In March the NYR Online published Amy Littlefield’s sweeping overview of the shifts in abortion access since the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization effectively outlawed the procedure in more than a dozen states. Many of these changes have been driven by the expansion of telehealth services that dispense Mifepristone and Misoprostol, the drugs involved in medication abortion, through the mail; as a result some parts of the country have actually seen an increase in abortion access since Dobbs. But by early May this state of affairs was in flux yet again: the Fifth Circuit Court of Appeals ruled on May 1 in favor of a requirement that doctors prescribe Mifepristone only in person, which would starkly curtail its availability. The Supreme Court has since stayed that ruling and sent the case back to the Fifth Circuit, but it is likely that the question will be taken up again soon, both by the Trump administration and by the courts.
I first met Littlefield in 2020, when we lived near each other in a green, outlying part of Boston. We went for walks with Amy’s new baby and both of our dogs and talked about the implosion of the media industry and the disastrous events we were covering, usually having to do with reproductive rights and the rights of women and gender minorities. By then I had already been reading her reporting for many years—first at the indispensable RH Reality Check (today Rewire News Group) and then at The Nation, where she is now the abortion access correspondent.
Even then, Littlefield was a veteran of the abortion beat, a reporter who had covered the intricacies of the state-level legislation and grassroots anti-abortion activism that had already de facto eradicated the right to end a pregnancy in much of the country. After the Dobbs decision, she wrote a definitive postmortem on the death of Roe v. Wade, “Where the Pro-Choice Movement Went Wrong.” This spring, Littlefield published her first book, Killers of Roe: My Investigation into the Mysterious Death of Abortion Rights, a frank and thorough account of where the anti-abortion movement went right, including candid interviews with the kinds of political strategists whose names usually remain unknown even as their ideas shape millions of lives.
Last week Littlefield and I spoke about the slow erosion of abortion rights, the fight over medication abortion, and the unexpected silver lining to the crises created by Dobbs.
Nora Caplan-Bricker: How did you begin reporting on reproductive rights? What drew you to the beat, and what kept you on it over the years?
Amy Littlefield: I volunteered as an escort at an abortion clinic in college; it was an extension of my interest in feminist politics. I spent one day a week walking with patients past anti-abortion protesters. And then after college, I worked in an abortion clinic. I had a job at a local newspaper in southeastern Massachusetts; I worked at the clinic on Saturday mornings—counseling patients before their procedures—and then I would punch out and go to the newspaper for my shift. At the time, I mostly wrote about city politics, but when I started to write national stories, I brought these two interests together, and now reproductive rights has been my beat for more than a decade.
There was a time when abortion was considered a niche area of coverage, when there were only a few of us doing this work full-time. Then, after Dobbs v. Jackson Women’s Health Organization, major news outlets suddenly put staff reporters on the topic. But now they’re shrugging their shoulders again. Even though the same number of people, if not more, are impacted by the issue, abortion seems to have fallen off the media radar.
That’s especially frustrating given that access to abortion had been eroded to a catastrophic extent long before Dobbs.
Those of us who have been covering abortion for a long time saw the incremental creep of restrictions that effectively rendered it off-limits for wide swaths of the population years before the Supreme Court overturned Roe v. Wade. Really, it started even before my lifetime, in 1976, when the Hyde Amendment banned federal funding for abortions. As a result, most Medicaid recipients had to raise hundreds if not thousands of dollars to pay for abortions out of pocket. That’s something we take for granted today, but it was first written into public policy during Gerald Ford’s administration and has been renewed by every subsequent Congress. I’ve spent much of my career reporting on the incremental restrictions that have led to the closure of abortion clinics: medically unnecessary laws that instituted seventy-two-hour waiting periods, for example, or required clinic hallways to be a certain width—barriers that made it more difficult to access an abortion or operate a clinic.
It was challenging to get people’s attention, because telling those stories often meant covering legislatures in red states. It meant looking at grainy video of hearings in Oklahoma or North Carolina or Kansas and listening to state lawmakers who were not household names. It’s hard to sound the alarm about an emergency that takes place in such slow stages. That was part of the genius of the anti-abortion movement’s strategy.
Your article for the NYR Online synthesized the changes to abortion access we’ve seen since Dobbs and showed how contradictory and even surprising the effects have been. You focused in particular on expanded telehealth provision of medication abortion. How did you arrive at your understanding of the paradoxical effects of Dobbs?
As long as I’ve been covering abortion access, it has been defined by wealth and geography. Even before the Supreme Court overturned Roe, a person’s ability to access an abortion depended on where they lived and how much money they had. People in blue states like New York and Massachusetts—especially in urban areas, where clinics tend to be concentrated—and with health insurance that covered abortion or the resources to pay for it had a relatively easy time getting an abortion. They still had to contend with protesters outside a clinic, they might still have had to contend with stigma, but getting an abortion was at least possible.
Things looked very different if you lived in the rural South, in a state where abortion was regulated with medically unnecessary restrictions that forced you to go back to the clinic multiple times and to wait forty-eight or seventy-two hours between appointments. Maybe you had to have an ultrasound or listen to a misleading script about how abortion supposedly causes breast cancer or mental health problems. A number of states only had one abortion clinic, so people had to travel hours and hours to get care. And, of course, most jurisdictions don’t offer state-funded Medicaid coverage for abortion. So by and large, poor people in red states and rural areas often had to turn to a crowdfunding network of abortion funds to try to raise money to pay for an abortion, or they simply wouldn’t find a way to get one at all.
I think we all expected that after the Dobbs decision those inequalities would be magnified—that abortion access would depend even more on where you lived and how much money you had, because now some states would ban abortion outright, meaning that people would have to travel even further and spend even more money. But what happened instead is that blue states passed the shield laws I write about in the essay, which protect telehealth providers who have figured out a way to provide abortion through the mail very inexpensively. And that led to something unexpected: abortion became available in parts of the country where it hadn’t been before, and for less money.
And yet there is still a major contradiction: people who need care in person are having a harder time getting it. People who do need to travel have to go a lot farther, on average, and pay a lot more money. And people who need emergency care—because they’re suffering a miscarriage, or because they have one of the rare complications that can result from an abortion—in states with abortion bans are getting very sick or even dying because doctors are afraid to intervene in time to save their lives.
How does the case that recently landed before the Supreme Court, Danco Laboratories v. The State of Louisiana, fit into the picture you just laid out?
The aim of the essay I wrote for the Review was to capture the intricacies of the national legal landscape for abortions at a very particular moment in time. It was an infrastructure that grew out of necessity and responded to a specific set of circumstances—including federal court rulings, conflicting state laws, and, in a broader sense, the racial and economic inequality of our imperfect nation. It’s not like this was anyone’s ideal plan for how to deliver abortion care. When we were working on the piece together, I felt like we were capturing in amber this contingent reality as it exists right now, knowing that it was going to change. The state of abortion access in the United States, which has expanded in ways that nobody anticipated even as it contracted in other ways, wasn’t going to last in exactly this form.
The first major setback came on May 1, when the Fifth Circuit Court of Appeals ruled that the FDA needed to reinstate the requirement that people go in person to get Mifepristone, the first drug in the two-medication abortion regimen that is now the most popular form of abortion nationwide and that has been indispensable to the expansion of abortion access that I describe in the piece. But again, something unexpected happened. Almost as soon as the circuit court had issued its ruling, telehealth providers began offering abortion using only the second drug in the regimen, Misoprostol. That’s not optimal—it’s slightly less effective, and it can cause more side effects than taking the two drugs together. But Misoprostol is used on its own all around the world as part of a World Health Organization recommended protocol.
Since then the Supreme Court has issued two stays on the Fifth Circuit ruling. On May 14 the Court sent the case back to the Fifth Circuit, which means it will likely make its way back to the Supreme Court again. We’re waiting to see what the Supreme Court will ultimately do on the issue of Mifepristone, and also what the Trump administration will do. I saw breaking news just now that Martin Makary, Trump’s FDA chief, is going to resign. Bloomberg News reported that he had instructed his underlings at the FDA to wait to release their purported safety review of Mifepristone until after the midterm elections. With him out, it’s unclear what’s going to happen with a review that’s supposedly about safety but of course has more to do with politics.
All of that means that access remains essentially what it was before the ruling, at least for now. Mifepristone can still be sent through the mail. Telehealth abortions still account for more than a quarter of all abortions nationwide, and they continue to be a lifeline for people in the thirteen states that have banned abortion outright and the four states that ban it after about six weeks.
If you were writing the essay today, would it look any different?
I think the biggest development is that we’ve now had a sort of fire drill. The Fifth Circuit ruling was an all-hands-on-deck moment, a test of the contingency plans that telehealth providers have been developing. It was a chance to see how quickly they could update their protocols, consult with their lawyers, interpret the ruling, update their websites, reassure their clients—and to see how quickly that information could make it to people who need abortions but are, understandably, a bit lost, confused, or anxious in this shifting landscape. I noticed, when I went to the websites for organizations like the Massachusetts Medication Abortion Access Project (MAP), which is one of the telehealth providers we cover in the piece, that they had quickly shifted to a Misoprostol-only protocol, and were already advertising it. That suggests that the abortion rights movement was far more prepared to meet the crisis of an adverse federal court ruling than it had been with the Dobbs ruling four years earlier.
You write about your sense that, no matter what, much of the infrastructure created in the past few years just can’t be undone, even by extraordinarily hostile political forces. How have the last few weeks informed your thinking on that?
I absolutely still have that sense. A court decision or a rule change from the executive branch could disrupt the work of shield law providers like the MAP and Aid Access, but it would not reverse the increase in medication abortions altogether. We would still have international providers. We would still have community activists handing out pills.
I’ve thought a lot about the fact that, in addition to abortion rights activists and clinicians learning how to pivot in response to a hostile court decision, there’s been a growing public awareness of the options that exist for accessing an abortion. Renee Bracey Sherman, a reproductive justice activist, has a saying: “Everyone loves someone who’s had an abortion.” Two thirds of abortions in the United States now are happening with medication, and so a lot of us now love someone who has had a medication abortion. That will undermine efforts by the anti-abortion movement to argue that these drugs are ineffective or dangerous. Meanwhile, a website like Plan C Pills, where people can find information about medication abortion, is becoming a kind of household name. One of my favorite stats in the piece we published is that Plan C Pills has circulated close to five million stickers. Someone who uses a restroom at a bar in, you know, Tuscaloosa might look up and see a sticker on the wall. That kind of cultural change and awareness is really hard to reverse no matter what the courts do.