The Fight to Protect Medication Abortion and Telehealth Continues

The most recent numbers show that two-thirds of abortions in the U.S. are medication abortions, while 29 percent of all U.S. abortions were telehealth medication abortions. Dr. Angel Foster, researcher at the University of Ottawa in the Faculty of Health Sciences, global abortion researcher, and co-founder of the Massachusetts Medication Abortion Access Project (MAP) sits down to talk with us about the work that MAP performs and the importance of shield laws for reproductive health care and gender-affirming care.

Mifepristone, the first of two medications that people will take during a medication abortion, was approved by the U.S. Food and Drug Administration in 2000. Decades of evidence shows its safety and effectiveness. Access to the two-drug regimen increased significantly via telehealth during the pandemic, which required a new regulatory framework in 2023. MAP, through state shield law protections, allows licensed Massachusetts clinicians to prescribe medication abortion to those anywhere in the country, regardless of the legal status of abortion in their state. This year, the Fifth-Circuit Court of Appeals issued a ruling that would prevent providers from sending medication abortion through the mail—thankfully, MAP was able to shift to a misoprostol-only regimen (also safe and effective)—but the mass confusion had been immediately impactful. As of now, a stay has been issued to halt this decision by the Fifth Circuit. 

LINKS FROM THIS EPISODE

Massachusetts Medication Abortion Access Project
Cambridge Reproductive Health Consultants
Cambridge Reproductive Health Consultants on LinkedIn
Cambridge Reproductive Health Consultants on Bluesky

Episode Art: PlanCPills.org

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Transcript

Jennie: Welcome to rePROs Fight Back, a podcast on all things related to sexual and reproductive health, rights, and justice. [music intro]

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Jennie: Hi, rePROs. How's everybody doing? I'm your host, Jennie Wetter, and my pronouns are she/her. So last week, I went to my first live podcast recording. I've seen a couple like live podcasts, like at conferences and stuff, but I've not seen one that was gonna be recorded to air, which was fun. I was really excited and I felt very lucky to get an invitation to go see a live taping of the Undistracted podcast with Britney Packnett Cunningham. One, I love that podcast. It is so wonderful. If you are not listening, you should definitely check it out. I feel like I've learned so much from listening to her over the years and following her on social. And I had such a great time going to listen to the episode. The main guest she had on was Nicole Hannah-Jones. So, it was also very delightful to listen to her talk. The focus of the episode is reparations, so definitely make sure to listen to it this week. It was a really insightful and thoughtful conversation. And it was also extra fun because one of the earlier panelists, she has like a section at the beginning that's like the group chat where she has a couple different guests come on and have a chat about like the week or the topic was Preston Mitchum, who many of you may know. He's been on the podcast several times. He's a rePROs Senior Fellow, but he also does so much other amazing work that it was so wonderful to get to see him speak. And as you would expect, he was absolutely amazing. So I highly recommend checking out that episode. I had so much fun getting to go to that live taping. And yeah, definitely check out Undistracted. It is a podcast I love. I never miss it. So highly, highly recommend. The other thing that has been on my mind this week is it's just there have been so many military flyovers this week, and we've just kind of gotten this blanket like FYI for the next like three weeks. There may be a lot of fighter jets flying overhead, and so you don't know when it's coming, and then all of a sudden, there's like fighter jets screaming over my building, and I'm like right on the flight path from I think Andrew's. So, if they're coming down to the mall and stuff, they fly right over my building, so it's really loud, and it’s stressful. DC is a restricted airspace, so you don't really hear that very often. And when I first moved here, the only time you heard fighter jets was if there was somebody in the airspace and they were like coming to intercept and turn a plane around or something. So, my body still has that stressful reaction. So, when I hear them, so the unexpected ones are not fun. Yeah, but there's been a lot, and we're expecting them, I think, for another two weeks or something. But anyway, I'm kind of over it already. There's already been a number of them. Yeah, so those are like the big things that have been on my mind this week, and obviously, with all of the Fourth of July festivities coming up, um, I'm sure there's just going to be a lot happening. And I have my usual Fourth of July plans. I'll probably watch Independence Day, which is kind of my annual personal tradition, and stay home because the kitties really kind of hate fireworks and get really stressed and want to be near me. So, I tend to stay home that weekend and stay close so that they are around me. And I don't want to go anywhere near the mall anyway, so you know it'll be nice. And I think I've talked about this before, but my building is like one of the last tall buildings, like right in my area. So, I have this really expansive view from where I look out my windows and I can see like all the neighborhood fireworks like north of me, and, just like, a complete 180 in the neighborhood of like fireworks, and my neighborhood tends to go all out on fireworks, so it is quite the show without having to deal with the crowds and going downtown. So, looking forward to that, even though it is going to be very stressful for the poor kitties. Yeah, I guess those are kind of the big things that have been on my mind right now. I hope everybody has a wonderful holiday weekend and gets to do something fun. And with that, I think let's go to this week's interview. I am so excited to have with me Dr. Angel Foster, the founder of the Massachusetts Abortion Access Project. It is a shield law medication practice medical practice that makes sure that they are getting abortion medication pills in the hands of the people who need them. We have a wonderful conversation talking about telehealth abortion access, talking about the importance of shield laws. It is a wonderful conversation talking about the really important work that they are doing. So, with that, let's turn to my conversation with Dr. Foster.

Jennie: Hi, Dr. Foster. Thank you so much for being here today.

Dr. Angel Foster: Thanks so much for inviting me.

Jennie: I am really excited to have this conversation today about medication abortion access. But before we get started, would you like to take a minute and introduce yourself?

Dr. Angel Foster: Sure. So, my name is Dr. Angel Foster. In my big girl job, I am a professor at the University of Ottawa in the Faculty of Health Sciences, and I hold a university research chair in medication abortion studies. I'm a global abortion researcher and lead projects in about 22 different countries and have been working in the medication abortion space for decades. But I'm also the co-founder of the Massachusetts Medication Abortion Access Project, or the MAP. We are a shield law practice that provides medication abortion care to patients in all 50 states, all U.S. territories, and to those with military and state department addresses.

Jennie: That's so great. I think before we start our conversation, since this is not gonna come out for almost two weeks, we are recording on June 18th in the morning, just because there are lawsuits moving, FDA review happening, like in case anything changes from when we have the conversation to when this airs— I'll record like an intro of something changes— but just-

Dr. Angel Foster: Super.

Jennie: -if what you're hearing from us is not the same as the status at the moment. Wanted to give that disclosure. Okay, so what is the current status of medication abortion access in the US?

Dr. Angel Foster: Well, first maybe we can talk about the regulatory status.

Jennie: Yeah.

Dr. Angel Foster: So, mifepristone was approved by the U.S. Food and Drug Administration back in September of 2000. So, we have more than a quarter century of use of medication abortion with mifepristone and misoprostol in the US, and millions and millions of women and other pregnancy capable people have used this two-drug regimen of mifepristone and misoprostol. The evidence is very clear. And it works about 98% of the time. And when it doesn't work, there are things that we can do to facilitate a complete abortion, and if there are complications, they can be treated, and they can be treated through standard practices that are done through emergency departments and done through obstetrics and gynecology. So, I say all of this because what we have is a very safe and effective two-drug regimen that's been approved and available for two and a half decades. And a couple of years ago, starting with the pandemic, we saw a real increase in the availability of this two-drug regimen through telemedicine care. So being able to interact either synchronously or asynchronously with a telemedicine provider and getting mifepristone and misoprostol in the mail as a result. This required a formal regulatory change, which took place in 2023 through the Food and Drug Administration. But we now have had this new regulatory framework for mifepristone and misoprostol officially for three years, but because of the pandemic, we've really seen this for about six years. And again, we have very good evidence that mifepristone and misoprostol are safe and effective and acceptable if provided through telemedicine services. So that's sort of the regulatory status of mifepristone. And I'm sure we'll talk about this in a few minutes, but this issue of can you send mifepristone through the mail is one that the courts have been grappling with now for the last couple of months. In terms of the accessibility of medication abortion in the US, one of the deep ironies that we've seen is that since the Dobbs decision, we've actually seen an increase in the number of abortions, and that is really driven by the increased availability of affordable medication abortion care with mifepristone and misoprostol. So, we actually see in many places, medication abortion as more accessible today than it was five years ago.

Jennie: It's a huge part, like you said, of why we've seen the increase, and it plays such a huge role that the thought of hearing they may scale back telehealth access would have huge ripple impacts on people's ability to access abortion in the US.

Dr. Angel Foster: Absolutely. So right now, our most recent national numbers indicate that about two-thirds of all abortions through the formal healthcare system in the US are medication abortions with mifepristone and misoprostol. And the most recent number that we have, so that's from December of 2025, 29% of all abortions in the United States were through telemedicine and were medication abortion and with this two-drug regimen. And again, these are only counting the abortions that are taking place in the formal healthcare system. We also know that there's tens of thousands of people each year that are getting care through community networks with medication abortion pills, that are self-sourcing pills through online pharmacies and resellers, and folks are getting medication abortion pills from international clinics as well. So, it really is the primary way that people are having abortions now in the United States.

Jennie: And I guess we should talk about then that's kind of where the MAP comes in, right? Can you tell us more about the Massachusetts Medication Abortion Access Project?

Dr. Angel Foster: Sure. So, in the wake of Dobbs, the Massachusetts legislature passed what's affectionately known as the Massachusetts shield law. And this took place in the summer of 2022. And the Massachusetts shield law does three things. The first is that it protects providers, helpers, and funders from criminal, civil, and licensure penalties when providing or supporting legal, reproductive health, and gender-affirming care. The second thing that it does is it protects patients who travel to the Commonwealth of Massachusetts for their care. So, it does a lot of protection of records and patient information. But the third pillar of the Massachusetts shield law is what makes it comprehensive. And the Massachusetts shield law effectively redefined the location of telemedicine care. So, if the clinician is licensed in Massachusetts, resides in Massachusetts, and is physically practicing from Massachusetts, then that care is considered to be taking place in Massachusetts regardless of where the patient is located. And this third pillar allowed for clinicians to care for patients throughout the country, regardless of what the legal status of abortion is in the state where the patient resides. And so, for the MAP, once the Massachusetts shield law passed, a small group of us got together and thought, you know, can we build a practice that's part of the formal health care system that takes advantage of the Massachusetts shield law? And for me and for others that I work with, we've had a lot of experience with medication abortion care internationally and had a lot of lessons that we'd learn. I co-founded over a decade ago a nonprofit organization called Cambridge Reproductive Health Consultants, which is incorporated in Massachusetts. And so, we wanted to use CRHC as the sort of home for this new initiative. And on International Safe Abortion Day of 2023, which is September 28th, we launched the MAP. And so, the MAP is an asynchronous telemedicine service. A patient goes online, completes a medical questionnaire and consent in consent forms. Then one of our clinicians reviews those materials, determines if the patient is eligible. If the patient is eligible, the clinician writes a prescription, and we send the package in the mail to the patient. If the clinician has questions, we follow up with the patient. We can convert to being a synchronous service, so we can have phone calls and things like that. But we do a lot of our communication with patients through messaging. And since we launched, which has been a little over two and a half years, we've cared for almost 60,000 patients. About a third of our patients reside in Texas, and about 90% of our patients are in states with near-total abortion bans or with gestational duration bans in the first trimester. And we just shifted to a new platform on June 1st, and as a result of that, our volume has increased dramatically, and we're now, it looks like our new steady state is we'll be caring for between five and six thousand patients a month.

Jennie: That's amazing. Hearing people being able to get access to the care they need is such a huge win. That is so wonderful for all of the people who can now get access to care and that the providers are protected.

Dr. Angel Foster: And I think one of the other things just to know about our practice is that, you know, when we started, we used a sort of sliding scale fee model. We charged $250, but you know, explained to patients that they could pay whatever they could afford to pay. We asked for a minimum contribution of $5. And we did a real deep dive with our patients, with about 2,000 patients that we had served in the first six months. And one of the things we found was that financial precarity was really prominent in our patients' lives. And it was shaping not only the decision to have an abortion, but also what kind of abortion to have and where to go to get that abortion care, whether that's online or through traveling to another state. And so, after our first year, we shifted our financial model, and so now our practice, the operating costs of our practice are fully covered by philanthropy, which is great. And so, we are able to offer care for $5 or more. So, we use a transparent pricing structure. We explain to patients that the package we send costs $75, and if they can pay $75, that's great. If they can pay more, that pays it forward. But we are able to provide care for $5 to anyone who requests it. And we've been able to do that by working with local and national abortion funds and by revenue from individual donations. And about a third of our patients pay $25 or less for their care.

Jennie: I mean, financial barriers are such a huge barrier in accessing abortion care that this already amazing program just got even better. That is so wonderful to hear because yeah, that keeps so many people from accessing care.

Dr. Angel Foster: It does. And one of the things that we really were thinking about as we launched the MAP was, as devastating as Dobbs is, Roe was always an imperfect decision. And there were tremendous barriers to access prior to Dobbs. And so, one part of our thinking about the map was sort of how can we use this moment to build back better? How can we use this as an opportunity to try to create the system that we would like to see? And one of the things that I'm a big proponent of is single-payer healthcare. I would love for us to live in a universe where we had that kind of health system, which we obviously don't in the US. But what we're trying to do with the MAP is to approximate that in some ways, which is to create something moving from a fee-for-service model to something that's more like a single-payer healthcare system.

Jennie: Yeah, it's one of those things when we talk about access, right? It sounds like it's so simple of a thing, but there's so much held within it where you know you should be able to easily access it, but that means afford it. There should be a clinic, or you can easily get it online. There are so many layers as part of access that I think when we talk about making sure that abortion is accessible, sometimes some of that nuance of all of the things held within that get lost.

Dr. Angel Foster: I agree.

Jennie: I would love to talk just a bit more about shield laws because they are this new and innovative thing that we have really seen pop up. And I also we'll focus on the abortion part, but I always try to talk about how the fight for abortion rights and trans rights are so interlinked, and it's the same groups fighting against trans rights that are fighting against abortion rights are using the same playbook. So, it's so wonderful to see a number of states also having shield laws around gender affirming care as well.

Dr. Angel Foster: Yeah, I think Massachusetts shield law was the first comprehensive shield law and did from the outset include both reproductive health care and gender affirming care. And I have some wonderful colleagues now based in the Commonwealth that are actually trying to move forward with a system of providing gender affirming care through the shield laws, and I am so glad that they're doing that work. Providing gender affirming care is a little bit different than providing abortion care, and part of that has to do with the continued relationship between the provider and the patient that you see with gender affirming care, which is quite different from abortion care. And so, for reasons that have to do with both the kind of clinical practice and the relative simplicity of the care, it has been much easier to get shield law abortion provision up and running. And it's more complicated to do that with gender affirming care. Not because I think there's not a will to do that, I think there's just other pieces that folks have to grapple with. And there certainly are folks who are providing gender affirming care through telemedicine, and then there's experience with that. For those who are thinking of using the shield law to provide gender-affirming care to patients in all 50 states, especially to minors, there are a number of different pieces that folks are trying to work out. But I agree with you, these are very related issues. The opponents of abortion rights and the opponents of both trans rights and just the existence of trans people, these are the same opponents. These are the same people, and you're right, they're playing from the same playbook.

Jennie: Yeah, and they try so hard to like peel people off from you know, in the feminist space or in all of these areas that we really need to keep an eye on it and make sure that we are standing so firm together because we are so much stronger if we stayed together in this fight.

Dr. Angel Foster: Totally agree.

Jennie: Okay, so what are you keeping an eye on at the moment? I feel like there is so much happening around medication abortion access. What are you keeping an eye on or worrying about or looking forward to?

Dr. Angel Foster: So, for sure, the thing that we are probably watching the most closely is this regulatory status of mifepristone. So, on May 1st, as a result of a case that was filed by the Attorney General in Louisiana and an individual plaintiff, the Fifth Circuit Court of Appeals issued a ruling that if it had gone into effect would prevent providers from sending mifepristone through the mail. Now, the Fifth Circuit announced that decision in the late afternoon, early evening on a Friday, which was May 1st.

Jennie: As I was leaving for vacation.

Dr. Angel Foster: And we had been watching this case closely. We had a lot of contingency plans in place for what we would do with mifepristone if we were no longer able to provide mifepristone as part of our practice. And so, we spent that weekend kind of doing a major pivot to be able to provide patients with a single drug regimen, which is the use of misoprostol alone. And this is a regimen that our team has a lot of experience [in]. We've worked with misoprostol alone internationally for decades, and we are very confident in the safety and efficacy of misoprostol alone, so we're grateful that we have an alternative. But that weekend was incredibly hectic because we were effectively dealing with three different sets of patients. We had about 300 patients who we had sent our mifepristone-misoprostol packages to prior to the Fifth Circuit's decision being released, but they hadn't got the medications yet. And so, we were inundated with questions from patients about, you know, would the medications arrive? Would the postal system intercept them? Was it legal for them to take the mifepristone and misoprostol? Just a lot of uncertainty. And we don't provide patients with individual legal advice, but what we were able to respond to these patients with was, you know, our understanding of the ruling is that it prevents us from mailing mifepristone. It does not prevent a patient from receiving mifepristone or using mifepristone. But the second group of patients that we spent, and really, I spent like all of my time with that weekend were the patients who had been approved for our service prior to May 1st, or on May 1st, but we hadn't sent them the packages yet. And because it was May 1st, it actually coincides with something that's pretty common with our patient population, which is that patients will fill out their forms and request pills in the last week of a month, but they'll delay making a payment until after the first of the month because that's when paychecks come through. And so, we had all of these patients who were kind of in this limbo state where they'd been approved, but they hadn't yet paid, and then they paid after the decision. And so, we were going back, there were like 200 of these patients that I was going back to and trying to explain. We were going to send pills on Monday. It would either be mifepristone or misoprostol, depending on what happened with the case, or it would be misoprostol alone, but basically had to consent all of these patients to accepting another regimen. And going through, you know, what that, what, what the difference is, what their options were, that they could still get mifepristone and misoprostol through a clinic or through community networks as well. And it was really interesting because some of our patients had heard of this decision and were very focused on what it meant for them. And the vast majority of patients just wanted to pivot to the misoprostol-only regimen, I'll say. But some of our patients had no idea what was going on. And so instead they're getting an email from their provider saying, hey, there's this court decision that's happened. It may affect your care. And so, then there was all this confusion: like, why is a court in a totally different region of the country telling me what I can do about whether or not I can use mifepristone? So, there was a lot of anxiety there. And then the third group of patients were the kind of new patients, where we made sure that we were informing them that we were offering misoprostol alone, consenting them to that, explaining, you know, changing, changing our website, changing our consent materials, making sure that all of our instruction sheets were up to date. And I say all of that because we were really prepared. We've been watching this closely, and it still wreaked havoc on our practice for a couple of days because I think part of the decision was intentional cruelty. Releasing that decision at that time of day and night and week and day of the month without thinking at all about the real people who were in the process of getting their abortion care was just cruel. And then, of course, we were prepared to send our patients misoprostol loan packages on Monday. We had them ready, but the Supreme Court, or Justice Alito, announced an initial stay in that in the Fifth Circuit's decision. And because Justice Alito announced that in the morning, we ship our packages in the afternoon, we were able to pivot again and get everybody mifepristone and misoprostol. It was a very hectic couple of days. I think it showed though, both for our practice and I would say the field overall, just how resilient our field is and our movement is, because people were really able to problem solve and make sure that patients would continue to get the care that they want, need, and deserve.

Jennie: Yeah, the other thing I was really keeping an eye on was still that piece around media education, like so many news stories about banning telehealth medication abortion, which was never what was happening. It was about the one medication used in one protocol. So, there was also again that confusion that was created by lack of understanding of how medication abortion works and that there are these two extremely safe, these are the WHO, both are WHO-approved protocols. The miso one is used in a lot of the world. So, it wasn't about medication abortion being banned, it was about the one method causing a problem.

Dr. Angel Foster: Absolutely. And mifepristone would still continue to be available through other channels. Yeah. In the formal healthcare system, that would mean clinics or individual practitioners' offices or hospitals. I mean, but mifepristone would still be available from brick-and-mortar facilities. And of course, international clinics and community organizations would still provide mifepristone and misoprostol. And so, I agree with you that the media coverage, at least initially, sort of talked about this as like a ban on medication abortion entirely without differentiating the different kinds of pills, and that this was targeting telemedicine providers and the ability to get mifepristone through a pharmacy. That was also part of this decision. And it did lead to a lot of confusion. But there's also an irony that every time abortion is in the news in a big way, we see real increases in requests for pills from our service. So, when we look at the numbers between April and May, we served about 15% more patients in May than we did in April. We about 1% of our patients overall are requesting pills for use in the future, what we call advanced provision patients. And so, in April, at this time we were caring for between 3,000 and 3,500 patients a month. And in April we had, I think it was 34 patients who were future use patients. We had about 150 future use patients in May. And we also saw a 40% increase in the patients from Louisiana. Wow. And I think that is because so much of the media coverage used the name of the state that was involved with this case. And one of the things that, you know, the Attorney General in the Fifth Circuit had argued is that you know Louisianians could, is that the right adjective? People from Louisiana. People from Louisiana could get abortion pills through shield law providers. And I think, again, the irony is that I think there were people in Louisiana who didn't know that that was an option for them until they saw some of this news coverage, which of course got a lot of play in local news in Louisiana. And so, I think that's why we saw such a surge in requests for patients from Louisiana. And so, that's the silver lining of this incredibly hectic period. So, I say all of this because we've been watching the regulatory status of mifepristone and whether that's around these legal cases or the FDA's review. Here I will just say the science is so clear on mifepristone that I welcome a real review of the science of mifepristone because we just win in that. It's such a winner for us. The science is so clear. A real review of the science would show that mifepristone is still encumbered with too many regulations.

Jennie: Yeah.

Dr. Angel Foster: So, if it's a real scientific review, that's great for us. If it's a politicized review with a predetermined outcome, that obviously is a problem. So, we're watching that as well. And then we also, of course, are watching, you know, whether the federal government will do anything around shield laws, around the resurrection of the Comstock Act, which I have to say, I think is so unlikely because it would wreak havoc on the entire field of obstetrics and gynecology. There's no universe where the resurrection of the Comstock Act doesn't dismantle a whole area of health. So, we're watching for those things, and we talk with lawyers and we talk with our AG's office all the time to kind of see what's coming down the pike.

Jennie: Yeah, I definitely keeping an eye on all the things. And it feels like so much, but seeing the burblings again around the FDA review taking on more speed this week has been concerning. Because again, like you said, I'm not concerned if there's like a real review, but I don't have faith in the people in place at the moment [for] it not [to] be a political review.

Dr. Angel Foster: Yeah. What I understand from how they've constructed the review though, it's gonna be really interesting. I think, you know, if what they're doing is using insurance data to look at who is using insurance coverage to obtain medication abortion and then who is using insurance coverage to get follow-up care from a medication abortion. This is all gonna be based on insurance and diagnostic codes. I think it's kind of fascinating because-

Jennie: That's such a specific group.

Dr. Angel Foster: It is. And it's not how the vast majority of people do not use private insurance to pay for their abortion care, in part because people live in states where that's prohibited, but also just the kinds of insurance that people have and the fact that Medicaid in most states does not cover abortion care. So, to me, there's something really fascinating about who that population is that they're studying. And this is a population that is much more likely to have a regular primary care provider. And so I think what we actually might see if you were to do this study for real, as I sort of hypothesize the findings, is that we would actually see less use of the emergency department for follow-up care in this kind of patient population because they're much more likely to have access to other healthcare professionals. The reason we see a lot of folks, particularly those who are insured through Medicaid, use the emergency department for follow-up is because they don't have access to other parts of the healthcare system. And so, we know that people present at emergency departments after medication abortion care for reassurance. They don't actually get treated, there's no intervention, it's working the way that it's supposed to, but they still are interacting with the health system. So, I think there's something fascinating about this FDA review that makes me kind of cautiously optimistic, despite all of the politics, that the way that this is structured is still going to be sort of true to the findings that mifepristone is safe and effective. Anyway, that's I mean, it's all very early, early days, and I have limits of what I know about this FDA review, but these the pieces that I have heard about this from you know very informed sources make me kind of cautiously optimistic, both in its design and the kinds of questions, but the devil will be in the details. Like, what are the questions that are being asked of insurers? What codes are being used, how is the FDA defining a serious adverse event? What information is getting captured?

Jennie: I can only also assume they're getting outside pressure from unlikely bedfellows, right? [The] pharmaceutical industry has got to be really pushing back on this of, like, if they're gonna do it with this thing, like what other things could it happen on? So, I'm sure there's lots of pressure outside of the abortion-specific moment that is being brought to bear.

Dr. Angel Foster: I think so too. I mean, I'm not a lawyer, but yeah, I have read a lot of the briefs that were filed in support of the continued, the continuation of mife's regulatory status, including a brief that was filed by the pharma sector, that's you know, which was arguing there has the FDA is a technocratic agency, it has to be permitted to do its job. You can't have judicial and political interference, or it dismantles the way that drug development works. And it wasn't about abortion, it was about the way that regulation of medications take place and all of the consequences if you can't trust that system. So, if you can't trust that the regulatory system will continue to be technocratic and evidence-based, then what does that do for the sort of calculation of whether or not to move forward with drug discovery?

Jennie: Well, Angel, I had a wonderful time talking to you, but I always like to end rapping with not just like things are oblique or this is what's happening, but with what can our audience do? So how can the audience get involved in this moment?

Dr. Angel Foster: It's such a great question. And so, a couple of things. Right now, the anti-abortion rights movement is using a strategy of throwing everything at the wall and seeing what sticks in order to try to restrict access to mifepristone. Now, obviously, telemedicine is one of their major targets, but they're trying to do this on a whole bunch of different fronts. And one of the things that we've seen are through different mechanisms in different states, um, state attorneys general who are trying to prevent information about medication abortion getting out there. And so the first thing I would say is that post information about medication abortion if you're on social media, if you have a website, if you've got something that's got resources, the more that information about medication abortion, the more that information about shield law providers is linked in to a whole bunch of other networks, the harder it is to dismantle it. And so, we've just got to get the word out there. One thing that I will say is that we have a whole sort of grassroots awareness-raising campaign about the MAP and about shield law provision. We've got stickers and flyers and leaflets. So, if you are someone who's in a state with a near-total ban or with gestational duration restrictions in the first trimester, you can reach out to me. I'm happy to provide a little packet. We put up stickers in public restrooms and on telephone poles and that kind of stuff just to get it out there. And we're seeing more and more patients who have learned about our service from these sorts of more grassroots campaigns. And then I guess the other thing here I'll just say, you know, for us, the biggest challenge that we face right now is not what the anti-abortion rights movement is doing, but it's really a legitimacy challenge. And here I'll just invite you to imagine that you're one of our typical patients. So, you're a 23-year-old woman living in rural Texas. You're not in college and you're not involved with the reproductive health rights and justice movement, so you don't really know that much about kind of abortion or reproductive rights. You've never been pregnant before, and you learn that you're pregnant and you don't want to be, and all you know about abortion is that it's illegal in Texas because that's what you've been hearing for years. And you go online and you find out that there's this group of clinicians in Massachusetts that will send you FDA-approved medication abortion pills to your home for $5. And it sounds absolutely bananas. How could that be true? How could the pills be real? How could this be legal? And so, for us, the real challenge that we face is this one of legitimacy. How do we communicate to that person that we are, we're real people providing real health care with real legitimate medications, and we're able as a nonprofit to provide it affordably. That's one of our biggest challenges. So, to the degree that anyone who's listening can help us get the word out to the folks who most need our services, that is incredibly helpful. And I'll also just say, you know, when I think about our sort of typical patient, it makes sense to me because, you know, although we know, those of us who live and breathe this work know that abortion bans are about the provision of abortion and about helping someone get abortions. There are obviously some states that are trying to move in a different direction, but right now, states are not criminalizing the pregnant person for having the abortion. In fact, that's explicitly excluded. There's a little bit of murkiness in Nevada, but everywhere else, it is not criminal to have an abortion, or that the pregnant person will not face criminal penalties for having an abortion. When you hear that something's illegal, most of the time we think it's illegal to do it, not to have it be done. And so, I think there's this chilling effect about the way that we talk about abortion bans, where people then assume that abortion it's illegal to have an abortion. And we know that there have been a handful of cases, and it's far too many, but a handful of cases where pregnant people have been criminalized for their pregnancy. Most of those have actually been around miscarriages and stillbirths, but there have been a handful of them around abortion as well. That is a misapplication of law, and it's usually not that somebody had an abortion, it's usually about how the remains of a fetus were disposed of or things like that. It's law enforcement agencies using different laws to criminalize someone's behavior. But those cases get a lot of attention in the media, and so I think it helps reinforce this narrative that it's illegal to have an abortion or that there are major criminal risks around having an abortion, and yet what we know is that we have tens of thousands of people who are having abortions in states with bans and restrictions each month, and a lot of that care is coming certainly from the formal healthcare system that's coming through shield law providers, and people are able to do that safely and are not being and the vast majority of them are not being criminalized. So, I think there's this tension that we have to be aware of, but I do think the way we talk about abortion bans has led to more people thinking it's illegal to have an abortion. And this was in relation to your question earlier of what we're watching out for. And here I just want to just really reiterate that we are obviously paying close attention to all of the different moving pieces, the legal pieces that are moving, the regulatory pieces that are moving, and we're doing a lot of strategizing and we talk to a lot of lawyers and we're in community with other groups. But our overarching practice motto is: no anticipatory obedience. And so, while we're watching all of this very carefully, it we will not change our practice unless we are legally required to do so. And that may mean, as we were prepared to do in May, switching from mifepristone to misoprostol, mifepristone and misoprostol to misoprostol alone. But we are gonna continue to provide care as long as we are legally able to do so. And we are in very close communication with our attorney general's office in Massachusetts to make sure that any changes we make to our practice are still legally compliant with the Massachusetts Shield Law. And so, I think there are other shield law providers that have taken on this attitude as well. And here I'll just say, like, you know, shield law provision is here to stay until it becomes illegal to be a shield law provider.

Jennie: Well, Dr. Foster, thank you so much for being here. It was so wonderful getting to talk to you today.

Dr. Angel Foster: Well, thank you so much for having me. This was really fun.

Jennie: Okay, y'all. I hope you enjoyed my conversation with Dr. Foster. I had so much fun getting to talk to her about the really important life-changing work they are doing, making sure that abortion pills are getting in the hands of people who need them. I learned things. I had such a great time talking to her, and it was so wonderful to hear about the amazing work they were doing. With that, I will see everybody next week. If you have any questions, comments, or topics you would like us to cover, always feel free to shoot me an email. You can reach me at jennie@reprosfightback.com, or you can find us on social media or at rePROs Fight Back on Facebook and Twitter, or @reprosfb on Instagram. If you like our podcast and want to make sure more people find it, take the time to rate and review us on your favorite podcast platform, or if you want to make sure to support the podcast, you can also donate it on our website at reprosfightback.com.