Tens of thousands of women who are not pregnant are ordering abortion pills just in case they might need them someday, especially in states where access is threatened, according to a study published Tuesday.
The practice, known as advance provision, is relatively new and has increased significantly since the Supreme Court's decision in 2022 to overturn the national right to abortion.
In the study, published in the journal JAMA Internal Medicine, researchers evaluated data from Aid Access, a European telehealth organization that has long provided abortion pills to women in the first 13 weeks of pregnancy and began offering the medication to women in the United States who weren't pregnant in September 2021.
Aid Access received about 48,400 requests from across the U.S. for advance provision from September 2021 through April 2023.
Before May 2022, when a draft of the Supreme Court decision was leaked, Aid Access had received about 6,000 advance provision requests, averaging 25 per day. Since then, it has received more than 42,000 requests, averaging 118 per day, said Dr. Abigail Aiken, an associate professor at the University of Texas at Austin and a co-author of the study.
Nationally, the average number of daily requests shot up nearly tenfold, from about 25 to 247 after the leak. In states where an abortion ban was inevitable, the average weekly request rate rose nearly ninefold.
The biggest spikes in demand occurred after events that raised doubts about the future availability of abortion.
Requests peaked in the weeks between the leak and the Supreme Court's decision in June 2022, and in April 2023 after a flurry of court rulings in a lawsuit by opponents of abortion seeking to curtail mifepristone, a key abortion pill, in a case now before the Supreme Court.
"People are looking at looming threats to reproductive health access, looming threats to their reproductive rights, and potentially thinking to themselves: How can I prepare for this? Or how can I get around this or get out ahead of this?" Aiken said.
Daily requests dropped to 89 nationally after the Supreme Court decision, the research shows, then rose to 172 in April 2023 when there were conflicting legal rulings about the federal approval of mifepristone.
The Supreme Court is expected to rule on limits on the drug this year.
Co-author Dr. Rebecca Gomperts of Amsterdam, director of Aid Access, attributed this spike to greater public awareness during times of uncertainty.
Rates of requests were highest in states where abortion bans were expected -- even higher than in states that already had bans. Asked why they requested the pills, most women said to "ensure personal health and choice" and "prepare for possible abortion restrictions," according to the study.
Data from September 2021 through April 2023 showed 48,404 advance provision requests and 147,112 requests from women seeking to terminate existing pregnancies. Women in both categories completed telehealth consultations and Aid Access evaluated their medical information before prescribing pills.
Advance provision requesters were more likely than those already pregnant to be 30 or older, white and childless, and to live in urban neighborhoods with lower poverty rates than the national average.
That might be partly because Aid Access offers free or reduced-price services to pregnant patients who need financial assistance, while advance provision requesters were expected to pay the full $110 cost, Aiken said.
And because few organizations offer advance provision, women from marginalized or lower-income communities might be less aware "that it's even a thing you can do," she said.
Recently, Aiken said, some other organizations have started offering pills in advance.
"It's a very new idea for a lot of folks because it's not standard practice within the U.S. health care setting," she said. "It will actually be news to a lot of people that it's even something that is offered."
Advance provision isn't yet reaching people who face the greatest barriers to abortion care, said Dr. Daniel Grossman, an OB-GYN at the University of California, San Francisco, who was not involved in the research.
"It's not surprising that some people would want to have these pills on hand in case they need them, instead of having to travel to another state or try to obtain them through telehealth once pregnant," he added in an email, also saying more research is needed into the inequities.
MOST PILLS NOT TAKEN
Medication abortion typically involves two pills: mifepristone, which has a shelf life of three to five years, followed a day or two later by misoprostol, which has a shelf life of 18 to 24 months.
Aiken said a subset of advance provision requesters -- 937 women, two-thirds of them in states with abortion bans or restrictions -- answered follow-up questions. Most still had the pills, but 58 had taken them and 55 had given them to someone else.
About 60% took the pills before seven weeks of pregnancy, early in the recommended time frame.
A vast majority reported having enough information, including about expected bleeding and cramping. All 58 said the pills worked. Five visited health care providers afterward, but none went to the hospital or had serious complications.
Legal scholars say advance provision may be legal in some states with abortion bans. "Many state abortion laws require a provider to know a person is pregnant," three law professors -- David S. Cohen, Greer Donley and Rachel Rebouché -- wrote in an article to be published in the Stanford Law Review. However, they added, in some states, abortion providers might be legally vulnerable since they know that "the pills are prescribed to terminate a future pregnancy."
Opponents of abortion object to advance provision and claim abortion medication is dangerous.
Abortion rights supporters say prescribing it in case of future need, like antibiotics for traveler's diarrhea, increases access and underscores that the pills are safe, as many studies show.
Information for this article was contributed by Pam Belluck of The New York Times and by Laura Ungar of The Associated Press.