New data released this week reaffirmed a seemingly paradoxical reality of the post-Roe v. Wade era: Abortion rates have continued to rise despite the increasing restrictions nationwide.
The latest data, compiled by the abortion rights research and policy organization the Guttmacher Institute, shows that throughout 2024, clinicians provided more than one million abortions in states without total abortion bans, a slight increase compared to 2023. A closer look at the data reflects how healthcare providers and patients have adapted to changing circumstances—which have made access both more difficult and, in some ways, easier—since the Supreme Court’s June 2022 decision in Dobbs v. Jackson Women’s Health Organization revoking the constitutional right to abortion.
About 14,000 fewer people traveled out-of-state for an abortion in 2024 compared to 2023. This can be partially explained by state bans that force people to travel further for care, as well as the logistical and financial difficulties travel involves. There were, however, about 40,000 more abortions provided through online-only clinics, which may be an undercount, since it doesn’t include medication abortions that are accessible through telehealth under shield laws. These laws seek to protect providers from prosecution for virtually prescribing and mailing abortion pills to people in states with abortion bans. (Texas Attorney General Ken Paxton is currently testing the limits of such laws by suing an abortion provider in New York—which has a shield law—for mailing abortion pills to a Texas patient.) Other research estimates telehealth provision of abortions under shield laws accounted for about 10,000 abortions a month in the first half of last year alone—most of which occurred in states with total or six-week bans, according to the Society of Family Planning, a reproductive rights research organization.
A new book co-authored by reproductive rights experts Carole Joffe, a professor emerita of sociology at the University of California, Davis, and David Cohen, a professor of law at Drexel University, helps explain how this came to be—and it’s not only because of the relative ease of access to abortion pills. After Dobbs: How the Supreme Court Ended Roe But Not Abortion digs into the various strategies providers have pursued to continue offering abortions, and the ways advocates have helped people access them. Just a few examples: Providers moved clinics out of banned states, prescribed pills online, and mailed them to patients, while advocates coordinated patients’ travel and raised money to help them get to their appointments.
“It was a half-century mission to overturn Roe, and the result is that there are more abortions than before.”
To write the book, Joffe and Cohen conducted interviews, which began before the Dobbs’ decision, with two dozen abortion providers and advocates throughout 2022. They then continued to track what unfolded just after, and at the end of the year. In the process, they learned how providers, patients, and advocates adapted to their new realities. Ultimately, what they found surprised them: Their interviewees were clear-eyed about the new risks and barriers they faced, but also defiant. “I think when we started, we expected to write a much more sobering and much sadder book than what actually emerged,” Joffe told me.
“It’s a story of resistance and resilience and hope,” Cohen added. “But better than hope, it also offers strategies for thinking about how to make people’s lives better and fight against oppression.”
We spoke via Zoom to discuss the post-Roe paradox, the “creative alternatives” providers are pursuing, and the increased risks they face now compared to the pre-Roe era.
This interview has been lightly condensed and edited for clarity.
You write in the book: “By any account, with the data we have so far, Dobbs has not had the devastating impact on overall abortion numbers that many predicted.” How would you characterize what a “devastating impact” looks like? Did you expect this would be the case when you began research for the book at the start of 2022?
Carole Joffe: “Devastating impact” would be thousands of people not being able to get the abortions they needed; “devastating impact” would be women who were ill, who should not be pregnant. I thought there would be deaths—which in fact, there have been, though we don’t know how many—but we have seen a rise in maternal mortality. ProPublica and other journalists have documented some deaths. I have every reason to believe from what I’ve read and been told by abortion doctors there have been more that have not been documented.
“It was never in my conception of what would happen after Roe was overturned that abortion numbers would go up.”
I knew that abortion provision would go on. David and I have studied this field for years. We know the dedication of the people who work in it and their allies at the funds and in the national organizations. I did not anticipate that the number of abortions would actually rise. I think our book helps explain that, documenting the extraordinary efforts, not just of the provider community but the people getting the people who needed abortions to the clinics.
David Cohen: I thought increases in abortion-related deaths would be staggeringly high and there would be prosecutions all the time. Those things have happened in much, much smaller numbers than we expected, and there hasn’t been a decrease in the number of abortions. It was never in my conception of what would happen after Roe was overturned that abortion numbers would go up.
Which of the “creative alternatives,” as you call them in the book, that providers have used to continue offering abortions most surprised you in terms of effectiveness?
CJ: I think what surprised me a lot was the incredible, rapid response of the patient navigators. We saw them at the National Abortion Federation and at local abortion funds. What really sticks in my head was having a doctor tell us, “We had a patient who was scheduled to come, but there was a snowstorm, so right away the patient navigator changed the flights and got her an appointment in Las Vegas where it wasn’t snowing.” In abortion care in general, time is of the essence—if it takes two weeks to arrange something, someone goes from the first trimester to the second, or the second to the third. Just the ability to move that quickly to arrange care for patients—it was extraordinary to see.
DC: Yeah, that’s been amazing. The other part for me is the telehealth shield provision of abortion and the impact on patients stuck in states where there are abortion bans.
This reminds me of a quote from Francine Coeuytaux, co-founder of the abortion pill information website Plan C, that you included in the book. She said she believes “there is better access these days” because of the greater awareness people have about how to access abortion after Dobbs. There are a few similar quotes from other people in the book. Do you agree?
DC: I think for a lot of people, it’s much easier now than it was before. Pills are available and cheaper. More people know about pills than ever before. There’s a lot more variety in delivery mechanisms. There’s a lot more support in terms of people who travel. But I do think there’s a big asterisk next to that statement—it doesn’t mean it’s true for everyone.
There are a lot of people for whom travel is just really difficult—whether it’s because of kids, work, concerns about being racially profiled, they don’t have a car, they don’t have the executive capacity or time to deal with all of the different appointments and people to talk to about the funding. So that can be really hard. For people who are dealing with emergency pregnancy complications, they might have the resources to travel from the middle of Texas to Colorado, but when you’re in sepsis, traveling is not easy. That’s catastrophic for people’s lives. Other people just didn’t even know about all these options we’re talking about, so thery are left out of this equation.
CJ: For the very sick, what’s going on is still barbaric. Women who are near death are not getting the care they need.
DC: For the states that are pro-choice, Dobbs was really a kick in the ass in terms of changing policy. People like us have been pushing them to change their policy, get rid of restrictions, fund abortion under Medicaid, and support providers. We’ve been pushing them to do this for decades, and a lot of them just ignored it because they didn’t think there was a problem. But once Dobbs happened, they re-evaluated their own laws and got rid of barriers that existed even in some of the most liberal states.
You write that Dr. Curtis Boyd, a Baptist preacher turned abortion provider in Texas and New Mexico, “predicted that relatively few doctors would perform illegal abortions in this new era.” Do you see these alternative methods—such as providing pills via telehealth or moving clinics across state lines—as replacements for back-alley abortions that were occurring pre-Roe?
CJ: There were different kinds of abortion provisions before Roe. “Back alley,” we normally code as bad—and they were bad, they were unsafe, and the people who did them were very unethical. There were also very decent doctors, like Dr. Boyd, who did abortions as a matter of conscience. So “back alley” did not mean defiance, but losers who wanted to make money off decent people like Dr. Boyd, who worked with the Clergy Consultation Service [a group of clergy members who helped people travel to access abortion] and took on great risks.
“People who don’t want to be pregnant will always search for abortion. This is a historical constant across societies.”
Speaking as someone who has studied that era, what I would say is, in those days, there were risks. There were some prosecutions—very few, as it turned out, against doctors, mostly against non-physicians who did them. When doctors were prosecuted and found guilty, the jail terms were typically one or two years. Several well-known African-American doctors were jailed, and their sentences were around two years. Now, in Texas and Alabama, it’s up to 99 years in prison for doctors. So risk-taking takes on a very different calculus. It’s very difficult for a grief-stricken provider who is going crazy because she can’t help her patients. But that has to be weighed against many years of imprisonment, losing her medical license, and having a huge fine.
As long as abortion remains legal in the states where it is not legal, I don’t see people doing illegal procedures. I see them continuing to still do the workarounds, whether it’s doing pills or moving across state lines.
DC: I think there are two other factors. Pills are just a huge difference from before Roe, because there weren’t pills that you could get somewhat freely on the internet, and now you can. The other big difference is social media and the internet. There were doctors before Roe who provided care, but they didn’t have the social media and the internet blaring this to everyone in the world that they were doing it. There was the doctor in Pennsylvania, Robert Spencer, who provided close to 40,000 abortions before Roe [Spencer claimed the amount was much higher: up to 100,000 abortions]. So people knew about him, but there weren’t websites devoted to telling authorities that he was doing this everywhere in the world. If someone starts doing illegal abortions now, there’s going to be a mob after them because of the internet.
Do you think the anti-abortion movement was prepared for the proliferation of these “creative alternatives” after Dobbs?
DC: I think they knew that pills would become a big story post-Dobbs. But I think they’ve been caught pretty flat-footed with how to respond to all of this. They have not been able to effectively stop pills—yet. They have not been able to stop most referendums. They have not been able to get complete bans in some states where we thought there were going to be complete bans, whether because legislatures don’t want to go that far or state courts have stopped them. And they haven’t stopped abortion travel.
I don’t know if many of these things would have surprised them, but I think they probably hoped they had better strategies to deal with them, and they just haven’t. It was a half-century mission to overturn Roe, and the result is that there are more abortions than before.
Do you see the persistence of the provision of abortions as a reason for hope at a time when it seems like many other civil liberties are at risk?
DC: I do, but not necessarily hope, as opposed to illustrating there are effective ways to go about resistance in a time of oppression. Certainly, it would be better if there were a national right and abortion were legal and accessible everywhere. As a result of that not being the case, there’s oppression happening. But there are people fighting back. This is a story of people who are looking at the situation and saying, “I am not okay with it, and I’m going to do everything I can to make sure that people are not as negatively impacted by this oppression as they could be.”
CJ: Whatever happens legally, pregnant people who don’t want to be pregnant will always search for abortion. This is a historical constant across societies.
This post has been syndicated from Mother Jones, where it was published under this address.