Expanding Abortion Access in Post-Roe America

(Photo by iStock/Joel Carillet)

The US Supreme Court overturned Roe v. Wade—which has protected the right to choose to have an abortion in America for almost 50 years—in late June 2022. Since that decision, at least 10 states have completely banned abortion, and four other states have outlawed the procedure after six weeks of pregnancy. Many other states are expected to follow suit. Based on data from the CDC, the Guttmacher Institute, and other sources, our firm, Dalberg Advisors, estimates that as many as 300,000 people per year may lose access to abortion across 26 states as a consequence of this decision. This represents approximately 40 percent of people in the US who legally have abortions each year, although exact estimates are hard to come by. We expect that bans will disproportionately impact Black, Hispanic, low-income, immigrant, and other historically marginalized people, the majority of whom may not be able to travel to access care (based on historical patterns of travel and patient demographics in “banned” states). Without access to safe abortions, people face impossible choices such as risking their lives with unsafe abortions or carrying unwanted pregnancies to term.

The current approach to delivering care was largely built when abortion was legal in all 50 states. It will fail patients and providers alike in a post-Roe reality. Today, independent or affiliated clinics, which often operate on razor-thin margins, deliver about 95 percent of abortion services. Providers in the 24 states that are unlikely to ban abortion are already struggling to absorb increased demand, as more and more people travel from states where clinics are closing down. Opening a new clinic is time-consuming and requires overcoming a series of hurdles, from sourcing funding to identifying space and navigating complex legal restrictions. Current options for fully remote care (i.e., accessing abortion pills by mail and/or via telehealth screening) are not always well understood by patients and often only serve a subset of those in need. Existing, tenacious efforts by abortion providers to adapt systems to this new reality (through for example, targeted expansions and better patient navigation) are under-resourced and not at scale. 

The abortion care ecosystem needs more resources and different strategies to adapt to this new reality. We can learn from and scale bright spots of success in strategies being tested across the country and in other parts of the world—such as Latin America, which has seen a “green wave” of abortion legalization in recent years. These bright spots can offer a roadmap for preserving access to safe abortion in the post-Roe era. This article focuses on four strategies that have shown particular promise in other countries or in smaller-scale settings in the US:

1. Equip patients with the information to safely and legally exercise their agency to make care choices, without threat of reprisal.
2. Increase access to remote medication abortion where it is medically appropriate and alongside in-person options for care.
3. Invest in patient accompaniment models, particularly for remote care.
4. Invest in long-term ecosystem building.

We will also focus particularly on the role of philanthropic actors in advancing these strategies, drawing on their capacity to swiftly and flexibly deploy capital to meet the urgent and evolving needs of our post-Roe reality.

Strategy 1: Protect Patient Choice and Agency

Increased access to medically and legally accurate knowledge and information has been shown to improve patient outcomes across health areas. Yet, finding medically accurate information about abortions is often confusing and can be further complicated by potential legal consequences for patients in states without privacy protections. Stigma about abortion services may limit general knowledge about abortion, and there is incomplete or misleading information about access to care in many geographies. Patients seeking care also need to navigate a complex web of screenings, funding support applications, and clinical interactions before accessing care, all while avoiding harassing disinformation from fake clinics. Where abortion is restricted or banned, the process of seeking care can get substantially more complex and dangerous. For example, privacy experts warn that prosecutors may be able to search phones, computers, and other devices to incriminate abortion patients—a practice that tends to sit in a legal ‘grey area’ where courts have not yet caught up to technology. In a 2017 case, Latice Fisher, a Mississippi mother-of-three was charged with second-degree murder after investigators found record of her searching online for abortion pills. Fisher was jailed for weeks before a grand jury eventually decided not to bring charges against her, showing how legal threats can make the safe exploration of medical options a stressful and risky act for patients.

There are ways to equip patients to quickly and safely make informed choices about their health. These include investing to strengthen and streamline online informational tools, investing in new solutions that connect patients to information and providers without a digital trace, and advocating for policies and practices that protect patients’ data privacy.

When it comes to abortion information services, funders need to boost investment in streamlined, coordinated, and patient-centric points of entry. Organizations like National Abortion Federation, Plan C, and Abortion Finder offer easily navigable, multilingual services to help patients secure funding, travel support, and appointments for their abortion care, but there are barriers to patients finding and using these resources. These barriers include, for example, the proliferation of coercive websites and hotlines like “crisis pregnancy centers,” which purport to provide unbiased information but whose main purpose is to prevent access to abortion. Thus, funders should consider (i) ramping up support to online abortion information services, (ii) advocating and supporting technology companies and legal entities to block advertisements rooted in misinformation (such as recent steps taken by YouTube) and (iii) investing to ensure search terms yield informative results, and (iv) supporting greater expansion and coordination of hotlines and navigational tools to provide a simpler end-to-end experience for patients.

Funders can support access to information in non-traceable settings (e.g., via services that leverage encrypted messaging apps like Signal, hotlines that can be called from public phones, or resources at public libraries). Funders can also support greater awareness of hotline numbers, increased resources to staff the lines, and informational tailoring for specific geographies and patient populations (e.g., additional language resources). While not a complete solution, tailored technological resources like anonymous hotlines and informational bots have supplemented advocacy to provide educational resources in constrained legal environments in Latin America and sub-Saharan Africa. With signposted safety measures throughout the patient journey (e.g., use private browsing when accessing services digitally, put phone on airplane mode when near an abortion clinic), these resources can provide information without risking patient privacy. Once information is delivered to individual patients, particularly adolescents, it is likely to be shared with others in friend or peer networks.

Looking ahead, we must also invest in deeper advocacy to enshrine and strengthen data privacy laws and pressure data companies to stop selling patients’ private information. Two policies that funders and advocates could put particular focus on are geofence warrants, which allow prosecutors to see who was near a certain location (e.g., an abortion clinic) and have become exponentially more common in recent years, and reverse keyword search warrants, which grant access to users who searched specific words (e.g., “how to get an abortion”) at a particular time. While these types of warrants are being found unconstitutional in some places, funders should advocate for lawmakers to define clearer lines against this type of overreach.

Strategy 2: Expand Equitable Access to Remote Medication

Medication abortion—or abortion by pill—now makes up more than 50 percent of abortions in the United States. Clinics offer the pills as an alternative to a surgical abortion procedure, up to 10 weeks into a pregnancy, and evidence now shows that in many circumstances patients can safely take the pills (typically a combination of misoprostol and mifepristone) outside a doctor’s office (“remote medication abortion”).

Remote medication abortion can greatly expand access to care. It can reduce the travel distance to accessing a legal abortion for patients who live in states that ban abortion. It can also reduce the patient load on clinics in states where abortion remains legal, allowing clinics to serve out-of-state patients and provide care in cases where remote medication abortion isn’t viable.

However, the promise of medication abortion is far from guaranteed. Patient awareness of the availability and safety of the procedure remains low—a poll in June 2022 by KFF showed that fewer than three in ten US adults (27 percent) said they have even “heard of the medication abortion pill known as mifepristone.” Language barriers, internet and digital literacy limitations, financial constraints, and mistrust in the medical system can also make it difficult for historically marginalized patients to access remote care. Providers are often small startup organizations who are seeking to establish their business models while navigating extremely complex (and evolving) legal landscapes. 

While remote medication abortion cannot offer medically appropriate care for all patients, it should be scaled to the extent possible as one of several care options, with greater focus on making this solution accessible for all patients. Funders can help expand remote medication abortion in the United States by investing in organizations that prioritize removing information or access barriers (e.g., accepting non-government IDs, offering SMS coordination options); providing culturally competent care for patients (e.g., offering services in multiple languages); and identifying existing providers that are interested in supporting telehealth abortion services. As the legal landscape surrounding medication abortion is complicated by changing state laws, it will be important to bolster these efforts with clear communications and local advocacy to protect patients and providers from liability, including in cross-state remote care provision. Further, funders can encourage deeper partnerships and coordination between remote-only providers and in-person providers, who often operate in parallel tracks.

Strategy 3: Expand Use of Accompaniment Models

There is clear evidence that women who receive abortions by choice, as one study explains, “are more financially stable, set more ambitious goals, raise children under more stable conditions, and are more likely to have a wanted child later.” However, the process of seeking an abortion can be difficult, even in states without legal restrictions, as highlighted by the Abortion Out Loud campaign. Abortion seekers report social stigma among family or friends, harassment from protestors outside clinics, unclear follow-up protocols, and emotional distress. Staff at abortion clinics often end up providing not just physical care, but also mental and emotional support to patients.

One model that has proven particularly effective at overcoming stigma, stress, and information gaps relating to abortion in both remote and in-person settings is the accompaniment model. The accompaniment model provides patients seeking an abortion with optional direct emotional support—and in some cases physical support—throughout the duration of their abortion. In many cases, patients are paired with an on-call volunteer or worker to answer any questions the patient may have. Abortion accompaniment (acompañamiento) originated in Latin America, where feminist activists adopted the practice to support women through self-managed abortions in geographies where abortion was illegal. Today, over 50 accompaniment organizations exist worldwide, and many have broadened their services to accommodate new models of care; for example, Aya Contigo, a project of the Canadian nonprofit Vitala, is piloting a virtual accompaniment model for women in Venezuela. A recent study of the accompaniment model in Argentina and Nigeria found that the vast majority (97 percent) of patients who receive an abortion via the accompaniment model ended their pregnancy without the need for surgical intervention—demonstrating its promise as a strategy for increasing access to safe and effective abortions.

In the United States, elements of the accompaniment model do exist. For example, many clinics have volunteer clinic escorts, who are dedicated individuals who focus on helping patients physically get from their car door to the clinic door without harassment. As the Abortion Out Loud campaign notes, hotline staff and/or clinic staff also often play this role for patients while seeking information or after they receive abortions. Dedicated organizations have also begun to support accompaniment in the United States, such as Las Libres, an organization originating in Mexico. However, accompaniment in the US needs to be scaled up in the context of both in-clinic and telemedicine abortion services to help address some of the socio-psychological barriers that many patients—particularly those already distrustful of the healthcare system—face in accessing care. This could include resourcing clinics and community organizers directly for additional investment in in-person accompaniment support and supporting remote abortion care providers to expand and enter into strategic partnerships with accompaniment providers for remote support.

Strategy 4: Strengthen the Ecosystem

The abortion care ecosystem in the United States today is large. It spans approximately 1,500 points of care, at least a hundred abortion funds, dozens of advocacy organizations (including the American Civil Liberties Union (ACLU), the Center for Reproductive Rights, and National Association for the Repeal of Abortion Laws (NARAL), digital platforms, telehealth providers, philanthropic investors, and other payors. It also includes a vibrant reproductive justice movement—led by organizations such as SisterSong, In Your Own Voice, and Spark—who seek a right-based, patient-centered, and culturally competent approach to care, particularly for BIPOC communities.

However, the ecosystem remains fragmented. Almost every single one of the 70 or so actors across the ecosystem that Dalberg has spoken with in the last six months identified a need for additional strategic coordination, particularly within the care provision ecosystem (e.g., between fully remote providers and in-person providers to ensure they collectively expand access, not threaten each other’s slim margins) but also more broadly (e.g., between states, between those working on shorter vs. longer-term protections). Stakeholders note that this fragmentation is driven by lack of time and resources, as well as differentiated realities and priorities in each state. The day-to-day challenges of doing this work are all-consuming, leaving limited time for strategic coordination. Resources are scarce and care providers in particular are very underfunded. A recent NCRP report found that anti-abortion crisis pregnancy centers hold a 5:1 funding advantage over legitimate abortion clinics and funds.

Post-Roe, without careful focus on ecosystem strengthening, existing fragmentation is likely to increase, making it even more important to continue longer-term planning and ecosystem building in the face of a far more coordinated anti-abortion movement. Specifically, philanthropists can consider (i) investing in the vision of grassroots organizations and women’s rights activists for coordinated actions within specific sub-sectors of the ecosystem (e.g., advancing legal protections, sustaining availability of in-person points of care, infusing a reproductive justice lens to care); as well as (ii) in creating and supporting broad and unusual coalitions that bring people together for coordinated action across sub-sectors.

The experience of other countries suggests that investing in the vision of grassroots organizations and women’s rights activists can preserve access to abortion and drive long-term transformation of the legislative, social, and health frameworks that regulate access to abortion. Recent landmark advances in abortion access in Latin America, such as the decriminalization of abortion in Mexico and added protections for abortion in Colombia and Argentina, have one commonality: grassroots support championed by women’s rights activists. Underpinning these wins is what has been dubbed the “green wave,” a movement in Latin America to fight violence against women and protect women’s autonomy and rights, including access to abortion. Green wave public demonstrations, social media campaigns, and efforts to shift public opinion created the environment for access to abortion care even in constrained legal environments and now legislative and court-backed shifts to reduce abortion restrictions.

In other regions, momentum and public support for abortion care has been built by unusual coalitions from within the ecosystem. As one example, the Campaign Against Unwanted Pregnancy (CAUP) in Nigeria selected a diversity of coordinators (physicians, a grassroots activist, and lawyer) to run a campaign to increase access to safe abortions, under a very conservative legal environment. The group tackled multiple approaches at once through published research, media advocacy, conversations with policymakers, and shifts in standard medical and law education curriculum, using momentum from each area to fuel the others. An evaluation suggests this approach helped CAUP take “a taboo topic and, in the midst of an extremely complex political and cultural environment, and [make] it a legitimate subject for public discussion and debate”

In the United States, there are many examples of emerging unusual coalitions for abortion access. For example, the Women’s Funding Network has laid out the Time is Now pledge, which coordinates philanthropic actions across states and types of philanthropy (e.g., women’s funds, family foundations) under a reproductive justice framework. One of the suggested actions under the pledge is to invest in unusual coalitions. Governors in California, Oregon, and Washington recently pledged to work together to provide access for people from restrictive states who are seeking abortions. Institutional investors have come together to file 11 shareholder resolutions to challenge companies to reform political spending and/or risk management techniques to be in line with their espoused pro-choice values. The recent referendum in Kansas—which affirmed Kansans’ resounding support for abortion rights within their state constitution—was made possible by a coalition of both Democratic and Republican voters (the latter of whom were persuaded in part by messages emphasizing individual rights and government overreach). Philanthropists looking to invest in long-term ecosystem building can help these types of coalitions grow, strengthen, and coordinate even further across each other.

Conclusion

Read more stories by Shruthi Jayaram, Eliza Ennis, Saalar Aghili & Erin Barringer.