Inside the Online Market for Overseas Abortion Pills

A few times each month, a 10” x 15” padded FedEx envelope arrives in Mark’s mailbox in eastern Florida. He doesn’t know when the packages will arrive, only that each shipment usually contains about a dozen individual mifepristone pills and several 10-packs of misoprostol, the two drugs used in a medication abortion.

He repackages the pills — one mifepristone and four misoprostol each — and then prints a one-page sheet of instructions before shipping the medication to U.S. customers who have placed orders from medside24.com, a website based in Kazakhstan that sells abortion pills exclusively.

Mark is one link in a supply chain for abortion pills sold outside of the formal U.S. health care system — a market that has expanded significantly in the last year and that includes both overseas manufacturers and ad hoc distribution networks in the United States.

“I’m not the dealer, I’m just forwarding the mail for someone,” Mark told me in February. (Because distributing medication from overseas is illegal, many people interviewed for this story asked to be identified by first name or first initial only.) “I’m not for abortion but I’m not entirely against it,” he added. “On some level, it’s none of my business.”

Websites selling pills offer a convenient — though legally dubious — route for people looking for a way around state-level abortion bans. In the nine months since the Supreme Court’s Dobbs decision, tens of thousands of patients seeking to terminate a pregnancy have gone online in search of pills. Often, it is the only option for those unable to travel for clinic-based care.

For years, the advocacy group Aid Access has provided pills to U.S. patients at little or no cost. But people are increasingly turning to other groups and to for-profit sellers like Mark’s employer for faster delivery.

In the span of two weeks in February, one online seller distributed more than 300 abortion pill orders, primarily to people in Southeastern states where access is restricted.

These sellers stand only to gain from further efforts to restrict abortion, experts told me.

“Patients are either going to be forced to use a less effective regimen, or it could potentially push people into unregulated informal networks,” Greer Donley, a law professor at the University of Pittsburgh who focuses on abortion, said of the ruling. “Those are the two consequences. It’s not going to stop people from obtaining abortions.”

In interviews over the past few months, sellers, shippers and patients described how the online market for abortion pills is operating — and how it has grown since the Dobbs decision.

Overseas suppliers appear on track to provide abortion pills to around 100,000 people in the United States in the year after the decision, or enough pills to cover about 10 percent of the country’s annual abortions.

Even anti-abortion groups say that it will be difficult to control this market. “It’s very amorphous,” said Sue Liebel, the director of state affairs at Susan B. Anthony Pro-Life America. “States are looking at ways to determine how they can keep these sellers out of their state, just as they would brick-and-mortar clinics. But it’s harder to regulate if it’s online.”

An influx of orders

Twenty-five states and Washington, D.C., allow abortion pills to be prescribed via telehealth and sent through the mail legally, which costs anywhere from $150 to $500 depending on insurance, and it typically takes less than a week.

But patients seeking pills by mail in other states have few choices but to look online to overseas providers for access to the drugs. Abortion pills are typically used for patients who are less than 12 weeks into pregnancy.

The most established and sought-after option for online pills is Aid Access, a service run by Dr. Rebecca Gomperts, a Dutch physician and activist. It has provided Americans with pills since 2018. The second is Las Libres, a Mexican activist group that works with U.S. volunteers who distribute pills free of charge.

For many patients, figuring out how to get pills begins with Plan C, an advocacy group that acts as a clearinghouse for online pill providers. Today, Plan C lists 23 for-profit sellers, largely based in India, with about two dozen more waiting to be verified and listed.

Even though Plan C has boosted the online sellers’ visibility and legitimacy, they remain a relatively small piece of the landscape.

Through February, Aid Access was receiving an average of 254 requests a day from people in the United States, up from 83 requests from before the Dobbs decision. Las Libres said it had received around 100 daily requests through the end of March, down from around 200 per day in December. (Not all requests will end in shipments.)

The online sellers I spoke with, by comparison, said they were each receiving anywhere from five to 45 orders per day.

Where the advocacy groups see injustice, the online sellers see a lucrative market. A medical termination of pregnancy kit, or “M.T.P. kit,” retails for as little as $5 in India but can be resold in the U.S. for more than 50 times as much.

To better understand how the sellers operate, I placed orders with four sites listed on Plan C, identifying myself as a reporter for The New York Times. Through one, I connected with Mahiwal, who said he answers customer queries over WhatsApp from Punjab for more than 80 websites that sell pills.

Mahiwal asked if I would like to become a shipper myself — for $2,000 he would send me 10 abortion pill kits, which could be resold for $350 each. He would handle the customer orders, and I would mail the packages and keep the profit. “U can buy Tesla with us,” he messaged me, assuring me of the easy money.

A Cleveland, Miss., man who goes by Guru is one shipper who took Mahiwal up on his offer. Guru said he got connected with buymtpkits.com through a relative in India who knew he was looking for work.

He ships 10 to 12 packages each day, for a total commission of about $40. “I thought, ‘This seems easy,’ I can do it from home. All I need is a printer,” he said.

Dr. Gomperts, of Aid Access, sees little problem with merchants selling pills purely for profit. “I have the medical background, I have the scientific background, and it is a better service because of that,” she said. “But to be honest, as long as the medication they’re sending is real, who cares?”

Weighing the options

The U.S.-based shipper network has been crucial to growing the business of the overseas sellers, who win customers by offering quick or even overnight delivery of the pills.

For most patients, the cost of the service remains the most important factor in deciding where to get pills online.

But shipping speed has become a priority too.

“I did consider Aid Access, but I was afraid by the time I got it I would be too far along. I didn’t want to take any chances,” said J., a 31-year-old mother of three from Indiana.

J. ended up choosing a seller called secureabortionpills.com. “It said fairly fast shipping, and it was one of the cheaper options. So I took a shot with them,” she said. She paid $310 and got a USPS tracking number via email. The pills arrived in four days.

A major difference in ordering from online sellers, compared with telehealth or in-clinic abortions, is that there is no physician oversight. Instead, many patients turn to resources like the Miscarriage and Abortion Hotline or lengthy Reddit threads with advice on how to self-manage an abortion with pills: when to take them, what to do for pain, how long to expect bleeding, cramping and other possible side effects.

While opponents of abortion argue that self-managing with pills is dangerous — and self-managing with pills from an unregulated overseas supplier even more so — there have been no publicly reported instances of serious complications for patients who took pills bought online.

Overall, abortion pills are exceptionally safe and effective, though some experts raised concerns about the possibility of patients receiving ineffective or damaged pills from overseas, especially misoprostol, which is susceptible to degradation in heat or moisture. Even the F.D.A.-approved regimen has a 3 to 5 percent chance of resulting in an unsuccessful termination in the first trimester.

And while abortion-rights groups are concerned about efforts to further restrict the availability of legal pills, the outcome of the F.D.A. lawsuit could ultimately drive interest in extralegal options.

“With each outrageous act of a court or legislature, that provides us with another opportunity to tell people about this robust alternate supply network that exists in the U.S.,” said Elisa Wells, the co-founder of Plan C.

Sidestepping the regulators

Most online providers, including Aid Access and to a lesser extent Las Libres, source abortion pills from India, the world’s largest manufacturer of generic drugs.

India counts the most abortion pill manufacturers among the countries that make mifepristone or M.T.P. kits.

Abortion pills technically require a prescription in India, but they can be purchased over the counter at local pharmacies and online marketplaces like IndiaMart and MedPlusMart.

“The system that governs how prescription drugs are dispensed is very leaky,” said Dinesh Thakur, a drug-safety advocate and former executive at the Indian drugmaker Ranbaxy Laboratories.

One supplier working for MedPlusMart, Ishan, told me he ships around 5,000 M.T.P. kits a month to the United States on behalf of privateemma.com, a seller listed on Plan C.

Indian pharmaceutical companies are producing the kits for the home market — there are an estimated 12 million medication abortions outside of health facilities each year in India — and they take little interest in how their products end up overseas.

Synokem Pharmaceuticals, a New Delhi-based manufacturer, said it was not “directly or indirectly” exporting its products to the United States. “We are not F.D.A.-approved, so no person can supply our products to the U.S. Not even an online pharmacy,” said Manmohan Juyal, the company’s senior manager for international business.

But at least two M.T.P. kits that Synokem manufactures — A-Kare and Killpreg — are sold by sites listed on Plan C. Ms. Wells estimated that Plan C has received about a quarter of the available global brands of M.T.P. kits through its own orders.

In most circumstances, importing drugs into the United States for personal use is illegal — but the F.D.A. does make exceptions, including in situations when “the drug is for use for a serious condition for which effective treatment is not available in the United States.” The F.D.A. declined to comment on whether mifepristone would meet this requirement.

Patients in states where abortion is banned may get away with ordering pills online for personal use, though they could face other charges. A woman in Texas last year was charged with murder for self-managing an abortion before the district attorney eventually dropped the case.

There is less ambiguity for the distributors — they are acting illegally. In 2020, the Justice Department prosecuted and a judge sentenced a New York woman to two years of probation and fined her $10,000 for supplying abortion pills from India to U.S. customers.

But enforcement remains rare. Over the years, the occasional Aid Access package has been confiscated by customs agents, but the service has remained largely untouched.

Under the current administration, the F.D.A. has been expanding legal access to medication abortion, allowing the pills to be sent in the mail and for retail pharmacies to dispense them too. And the agency is appealing the ruling that seeks to limit access to mifepristone.

Experts say a federal crackdown on abortion pills — even those arriving from overseas — is unlikely.

“In this climate, it’s almost certain the F.D.A. is not going to go after people who are doing this,” Ms. Donley, the abortion law expert, said.