A year after the fall of Roe v. Wade, a fragile new phase of abortion in America

Republican-led states started banning abortion more than nine months before Roe v. Wade was overturned.

Texas was the first to act, outlawing most abortions on Sept. 1, 2021.

Oklahoma went one step further in May 2022, enacting a near-total ban that forced all of the state’s clinics to stop providing abortions while Roe was still the law of the land.

Then came the day - June 24, 2022 - when abortion access was upended nationwide. With its landmark decision in Dobbs v. Jackson Women’s Health Organization, the Supreme Court cleared the way for 11 states to immediately halt all or most abortions. For the first time in nearly 50 years, abortion was no longer a constitutional right in the United States.

Today, one year after the court swept away the protections established by Roe, 17.5 million women of reproductive age - about a quarter of all women in that age bracket in the United States - live where abortion is banned or mostly banned.

New restrictions across the South and Midwest have led to at least 24,290 fewer legal abortions since the ruling, according to research conducted by the Society of Family Planning, which supports abortion rights. The laws have also prompted widespread confusion and fear as hospitals have turned away patients with potentially life-threatening pregnancy conditions. In a new survey of OB/GYNs conducted by KFF, a nonpartisan health research organization, approximately 40 percent of respondents who practice in states with abortion bans say they have faced constraints caring for patients experiencing miscarriages or other pregnancy-related emergencies since the ruling.

But in many respects, as America begins the second year of life after Roe, the full impact of the ruling remains unclear - and in flux.

Interviews with more than 30 key players in the abortion rights debate, including advocates, lawmakers and doctors, found that the stark lines dividing post-Roe America - with some states restricting abortion access and other states expanding it - have become far blurrier than many anticipated in the 12 months since the ruling.

A rapidly expanding underground network of abortion pill providers is helping people who live in states with bans self-manage their abortions - ending an unknown number of pregnancies.

Meanwhile, the swell of criminal prosecutions that many abortion rights advocates feared would follow the ruling has yet to materialize, further empowering those who are helping to distribute pills to people in states where abortion is banned.

In addition, legal abortions have spiked in states that neighbor regions with abortion bans - including North Carolina, Illinois, Colorado and Florida - suggesting that tens of thousands of patients have traveled out of state since the decision.

And while many Republicans raced last summer to embrace the strictest abortion bans possible - at times without exceptions for rape or incest - some in the party have become reluctant to crack down further, fearing political backlash from voters who have repeatedly demonstrated their support for abortion rights. Lawmakers in some Republican-led states have started coalescing behind bans after 12 weeks of pregnancy that allow most abortions to continue.

Now, the fight over abortion has entered a fragile new phase, in which access could be upended again by the 2024 presidential election and several pending court decisions. Strict bans are blocked by the courts in at least six states, while the Supreme Court may take up a case that could revoke government approval of a key abortion drug used nationwide. In addition, a new ban in Florida could soon halt most abortions in the country’s third most populous state, if the state Supreme Court allows it to take effect.

“The system is still trying to find its balance,” said Rebecca Gomperts, the founder of Aid Access, a Europe-based organization that mails abortion pills to all 50 states, including states where abortion is banned. “There is still a lot to come.”

Antiabortion leaders say they are eager and determined to crack down further.

“I think we’re farther than anyone would have expected we would be,” said Kristan Hawkins, president of Students for Life of America, a national antiabortion organization. “But am I complacent with that? Hell no.”

Whether the bans are succeeding in compelling significantly more women to carry their pregnancies to term remains unknown, with data on legal abortions muddied by the many who are choosing to self-manage abortions with medication.

Only in Texas, where a roughly six-week abortion ban took effect in 2021, has relevant birth data started to emerge. Early government numbers show that the Texas birthrate spiked by 4.7 percent from 2021 to 2022, the greatest increase in birthrate of any state in the country during that period - a pattern that experts say can be partly attributed to the state’s abortion restrictions.

Not everyone with an unwanted pregnancy has been able to effectively navigate the complicated post-Roe landscape, said a woman who joined the abortion pill network a few days after Roe was overturned. Many people have never heard of the various overseas organizations offering abortion pills, she added.

“Band-Aids can’t fix bullet holes,” she said, speaking on the condition of anonymity to discuss illegal activity. “And we are just a Band-Aid . . . trying our best to stop the rain with our hands.”

Abortion access one year post-Roe

When Alan Braid was forced last June to stop providing abortions in San Antonio, the now 78-year-old doctor had already mapped out plans for his post-Roe future. He soon opened two locations close to red-state borders in New Mexico and Illinois, Democrat-led states where abortion is likely to remain protected.

His first new clinic, outside Albuquerque, quickly had a full schedule, he said, with over 90 percent of patients coming from out of state, almost all from Texas.

“To drive here from the Rio Grande Valley, Corpus Christi and places like that, it’s somewhere between 10 and 12 hours, or more.”

Still, Braid said, they come.

The pattern reflects an evolving post-Roe landscape of abortion access, with 55 clinics across the South and Midwest forced to stop providing abortions and 16 new abortion clinics opening in states where abortion is legal, according to a database maintained by Caitlin Myers, an economics professor at Middlebury College who studies abortion.

But while many women have been able to travel to states where abortion is legal, those journeys come with a high price tag - hundreds of dollars for transportation, hotels and child care, in addition to the $500 to $800 typically required for the procedure or medication itself - making such an option inaccessible to many low-income patients who can’t cover the costs or take time off work.

Aid Access received almost 60 percent more requests for pills this spring than in the months immediately following Dobbs, fielding an average of 344 orders per day in April, in the wake of attempts to ban a key abortion drug nationwide, according to Abigail Aiken, lead investigator of the Self-managed Abortion Needs Assessment Project at the University of Texas at Austin. (Some people order pills in advance to use if they become pregnant in the future, Gomperts said.)

“Because of what happened, people became more aware of the possibility of pills - they learned that they can do it themselves, and it’s easier, cheaper,” Gomperts said.

Other overseas organizations say they don’t keep track of exactly how many pills they mail, making it hard to know the number of abortions occurring outside the traditional health-care system.

“We don’t keep any records for security reasons,” said Verónica Cruz Sánchez, the director of Las Libres, a Mexico-based organization that mails abortion pills. The demand, she added, “maintains a steady pace.”

For Aid Access, the process of mailing pills became even more streamlined in mid-June, Gomperts said. The organization revamped its operation to allow doctors in Democrat-led states with “shield laws” - designed to protect health-care providers from abortion bans - to mail abortion medication to patients in states where abortion is illegal, rather than shipping pills from India, as the organization has done for years.

“I think this will make all these bans more or less ineffective because it is within the U.S. itself that the providers are stepping up,” she said.

For many people who have learned about abortion pill websites, she added, she believes abortion is now more accessible than it was before Roe fell.

The option is not a substitute for widespread access to abortion in clinics, several abortion rights advocates said. Many people aren’t comfortable taking a pill to end their pregnancies, preferring a surgical procedure, while others fear the potential risks associated with ordering illegal pills online and taking them at home alone without easy access to a medical professional.

“It is not the same consistent access of being able to go to a provider in your community, ask for the care that you seek and receive it,” said Alexis McGill Johnson, the head of Planned Parenthood Federation of America, referring to both out-of-state travel and obtaining pills online.

While those who help to distribute abortion pills in antiabortion states could be charged with a crime - and sentenced to at least several years in prison across much of the South and Midwest - state laws explicitly exempt those who are seeking abortions from prosecution.

Online chat groups and forums have emerged as a critical gathering spot for people in antiabortion states who learn they are pregnant and suddenly face a ticking clock if they want to end their pregnancies. On r/Abortion, an abortion-focused Reddit forum that helps people navigate their options, users frequently ask about Aid Access and other online pill websites, said Ariella Messing, the executive director of the Online Abortion Resource Squad, the organization that runs the forum.

“They come seeking confirmation that these things are legitimate,” said Messing, whose team now fields about 1,300 posts per month, a number that has increased significantly since the ruling. “They’ll say, ‘I just heard about this thing called Access Aid. Is this real?’” (Aid Access is widely regarded in the medical community as a safe resource for medication abortion.)

Many people seeking abortions lack accurate, up-to-date information about their options, said Messing, whose team provides information about both out-of-state clinic options and self-managed abortion. She said she’s aware that her forum serves only a select group: those who know where to seek out information.

“It’s a subset of the population who comes to this subreddit,” Messing said.

Countless other women will never find it.

Antiabortion activists push for more

One month before Texas lawmakers convened for this year’s legislative session, the state’s largest antiabortion group delivered an urgent message at the Capitol: Despite a near-total ban on abortion - which slashed the number of legal abortions in the state from 50,000 a year to a handful each month - thousands of Texas women were still finding ways to end their pregnancies.

“The new abortion clinic is as close as your pocket and your cellphone, where you can go to these websites,” John Seago, the president of Texas Right to Life, recalled saying to a group of over 100 state lawmakers and their staffers. “This is the new threat.”

Seago ticked through a list of solutions in a presentation titled “Post-Roe Lawlessness”: Block abortion pill websites. Expand civil liability. Empower the state attorney general to prosecute anyone who breaks the law.

But the same Republican-led legislature that had passed multiple abortion bans before Roe was overturned showed little interest in embracing those ideas. One by one, each of the antiabortion bills prioritized by Texas Right to Life died before it got a hearing, signaling that, at least for now, Republicans representing the state at the forefront of the antiabortion movement felt that they had done enough.

That sentiment appeared to grow across several Republican-led legislatures, where a driving desire to ban all or most abortions gave way to fear of political backlash in the wake of multiple victories by pro-abortion-rights candidates and ballot initiative campaigns during the 2022 midterm elections.

After months of debate, lawmakers in conservative Nebraska and North Carolina passed 12-week bans in May, significantly narrowing the window for legal abortion but still allowing over 90 percent of abortions to continue.

“The majority of Americans are really moderate people who want to live and let live,” said North Carolina state Sen. Amy Galey, who was part of the Republican working group that devised the 12-week law. “They don’t want a government who is probing into people’s personal lives excessively.”

That view has not prevailed everywhere. Republican-led legislatures in South Carolina and Florida recently passed laws to ban abortion after six weeks of pregnancy, before most people know they are pregnant - though neither law is in effect, each pending a court decision expected in the coming months. Abortion is currently legal up to 22 weeks in South Carolina and up to 15 weeks in Florida.

Florida’s six-week law, which Gov. Ron DeSantis (R) has touted as a sign of his conservative bona fides as he launches a 2024 presidential bid, could singularly alter the national abortion landscape once again, given the number of abortions in the third most populous state. Clinics in states where abortion is legal are already scrambling to meet an elevated need - and demand would grow more intense if even a fraction of the more than 80,000 people who get abortions in Florida each year attempt to travel elsewhere.

The law is written to take effect only if the state’s conservative-leaning Supreme Court approves Florida’s existing 15-week ban, which passed last spring and took effect shortly after the Dobbs ruling.

There are some indications that a six-week ban in a large state can have a measurable impact on the number of births. In the year after Texas implemented Senate Bill 8, which outlawed abortions after roughly six weeks of pregnancy, the birthrate in the state rose by 4.7 percent, according to a Washington Post analysis of provisional data from the Centers for Disease Control and Prevention, while birthrates across the country remained flat, upticking by only 0.2 percent.

Experts say the Texas abortion ban has probably played a role in the state’s rising birthrate. Several other factors also led to the spike, according to three demographers, including a rise in births amid a post-pandemic spike in immigration from Latin America, among a population that tends to have a higher birthrate. Florida - which, like Texas, has a large Hispanic population - also experienced a significant rise in birthrates without a strict abortion ban in place, but slightly less than in Texas.

“At least some of the increase in 2022 seems to me very likely because of S.B. 8,” said Ushma Upadhyay, a professor of demography and public health at the University of California at San Francisco who focuses on abortion. “We know that people are self-managing, but not everyone is self-managing.”

Antiabortion hard-liners, like Seago, are also hoping that, in time, Republicans will be more willing to crack down on the illegal abortion pill networks, backing measures that would help states to fully enforce their abortion bans.

Farah Diaz-Tello, legal director at If/When/How, an abortion rights organization that offers support to people who fear they might face legal consequences for their abortions, said she had not seen any situations in which people - such as community activists or family and friends of the person seeking an abortion - had been charged for distributing pills under new laws in antiabortion states. Several antiabortion activists interviewed for this story said they too had not heard of any examples of prosecutions.

One civil case has been filed by the now ex-husband of a Texas woman who obtained an abortion, against three friends who allegedly helped her access abortion pills - but documents released have called some of the ex-husband’s claims into question.

When Seago urged Texas Republicans to crack down on people involved in the illegal abortion pill network, he said, lawmakers did not want to engage.

“I heard from elected officials that women were not considering abortion in Texas anymore,” he said. “That is a delusion. It’s completely disconnected from reality.”

The road to 2024

The future of abortion access in America is far from settled.

A high-profile case to revoke government approval of mifepristone, one of two drugs used in over 50 percent of abortions across the country, is still making its way through the courts - and is likely to reach the Supreme Court for a second time in the coming months or years.

Meanwhile, antiabortion activists are pressuring Republican candidates to back a national ban on most abortions at 15 weeks or earlier.

“It’s not just that different states are going to play it out,” said Sen. Elizabeth Warren (D-Mass.), a vocal supporter of abortion rights. “The extremists are still trying to block abortion everywhere, looking for every tool to do it.”

Marjorie Dannenfelser, the head of prominent antiabortion group Susan B. Anthony Pro-Life America, countered that it’s Democrats who hold “extreme” views on abortion, contending that many refuse to say whether they support any limits.

A lot hinges on the 2024 presidential race. President Biden is expected to make his support for abortion rights a centerpiece of his reelection campaign. While the federal government’s ability to intervene in state legislation is limited, the Biden administration has issued various guidelines, executive orders and legal interpretations to protect abortion and reproductive health care, which could be rescinded by a Republican president.

“Another administration could come in and remove those protections,” Jennifer Klein, the director of the White House’s Gender Policy Council, which helps oversee the administration’s abortion policy, said in an interview. She said the administration is cognizant that “nothing will replace federal legislation,” which is why it is pushing to codify Roe into law.

When Roe was overturned, some antiabortion activists shifted their focus to the Comstock Act, a long-dormant 150-year-old law that made it illegal to send “indecent” publications through the mail, including anything that could be used for an abortion. While Biden’s Justice Department has issued guidance making the Comstock Act largely inapplicable, a Republican administration could revoke that guidance, said Jonathan Mitchell, the antiabortion lawyer behind the novel Texas abortion ban that took effect in 2021.

“I don’t think they’ll say a thing about it on the campaign trail,” Mitchell said. “The question is what will they do after taking office.”

Some Republicans in the 2024 field have struggled to articulate whether they would sign a bill imposing federal limits on abortion, and what those limits would be.

Sen. Tim Scott (R-S.C.) initially refused to answer direct questions on what national restrictions he’d support, before committing to sign a 15-week ban. In April, former president Donald Trump drew the ire of antiabortion groups when his reelection campaign said abortion restrictions “should be decided at the state level,” and has since met with antiabortion activists.

Abortion rights advocates who scored major victories in last year’s midterm elections are now grappling with how to sustain that momentum throughout the 2024 campaign.

Part of the strategy, according to some Democrats, is to characterize any abortion limits as extreme, including 12-week bans. In response to North Carolina’s new 12-week law, for example, abortion rights groups have deployed the same rhetoric they’ve used to fight restrictions earlier in pregnancy, arguing that all abortion decisions should be between the patient and their doctor and fiercely opposing Republican efforts to describe 12-week bans as “mainstream.”

“It’s the same message, and we’re winning on that message,” said Mini Timmaraju, who leads the abortion rights group NARAL Pro-Choice America. “The longer these bans are in place, all of the bans, the more unpopular they’re getting, so our goal is defining them all as bans. None of them are good.”

Dannenfelser described every restriction passed as an “incremental gain” for the antiabortion movement, even if it doesn’t stop most abortions.

“We would say 12-week protection, we would say 12-week limit, but they would just say a ban because they want people to think that all abortions have been banned,” Dannenfelser said.

At the state level, abortion rights groups are seeking to counteract abortion bans and enshrine access to the procedure into constitutions in a handful of red states. They’ve launched campaigns to gather signatures to put abortions rights on the ballot in Ohio and Florida, while activists in Missouri have begun the lengthy process to kick off their own effort. It’s possible more states could follow suit.

Nationally, Biden has called for the Democratic-controlled Senate to scrap its long-standing filibuster rules to enshrine abortion rights into federal law. But a top Senate Republican, Minority Whip John Thune (S.D.), told The Post that the GOP, if it wins back the majority, wouldn’t use similar tactics to pursue its abortion goals and intends to keep the rule requiring 60 votes to pass legislation in place for abortion policy. Aware that a move against the filibuster by antiabortion lawmakers could backfire if party control of Congress flipped again, Dannenfelser said she also is not advocating such a move.

“There are rules we have to play by here,” Thune said.