It seemed only logical after the Supreme Court overturned Roe v. Wade that abortion rates would go down and births would go up.
Instead, the opposite happened: Abortions went up last year and the country’s fertility rate hit a historic low.
More than 1 million abortions were recorded in the United States in 2023 — the highest in a decade, according to the Guttmacher Institute, a research group that supports abortion access. So far this year, abortion rates have remained about the same as in the last six months of 2023, preliminary data show.
“The post-Dobbs world wasn’t as bad as we expected,” said Diana Greene Foster, a reproductive health researcher at the University of California, San Francisco. “It happened that people were denied abortions before Dobbs. It’s likely happening after Dobbs, but not to the extent that I, at least, was worried about.”
Foster predicted in 2022 that a quarter of women who wanted abortions in states with bans would give birth instead. Now, she thinks the share might be somewhere in the low single digits.
What happened to keep the abortion rates from falling?
To answer that question, NBC News sought out the people and systems behind the trend — spending a day at an Illinois Planned Parenthood clinic, meeting with the Dutch doctor whose work was crucial to preserving access to abortion pills in the U.S., and speaking with key players from all corners of the abortion rights landscape: providers, researchers, abortion fund directors, advocates, lawyers, policy experts, and anti-abortion groups.
Much of the story, it turns out, comes down to a small network of medical providers who found ways to prescribe and ship abortion pills around the country from places where they’re still legal.
That was only possible because of significant action taken by the Food and Drug Administration during the Covid pandemic, which allowed the pills to be dispensed via telemedicine. Then, in the wake of the ruling in Dobbs v. Jackson Women’s Health Organization, eight states passed laws that protected providers from being sued for prescribing abortion pills virtually to people from other states.
“The obstacles are actually lower than before Dobbs,” said Dr. Rebecca Gomperts, the Dutch physician who founded Aid Access, an organization that mails abortion medications to individuals who request them. “For people that didn’t have the financial resources or the infrastructure, the logistical structures in place to go to a clinic … I think the landscape now is much better.”
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Outrage over the Dobbs decision also spurred a wave of donations and educational campaigns that helped expand access to in-person abortions at clinics. Funds that provide financial support to people seeking to end their pregnancies used that money to help discount or cover the cost of abortions, including travel and lodging for those who crossed state lines. Abortion providers, meanwhile, got an influx of funding that enabled them to set up new clinics and extend hours in states where abortion is still legal.
“It was kind of all hands on deck after Dobbs to get people the information and access to make sure that these abortion bans were not going to stop people from being able to access care,” said Serra Sippel, executive director of The Brigid Alliance, a service that provides abortion seekers with support for travel, food, lodging and child care.
Donald Trump’s election victory, however, could change that new status quo. Abortion pills are a target for anti-abortion activists, who hope the incoming administration might revoke provisions that allow the medications to be prescribed via telehealth and mailed nationwide.
When asked about that possibility, Karoline Leavitt, a Trump-Vance transition spokeswoman, told NBC News that “President Trump has long been consistent in supporting the rights of states to make decisions on abortion.”
Still, advocates on both sides of the issue said they are gearing up for a fight.
“We were under no illusions that Dobbs was going to solve the problem,” said Randall O’Bannon, director of education and research for National Right to Life, an organization that opposes abortion. “The work is still very much going to need to be done, and we don’t expect that the other side is going to give up or quit trying.”
How pills preserved abortion access
Raised in a harbor town in the Netherlands, Gomperts has dedicated her life to preserving abortion access. Over coffee during a visit to New York City, she spoke about the subject with a clinical sensibility — perhaps because of her background as a physician, perhaps because of how often she has to assert her viewpoint.
In 1999, Gomperts founded an organization that transported women from places with restrictions to a ship in international waters to obtain abortions. She launched a global telemedicine abortion service six years later, then in 2018 started Aid Access, which is headquartered in Austria.
“We know that people are scared,” Gomperts said. “Because of all the misinformation out there, they think that they’re breaking the law, which they’re not. It’s legal for women to do their own abortions.”
To obtain pills via Aid Access, people fill out a questionnaire, sign a consent form, email an image of their ID and pay $150 — though the bill is adjusted on a sliding scale. The pills usually arrive within five days of being prescribed.
Since the Dobbs decision, Gomperts said, Aid Access has seen a tenfold increase in demand.
The group’s operating model relies on several FDA policies. In 2016, the agency enabled mifepristone — one of the two pills used in medication abortions — to be used up to 10 weeks’ gestation instead of seven. Three years later, it approved a generic form, which increased supply.
Then came the biggest change: In 2021, the FDA eliminated the requirement to dispense mifepristone in person.
By last year, medication abortions accounted for 63% of abortions nationwide, up from 53% in 2020, according to the Guttmacher Institute. The institute does not disclose which providers are represented in its estimate, but some medication abortions are left out, including in states with bans, so the numbers are likely an undercount.
The pharmaceutical company that makes mifepristone, Danco Laboratories, said it does not publicly share its sales data. GenBioPro, the company that makes the generic version, also declined to provide such numbers.
At the time of the Dobbs decision, 19 states banned or restricted telehealth prescriptions of abortion pills. Aid Access bypassed those laws because it was based overseas — physicians in Europe prescribed the pills to patients in the U.S. via a pharmacy in India.
Once post-Dobbs “shield” laws protected some providers who prescribe pills to patients in states where abortion is banned, Aid Access switched to partnering with a U.S. pharmacy and providers. Other telemedicine groups also began offering the pills nationwide, including A Safe Choice and the Massachusetts Medication Abortion Access Project, both of which said most of their patients are in states with abortion restrictions.
“Aid Access created and provided a model for other providers to replicate — not just replicate, but to expand upon,” said Dr. Remy Coeytaux, a representative for A Safe Choice.
“Had this small network of physicians not done this, there wouldn’t be access to telemedicine abortion” in states with bans, he added.
It’s no surprise that anti-abortion groups are keen on stopping this work, and want to see the FDA changes rolled back.
“The ability of women to get these drugs online now, without an in-person visit, because of what the FDA did has essentially circumvented any law that a state might pass,” said Dr. Christina Francis, the CEO of American Association of Pro-Life OBGYNs, an anti-abortion group.
A surge in interstate travel for abortions
Although procedural abortions are harder to obtain post-Dobbs, out-of-state travel is another reason why abortions rose last year.
Nationally, more than 171,000 people crossed state lines to obtain an abortion in 2023 — roughly double the number in 2020, according to the Guttmacher Institute. Illinois has seen more out-of-state abortions than any other state, a 71% increase from 2020 to 2023.
Nekia, 25, traveled to Illinois from Whitestown, Indiana, to obtain an abortion last year; she asked that her last name not be published because of privacy concerns.
Nekia said she found out she was pregnant just after her state’s abortion ban took effect in August 2023. At the time, she added, she was pursuing a master’s degree and working full-time in marketing, and money was painfully tight.
“The last thing I could afford to do was to have a pregnancy,” she said. “That was a big motivating factor for me. I was like, ‘Regardless of how hard it is to figure this out, I’m going to get it figured out, and I’m going to make sure that I get to Illinois so I can get this done.’”
Not being able to afford a child is the most commonly cited reason for seeking an abortion, and the majority of women who do so are mothers already. About half are below the poverty line.
Nekia traveled to a Planned Parenthood clinic in Champaign, Illinois, about 2½ hours away, but said coming up with the money for gas and the procedure was a struggle.
“It was just stressful,” she said. “It was a lot of thinking, a lot of anxiety … Maybe I shouldn’t do this. Maybe I should just carry to term, because it just feels like there’s so many obstacles.”
To her relief, she said, Planned Parenthood gave her a prepaid gas card and discounted her procedure.
Donations to abortion funds and clinics have helped enable travel for people like Nekia. Last year, abortion funds provided more than $36 million in aid to those seeking abortions, according to the National Network of Abortion Funds.
At the same time, a new public spotlight on abortion has helped advocates promote resources for people seeking them.
“One of the positive consequences of the horrific decision overturning Roe, was that people became more aware of their rights, even as these rights were taken away,” said Julie Kay, executive director of the Abortion Coalition for Telemedicine Access.
However, leaders of abortion funds and networks said donations have waned significantly in the last year, raising questions about whether interstate travel for abortions will continue at the same pace in the future.
“To be able to remain open to serve multiple people, we have to put limitations on the amount that we support per client,” said Stephanie Loraine Piñeiro, executive director of the Florida Access Network, an abortion fund.
What the data hides
The nationwide rise in abortions can obscure the reality that some people who want abortions still can’t get them — particularly low-income women of color.
Dr. Amy Whitaker, chief medical officer at a Planned Parenthood clinic in Flossmoor, Illinois, said the Dobbs decision has made it significantly harder for patients to reach her.
“Even the ones who make it to care, they just have had to go through so much more,” she said.
Indeed, the waiting room at her clinic was packed on a Friday morning in September. Many patients travel long distances to get there from states with abortion restrictions — the clinic estimates they make up about 22% of its abortion patients.
Data isn’t available on how many unwanted pregnancies have been carried to term since the Dobbs decision, but an April study found that abortion bans had resulted in a 2% average increase in births in the states that implemented them.
“You can clearly see that there is a little bit of an increase in childbearing relative to the nonban states,” said Sarah Miller, a health economist at the University of Michigan.
Whitaker is known for her exuberance among her staff — sometimes dancing in the hallways between appointments — but the aftermath of the Dobbs decision has changed her demeanor.
“When you know your patients are struggling and suffering, it affects your day to day,” she said. “I cry more often. I’m just so sad.”
What comes next?
Advocates on both sides of the abortion rights issue don’t think a federal ban is likely after Trump takes office, but they anticipate that the new administration could restrict abortion in other ways. One avenue they described is for the FDA to rescind the licensing of mifepristone or roll back the changes that expanded its access.
“My expectation would be that his FDA would re-evaluate the Biden FDA’s decision to authorize mail-order abortion and determine that it was unlawful and dangerous to do so,” said Erik Baptist, senior counsel for the Alliance Defending Freedom, an anti-abortion legal group.
The attorneys general of Idaho, Kansas and Missouri also filed a lawsuit last month challenging the FDA actions that expanded mifepristone access. The case was filed in a federal court in Texas where the sole judge, Matthew Kacsmaryk, is a Trump appointee.
Kacsmaryk previously ruled in favor of abortion opponents who challenged mifepristone, but the Supreme Court said the plaintiffs lacked standing to sue. Reproductive rights lawyers said that this time, Trump’s Justice Department could choose not to appeal if Kacsmaryk sides with the attorneys general.
Additionally, the lawyers raised the possibility that the next attorney general could try to enforce the Comstock Act, an 1873 law that prohibits mailing and receiving “obscene” materials and those designed or intended to procure an abortion.
The Center for Reproductive Rights and the American Civil Liberties Union — the legal groups behind several major abortion rights cases — said they have strategies to counter any future changes to FDA rules or enforcement of the Comstock Act. The Center last year also filed a lawsuit challenging some remaining FDA restrictions on mifepristone. Planned Parenthood, meanwhile, has said it will continue fighting for abortion rights via state ballot measures.
To Gomperts, whose organizations have managed to skirt abortion restrictions around the world for decades, the election results aren’t cause for panic.
“Whatever happens, people will get their abortion pills no matter what,” she said. “I don’t think that is ever going to go away.”
This article was produced in collaboration with the USC Annenberg Center for Health Journalism’s 2024 National Fellowship Fund for Reporting on Child Well-being.
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