enough in your pregnancy and deemed eligible, then you’re referred to a provider. People living in the country’s more liberal states and Washington, DC, are referred to a US-based provider who fills prescriptions that ship typically in two or three days. For women living in the 31 states that Aid Access counts as having tighter abortion restrictions, Gomperts sends the prescriptions to a pharmacist in India, who then mails the pills directly to patients in the US. (Aid Access chooses India in part because the country produces regulated, high-quality generics, Gomperts has said.)
Gomperts and the women she prescribes pills for operate in something of a legal gray area. As a result of being registered to practice medicine in Austria, she is subject to Austrian law, and therefore exempt from specific rules and regulations affecting doctors in the US, like state requirements for ultrasounds or 72-hour waiting periods. And while personal imports of drugs from other countries are usually against US law, the Food and Drug Administration (FDA) has said it generally avoids going after individuals who bring medicines in for personal use.
It’s a model Gomperts developed first in 2005 with Aid Access’s older sister organization. Since its founding, Women on Web says it has delivered abortion pills to more than 100,000 women across the world, reaching pregnant patients in countries with restrictive laws, like Sudan, Hungary, and Brazil. In 2018, Gomperts set up Aid Access under a separate corporate structure, to serve the US while protecting Women on Web from the aggressive US anti-abortion movement.
Activists note that medication abortion is far safer than many painkillers easily purchased over the counter, and the World Health Organization maintains that individuals can self-administer the drugs without direct supervision of a health care provider during their first trimester. New Lancet research published in February affirmed the safety of the Aid Access model, which also provides the medication at significantly lower cost than in-person surgical abortions or even the new crop of US startups like Hey Jane, Abortion on Demand, and Carafem.
Aid Access says its work will continue in a post-Roe environment, and that requests for pills and information tripled in the wake of Monday’s leaked Roe opinion draft.
Christie Pitney, a midwife who fills prescriptions for Aid Access patients in California, Massachusetts, Oregon, and DC, said that while patients in some states with trigger bans may have to switch from US-based providers like Pitney to Gomperts, Aid Access will keep serving them. “We’ll still be here,” she said.
“We’re pretty nonplussed, to be honest,” Pitney told Vox. “I don’t see a route [to stopping us]. It’s not to say that it’s impossible, I just don’t see a route for politicians to eliminate access to Aid Access; they just don’t have the jurisdiction to criminalize an international doctor.”
Other international doctors could also join Aid Access if Roe were struck down to help Gomperts prescribe the abortion pills, though she told Vox that thus far she has not been approached by any physicians.
A struggle for internet traffic
Despite the unique strategy Aid Access and Women on Web deploy, over the past two years, the organizations say they have been fighting against search engine algorithms that deprioritize their services, and opaque social media policies that limit or block their posts.
Earlier this year, in an interview with the New York Review of Books, Gomperts said that “the algorithms of Google are suddenly becoming the de facto gatekeeper to access to safe abortion services in the US.” When Google set out to correct Covid-19 misinformation and started elevating more health sites that were officially government-sanctioned, Gomperts said it had the side effect of demoting sites like hers.
Searches like “abortion by mail” and “online abortion” no longer led users to Gomperts’s groups, she says. Women on Web, for example, says it saw a 90 percent drop in daily global traffic after Google rolled out a new update on May 4, 2020. A subsequent update brought back some of what had disappeared, doubling its now-minuscule traffic, but then a third algorithmic update six months later took 40 percent of what remained. “We’re back to pretty low,” said Venny Ala-Siurua, the executive director.
Ala-Siurua told Vox that deprioritization in internet search results remains one of their biggest barriers. Google “keep[s] pushing up traditional health providers, brick-and-mortar clinics, but they’re missing what’s happening in the digital world today,” she said. “The algorithm is not neutral. It was built and written usually by white men in the Bay Area who might not really be in tune with what the needs are here.”
Aid Access isn’t alleging Google is intentionally restricting access to its site specifically, but Gomperts told the New York Review of Books that they might eventually launch a lawsuit over this. “The algorithms are making it much harder to find the places where you can obtain these medicines,” she said. “That is what people don’t realize: It’s Google that is filtering people’s access to information.”
Lara Levin, a Google spokesperson, told Vox that their search ranking systems “are designed to return relevant results from the most reliable sources, and on critical topics related to health matters, we place an even greater emphasis on signals of reliability.” Levin added that no update is made to benefit or penalize any one site. “We give site owners and content producers ample notice of relevant updates along with actionable guidance,” she said.
The Facebook and Instagram accounts for Women on Web have had spending restrictions placed on them for more than a year, after their ads were flagged or hidden by other users who oppose their work or who found their content “to be offensive … violent, [or] about a sensitive topic.” Some of their ads for medication abortion have also been rejected, with rationales like “Ads must not promote the sale or use of unsafe supplements, as determined by Facebook in its sole discretion.” One Women on Web Instagram post that read, “You can now order abortion pills BEFORE you are pregnant,” and included a link for advanced provision was taken down for not following “community guidelines.”
Facebook did not respond to a request for comment on the Women on Web ads specifically, but pointed Vox to company policies from Meta (Facebook and Instagram’s parent company) including ad prohibitions for direct sales of prescription drugs, and for ads promoting reproductive health products or services to people under age 18. In November 2021, Facebook also announced it would remove ad targeting options for topics people may perceive as “sensitive” — including health-related causes.
But at least one of the examples Women on Web showed Vox — the one about ordering pills before you’re pregnant — wasn’t an ad. It was a regular post to the group’s Instagram profile that they didn’t pay to amplify or target.
The algorithmic battles playing out reflect broader challenges faced by tech companies, which are under pressure to crack down on misinformation and propaganda and to take clearer stands on polarized political issues that users may be researching. The last few years have also brought greater attention to the ways in which machine learning and AI more broadly can reflect bias and discrimination, even while purporting to be objective and neutral.
“We have to be careful not to frame questions as one of adapting to technology,” said David Broniatowski, a professor at George Washington University who has studied anti-vaccination communities online. “The technology is out in the world, so we should ask how to remake technology so we can achieve goals that are of best benefit to society.”
Aid Access has withstood legal challenges, so far
Aid Access has faced one regulatory challenge, in 2019, when the FDA sent the group a cease-and-desist letter, claiming that its generic mifepristone drug represented a “misbranded and unapproved” drug that posed risk to consumers. (The FDA approved one brand of mifepristone, Mifeprex, in 2000, and in 2019 approved a generic version.)
Aid Access, in turn, sued the FDA, alleging the agency was impeding Americans’ constitutional right to an abortion and that its drugs were, in fact, approved. Aid Access also maintained that the FDA had no legal jurisdiction over Gomperts. The case was dismissed in part because the FDA never took action following its letter.
The Biden administration has taken a friendly stance toward medication abortion, but a change in the White House in 2024 or beyond could mean new challenges from the FDA or other agencies. Legal threats against Aid Access without the constitutional protection of Roe might make things even more complicated.
Anti-abortion activists and lawmakers have been ramping up their efforts to crack down on abortion pills, an unsurprising development given that medication abortion accounted for 54 percent of all US abortions in 2020. In 2022 alone, according to the Guttmacher Institute, lawmakers in 22 states have introduced new legislation to restrict the drugs.
Rather than punish those who seek abortions, the slew of anti-abortion laws introduced over the past decade has targeted physicians, clinics, and anyone else who helps to “aid and abet” someone who has an abortion, as Texas’s recent ban put it. Abortion activists have worried about the criminalization of patients, but so far efforts have been limited and largely unsuccessful.
Whether any of these new laws could affect Aid Access’s operations or the patients who seek out its services remains an outstanding question. It’s hard to know what abortion access in the US will look like in a year, or five.
But for Americans seeking to end their pregnancies now — whether they live in red states with heavy abortion restrictions or in blue states with more liberal laws but heavy financial barriers — Aid Access represents a lifeline. If they can find it.