Illustration by Hanna Barczyk.

The door of the Planned Parenthood clinic in Columbus was locked when Larada Lee arrived for the first of two appointments she needed to get an abortion under Ohio state law. About a dozen anti-choice protesters had gathered outside, without masks, calling Lee a baby killer as she approached the door. Lee felt nauseated from her pregnancy, at times unable to keep down even water. Her bones ached. She was missing her classes at Ohio State University. The fatal shootings of Ahmaud Arbery and Breonna Taylor in recent weeks were weighing her down with a sense of hopelessness. Meanwhile, Ohio officials had sparked confusion by ordering a halt to “nonessential” abortions. “Being Black in the middle of trying to seek an abortion in the middle of a pandemic—it was really difficult to navigate all of those feelings while also trying to focus on ’I hope that they don’t take this away from us,’” Lee said in a recent interview with The Nation, recalling her experience back in March and April. The day before, when she went to an urgent care clinic wearing her hijab, the white male doctor had seemed to belittle her, calling her brave for coming out in a pandemic just to get a pregnancy test. “You could tell that they just were being, like, really short because it wasn’t at the forefront of their concerns—which, it was at the forefront of mine, because I’m pregnant in the middle of a pandemic,” Lee said.

She felt clear about her decision to have an abortion. But her path was full of obstacles sown by the collision of the pandemic and state laws designed to make having an abortion as prolonged and difficult as possible. After finding the door locked, Lee called the clinic from the parking lot. The next available appointment was a month and a half away, she was informed. A clinic escort told her the doctor Lee was supposed to see that day was sick. The country was in chaos.

“I went home, broke down, and cried,” Lee said.

Abortion access was in crisis in the United States before the Covid-19 pandemic. In many states, getting an abortion can involve waiting periods of up to three days, unnecessary visits to a clinic, counseling sessions rife with false information, trips of hundreds of miles, and bans that force patients to raise hundreds of dollars. When Covid and the ensuing economic recession hit, each unnecessary trip or encounter with staff became an additional infection risk, and many patients faced these barriers with fewer financial resources than ever.

The early weeks of the pandemic became what many advocates saw as a dry run for the overturn of Roe v. Wade, the landmark Supreme Court case that legalized abortion and is now in greater peril than ever after the confirmation of Justice Amy Coney Barrett. Several states tried to use Covid as a pretext for banning abortion as a nonessential service under the guise of preserving personal protective equipment. “The brutality of it was terrible to experience,” said Dr. Amna Dermish, regional medical director of Planned Parenthood of Greater Texas. “We talk about the end of Roe v. Wade a lot…but nobody really thinks it’s going to happen or really understands what that looks like when it happens. We had the unfortunate experience to see what that looked like.” In Texas, a legal battle over the state’s attempt to shutter clinics prompted a revolving door of closures and reduced services that Elizabeth Gelvin, the client and community coordinator at the New Orleans Abortion Fund, called “the most sickening game of whack-a-mole we’ve ever seen played on a grand scale.” Over a period of four weeks, abortion access was switched on and off eight times. The ensuing chaos sent patients scattering across the country. Some saw their appointments canceled without notice as they sat in clinic waiting rooms.

The resulting migration of patients from Texas and other states where the clinics closed or limited their services “was a really huge kick in the pants, basically, to figure out what our systems look like for moving people out of states,” said Robin Marty, author of The New Handbook for a Post-Roe America. Even as the pandemic raged, patients boarded airplanes and buses to reach far-flung cities and hopped into cars with masked strangers who risked their own health to pick them up at airports. In increasing numbers, people flocked to the Internet for help, sharing information on how to access abortion-inducing pills by mail from overseas pharmacies and a burgeoning array of online clinics in the United States.

On the ground, meanwhile, clinics in hostile states scrambled to shift their protocols and protect staff while grappling with the nationwide shortage of PPE and slogging through court battles to fend off the states’ attempts to shutter them. South Dakota’s last abortion clinic, which relies on fly-in providers from out of state, went dark for seven months. All of this provoked an onslaught of calls to staff members and volunteers at abortion funds, who engaged in acts of unseen heroism to preserve access.

Still, according to Yamani Hernandez, executive director of the National Network of Abortion Funds, the pandemic has confirmed that “the system is just broken…. People have had this sort of talking point of, you know, ‘Abortion funds are the network on the ground that is going to make abortion access possible,’ and I think that that is true. But it’s also a very precarious network.”

Roe in peril: With Amy Coney Barrett confirmed to the Supreme Court in October, the Roe decision has never been under greater threat.(Tasos Katopodis / Getty Images)

Dermish was sitting at her dining table when she heard the news. On March 23, Texas Attorney General Ken Paxton announced a ban on all abortions in the state that weren’t “medically necessary to preserve the life or health of the mother.” “I was just completely stunned,” she recalled, “and then just kind of collapsed into tears because I couldn’t process it.” Dermish’s staff became, in her words, “agents of the state’s cruelty.” One by one, they called patients to tell them that their abortions had been canceled and that they didn’t know when they could be rescheduled. “To call somebody and tell them that you have to cancel their abortion appointment—I mean, this is a life-changing decision,” Dermish said. “To have that capacity for self-determination taken away from you is traumatizing.” Even worse, as the legal battle raged over the next month, access to abortion in Texas disappeared, then came back for a matter of hours, then was gone again. There were stretches when medication abortions and procedures close to the state’s 22-week gestational limit were allowed, and times when they were not.

“We were regularly telling patients in the waiting room who were there for their medication abortions, ‘Actually, sorry—turns out an hour ago we could have done your medication abortion, but now we can’t,’” Dermish said. Once, her phone rang during her last abortion procedure of the day; when she called back, she learned that the ban was back in place. “That was March and April for us.”

The ban in Texas prompted a scattered migration of patients aided by networks of clinic staff members and people like Sarah Lopez, the program coordinator at Fund Texas Choice. “Usually, if someone is going out of state, they’re going to New Mexico or Colorado, every now and then to D.C. But I was sending folks to Oklahoma, to Kansas, to Arkansas,” Lopez said. Data provided by Planned Parenthood of the Rocky Mountains shows a surge in Texas patients who made their way to Colorado, New Mexico, and Nevada during those tumultuous weeks, with 212 people doing so in April, compared with just 16 in February before the ban. Overall, 947 Texas residents made it to out-of-state facilities in April, according to a research letter published in the Journal of the American Medical Association. Many more saw their care delayed; in May, the study found, after the ban was lifted, there was an 83 percent jump in abortions at 12 or more weeks.

Lopez said her clients were lured by offers of free ultrasounds to anti-abortion crisis pregnancy centers that were allowed to operate even as abortion clinics were being shuttered. As they traveled out of state, some patients were still being hounded by calls from anti-choice activists who wanted them to keep their pregnancies. Then there was the crushing economic fallout from the pandemic. In 2019, 58 percent of callers who received help from the Lilith Fund, another abortion fund in Texas, were employed; during the pandemic, that share dropped to 39 percent. The amount that the fund gave these callers increased, as did the distance they traveled, from 158 miles on average in 2019 to 272 miles during the period from March to October 2020.

Elsewhere in the country, other abortion funds saw a similar level of economic devastation. “What we’re seeing now is, people have nothing,” said Kelly Nelson, cofounder of Tampa Bay Abortion Fund in Florida. “The bulk of the ones that are calling us have been affected by Covid. They’re unemployed, they’ve had other issues, they’re barely making it—and then they find out that they’re pregnant.”

Faced with this mountain of financial and logistical barriers, an untold number of people could not get the care they needed. “If I’m being honest, some teens during the abortion ban did end up continuing pregnancies that they didn’t want to continue, because it was just impossible for them to get care,” said Rosann Mariappuram, the executive director of Jane’s Due Process, an organization that helps minors in Texas navigate the parental consent laws on abortion and birth control. Teens in Texas whose parents can’t or won’t sign off on their abortions, as state law requires, must apply for a judicial bypass. Despite the pandemic, they must sometimes appear in person in front of a judge after they have already undergone an ultrasound conducted by the doctor who will perform their abortion. The whole process, including the abortion, takes about three weeks. Mariappuram can’t say how many people stayed pregnant because of these barriers, but she does know that in March, almost a third of the organization’s callers simply dropped off.

Pregnant in a pandemic: When Larada Lee went for an abortion in March, the clinic door was locked—the doctor was sick.

Providers elsewhere noticed this, too: Certain patients seemed to disappear. In New Mexico, Dr. Lisa Hofler noticed a dramatic decrease in the number of Indigenous patients who were making it to the University of New Mexico Center for Reproductive Health, where she is the medical director. The clinic’s staffers had braced for an influx of out-of-state patients and managed to safely see two and a half times as many people in April as they had in any month before the pandemic, Hofler said. “The people that I noticed not being there were our Native patients.” (In New Mexico, Native people make up 11 percent of the population.) “It felt like the Native people didn’t make it.”

In fact, Native American reservations were decimated by the pandemic. The Navajo Nation, in May, had the highest per capita infection rate of anywhere in the country. Tribal governments sought to contain the toll by locking down, in some cases requiring a doctor’s note for residents to leave for medical appointments. Tribal members who needed abortions turned to the abortion fund at Indigenous Women Rising, a reproductive justice organization cofounded by Rachael Lorenzo. The organization became a bridge between clinics and tribes, negotiating to get providers to send doctor’s notes on letterhead that would protect the patient’s privacy. “Abortion care is already hard to come by for Indigenous people,” Lorenzo said. “Now we’re having to get creative with how we make that a reality for [patients] while respecting their tribes’ sovereignty.”

On the day I spoke with Lorenzo, they were helping four patients seek care in three states—New Mexico, Colorado, and North Dakota. Two calls came in during the first half-hour or so of our call. Lorenzo, who has two other jobs and two kids, is proud of what their group was able to achieve against seemingly insurmountable odds. One moment from the summer stands out: A patient had been trying for months to get the money for an abortion together and had been pushed to 26 or 27 weeks of pregnancy, which meant there were only a few clinics in the country where she could get care. Then, when she finally had the money, her car wouldn’t work. So “someone donated their time as an airplane pilot and flew to Montana and picked up the patient at a small airport, which was like 20 minutes away from her home, because she didn’t have a reliable car to drive all the way from Montana to Colorado.”

Access for all: Rachael Lorenzo is a cofounder of Indigenous Women Rising, an abortion fund serving Native Americans.

Before the pandemic, Dr. Sarah Traxler had a straightforward routine during the one week a month when she was South Dakota’s only abortion provider: Her husband would drive her to the train station, and she would head to the airport and board a plane from Minneapolis to Sioux Falls. Traxler would fly in on Mondays, counsel patients at the Planned Parenthood clinic there, then fly home. On Thursdays, she would fly back to see the same patients she had met with earlier in the week. Under a decade-old South Dakota law, these patients had to meet with a doctor, sign a lengthy consent form laden with information designed to convince them not to proceed, and then wait 72 hours before having their abortion performed by the same doctor.

For 25 years, the clinic has relied on providers like Traxler, because the doctors who live in the state and are willing to perform abortions at the clinic are banned from doing so by their employers. Traxler and three other providers each covered one week per month.

Then Covid hit. “We made the decision to suspend services in South Dakota until we had a little better understanding of what the impact of Covid would be on people who were traveling,” Traxler said.

The clinic suspended abortions in March. Seven months later, it found a provider willing to travel to Sioux Falls once a month. But it’s unclear whether that will continue. “I hope that we’ll be able to survive it,” said Sarah Stoesz, the CEO of Planned Parenthood North Central States. “I just don’t know, though, because even without the pandemic, the financial burden of ensuring abortion access in South Dakota is becoming somewhat insurmountable, frankly. And I say that with a terribly heavy heart.”

South Dakota is one of the states where the dress rehearsal for the end of Roe started years ago. Many patients were already traveling out of state to avoid the 72-hour waiting period. “I feel like the last 20 years have been a practice run with them chipping away at access,” said Kim, who helped launch a new abortion fund in South Dakota called the Justice Through Empowerment Network (JEN) and asked us to withhold her last name. “It’s to the point that now, if it goes away, it’s like this tiny little beeping light that will just go out.”

If that happens, it could mean more trips like the one Will and Caitlin Anderson made one morning in July, when they put their sons in the back of their car and drove to meet a stranger two hours from their home in Sioux Falls to take her to her abortion appointment in Fargo, N.D. For hours, they drove past cornfields and a number of billboards that admonished them to choose life. Will thought about the law—already on the books in South Dakota—that would ban abortion and make facilitating it a felony under state law if Roe falls.

“If the work that we’re doing is potentially a future criminal activity that could land us in jail… if it comes to that, I don’t think we’re going to stop,” said Will, a self-described gun-toting, bearded bartender who serves on the board of JEN. “I know I don’t plan on stopping helping people.”

The Sioux Falls clinic had been there for him and Caitlin when she needed an abortion in 2015. They had three kids and couldn’t afford another. For Caitlin, the pandemic has underscored “just how heavily we depend on outside forces, and other people, and other people’s kindness.”

A new landscape: During the early months of the pandemic, regulators eased restrictions on the provision of abortion medication by telemedicine. (Olivier Douliery / AFP via Getty Images)

Larada Lee describes herself as someone who likes to have a backup plan. That’s why she made a second appointment for her abortion at an independent clinic in Columbus, just in case. Two weeks after her appointment at Planned Parenthood fell through, Lee sat in a waiting room at Your Choice Healthcare, texting her best friend. She looked around at the masked faces of strangers sitting spaced apart; like her, they were alone, their partners and friends banned due to Covid precautions. Lee’s friend had refused to leave her and was waiting in the parking lot. Under Ohio law, Lee had to undergo a counseling session, in person, that included information designed to discourage her from having an abortion. Since her first appointment was on a Friday, she had to wait until the following Monday to return, take the first pill in the clinic, and bring the rest of the medication home.

As she waited, Lee, whom I connected with through the abortion storytelling project Youth Testify, thought about the people who wouldn’t be able to manage that. She was missing classes and would end up failing one, but she didn’t have to work that day. Since her Ohio Medicaid didn’t cover abortion, she’d secured $400 from the statewide abortion fund Women Have Options.

Lee wanted the security of a doctor’s guidance, even though she preferred to take the abortion pills at home. What frustrates her is that Ohio law prevented her from having her appointments online. “I risked my health to go out [and] get my abortion pills, and they could have just mailed them to me and I could have done my abortion at home, like I did,” Lee said. “Having to go back two to three times for two to three hours at a time was also not the best in a really small room in the middle of a pandemic, even though they were trying to implement social distancing.”

For patients who look outside the traditional clinic model, the process can be very different. Tessa (a pseudonym) managed her abortion with the same medications as Lee, using pills delivered to her by the US Postal Service. She’d found out that she was pregnant in the fall, just as she became another of the tens of millions of people who have lost their jobs during the pandemic.

“I’m having an abortion, but I can’t afford it,” Tessa posted on a Reddit forum dedicated to abortion in November, nine days after the presidential election. Her partner, she explained, had been waiting to receive his unemployment benefits for two months and was regularly calling for updates, to no avail. Meanwhile, she was throwing up anything she tried to eat or drink, spending her days and nights hovering over a bucket or lying in bed. “I’m miserable and really have no one else to turn to,” Tessa wrote.

Within hours, strangers posted replies directing her to Aid Access, an organization based in Europe that ships abortion pills around the world. Founded by Dr. Rebecca Gomperts, Aid Access has continued to serve patients in the United States while challenging a cease-and-desist order from the Food and Drug Administration, which seized some of its shipments in 2019. In a handful of states, Aid Access has enlisted US-based doctors to send abortion pills to patients by mail. But in most states, patients navigate a murkier legal territory, e-mailing their Aid Access prescriptions to a pharmacy in India that then ships the pills to them. The commenters suggested that Tessa could get an abortion through the organization for about $100. She placed an order and, two weeks later, received a pink envelope sealed in plastic. After taking the enclosed pills according to the instructions she’d been given, she started passing blood clots and suffering painful cramps that sent her lurching between the bathroom and her bed. But that didn’t stop her from returning to Reddit, offering advice and reassurance to people awaiting packages of their own. “Any questions I’m here for you,” she wrote.

This subreddit and a few others like it have become unofficial support groups for people struggling with the challenges of seeking an abortion during a pandemic. Strangers go there to vent, grieve, brainstorm, or ask advice about navigating access to a clinic or buying abortion pills online. Behind the scenes, a group of volunteers coordinates in a private chat group to make sure every question gets at least one accurate and supportive response. Ariella Messing and Kate Bertash had lurked on the platform before launching the Online Abortion Resource Squad in 2019. Messing, a doctoral student working on a dissertation about abortion funds, and Bertash, the director of the Digital Defense Fund, which provides digital security to the abortion access movement, had noticed a flaw in the existing resources for abortion access: A lot of people simply didn’t know about them.

“There are a lot of apps and websites all about abortion, but they assume that people know how to get there,” Messing said. “And Reddit seems to be a place that people go to ask anonymous questions, and so we just sort of felt that one way to do this is to go where people are already.”

After Covid struck, Reddit exploded with questions. The pandemic disrupted the Aid Access supply chain, leading people to turn to less proven sources for abortion pills. Messing, Bertash, and their team scrambled to provide reliable answers in a rapidly shifting landscape. As the chaos of the initial weeks subsided, people like Tessa came to the platform to share their experiences with managing their own abortions.

The subreddit reflects a seismic shift in how patients in the United States obtain abortions. In July, because of the pandemic, a federal court temporarily suspended long-standing restrictions that are widely interpreted to require patients to go to a health center in person to pick up mifepristone, the first of two drugs typically used in medication abortions. Advocates recruited doctors to write prescriptions for abortion medications to be filled by online pharmacies, and digital abortion clinics sprang up, offering telehealth visits and abortions by mail to patients in states with laws that would allow it. Then, on January 12, the Supreme Court reinstated the rule, blocking pharmacies from mailing the pills to patients and casting doubt on this new landscape.

The earlier reprieve offered a glimpse of the dream that Elisa Wells, cofounder of the medication-abortion advocacy group Plan C, has been waiting for since mifepristone was approved for use in the United States in 2000. “Hallelujah for this new model of care, which eliminates those types of barriers and helps to create more equity in access,” Wells said. In the wake of the July court decision, digital clinics started offering consultations and abortion pills by mail for as little as $199 to patients in states like California, Minnesota, New York, and Washington. The TelAbortion Project, which began shipping the pills before the pandemic as part of a research study, has expanded to 15 states and Washington, D.C. “What we’ve been seeing…are people crossing the border into the TelAbortion states from states that have restrictive laws,” said Tara Shochet, the project’s director.

But within these innovations lie the seeds for an even more divided system. Eighteen states have active laws requiring physicians to be physically present when medication abortion is administered, making remote abortion care impossible. Even if the Biden administration eases the federal restrictions on mifepristone, telemedicine abortions will remain off-limits in many states. “Right now we’re seeing this impression that everybody can access abortion because of telemed expansion,” said Robin Marty, who serves as communications director for the West Alabama Women’s Center. “But all of the states where access is the worst, where there are no clinics and there are no doctors, are the same states that have telemed abortion bans.”

This divide seriously affects how clinics are able to protect their patients and staffs. Amid the pandemic, many shifted their protocols to minimize contact, and some began mailing abortion pills to patients after a telehealth visit. But providers in abortion-hostile states were limited by state law: A study of independent clinics found that while 73 percent of facilities in the Northeast reported that they had started or increased telehealth services during the pandemic, only 23 percent in the South had done likewise.

Advocates hope that the Biden administration will further ease the restrictions on mifepristone even after the pandemic ends, allowing it to be picked up at a pharmacy like other drugs. But the prospects for that and other changes remain unclear. On the campaign trail, Biden reversed his long-standing support of the ban on federal funding for abortion known as the Hyde Amendment, declaring, a day after his campaign had said otherwise, that he could no longer support a policy that made health care access “dependent on someone’s zip code.” Reproductive justice groups hope that Biden will go beyond repealing the Trump-era restrictions on abortion—such as the one that stripped federal family-planning funds from clinics that make abortion referrals—and send Congress a budget that strikes down Hyde, which has been in place for more than 40 years. But even with executive action, the Supreme Court’s likely willingness to uphold even the most onerous state restrictions has left experts like Marty concerned.

“We’re going to see an even greater divide over who can and can’t access abortion,” she said. “We are truly going to have the most inequitable system, even more so than we do now.”