Aleisha Reynolds, 43, of Portland got an early medication abortion when she was an art student in Massachusetts in 2001. Brianna Soukup/Staff Photographer

When she found out she was pregnant in 2017, Savannah did not know what to do. Just 19 years old, she didn’t want to have a baby – not then, not ever – but she tried to wish the pregnancy away, afraid that she would be judged or forced to carry it to term if she told anyone her secret.

“I just wanted to die,” said Savannah, who didn’t want to give her last name. “I just pretended I didn’t know because I didn’t know what to do.”

Nine weeks passed before a friend guessed she was pregnant and told her about Maine Family Planning.

An abortion counselor in Augusta took Savannah’s medical history and walked her through her options. Before leaving the clinic, the Rockland teen took the first of two abortion pills to induce the miscarriage that would end her secret pregnancy later that night in the privacy of her childhood bedroom.

Privacy is one of the major reasons that medication abortion has become the preferred way of ending an unwanted pregnancy. Nationally, about 54 percent of U.S. women chose the abortion pill over a surgical abortion in 2020, according to the Guttmacher Institute, a reproductive health research group.

Maine women show an even stronger preference for medication abortion, especially since the pandemic, according to Maine’s three abortion clinics, ranging from half of abortion recipients at Mabel Wadsworth Center to about two-thirds of Planned Parenthood and Maine Family Planning patients.

When a patient finds out they are pregnant, and they don’t want to be, they usually want to remedy the issue as soon as possible, said Andrea Pelletier, the medical director at Planned Parenthood of Northern New England. A clinic has a lot of flexibility to quickly add medication abortions to the schedule.

“Women have a lot of feelings about their abortions, one way or the other, so anything that gives them a little more control over it, that’s a good thing,” said Pelletier. “And it’s nice that Maine women have that choice. As we all know, not all women do.”

That flexibility means that Maine has the ability to absorb patients traveling from states that are either banning or curtailing abortion in the wake of the U.S. Supreme Court’s Dobbs v. Jackson ruling – often arriving here in their second trimester, in need of a surgical abortion – while still serving Maine women.

Maine clinics have provided abortions to a few dozen out-of-state patients who have traveled here to get the care that is now illegal in their home state, but not in big enough numbers to cause anybody in need of a surgical procedure to have to wait any longer than normal to get an appointment.

In fact, international companies beyond the reach of U.S. courts that are willing to mail abortion pills to women who live in states where abortion is now illegal may mute the practical impact of the Dobbs ruling, providers here say.

Patients who opt for medication abortion also like the flexibility of taking the pills where and when they want, saying they want to decide when to take the pills that induce the heavy cramping and bleeding so they can take a day off work, have someone there to help them, or send their kids to a friend’s house.

Although Maine’s clinics charge the same for a typical medication abortion as a surgical one – $500 to $550 – the soft costs are often lower. Some providers approve medication abortions through telehealth appointments and mail the pills; those patients don’t have to miss work, hire babysitters or pay for travel.

The use of medication abortion has been growing steadily since its approval in 2000 by the U.S. Food and Drug Administration, but pandemic-related changes to the healthcare setting and patients’ desire for no-touch medical care led to a dramatic surge in medication abortions during the pandemic.

At Maine Family Planning, which operates 18 clinics in far-flung communities across the state, about a third of all pre-pandemic abortion seekers opted for medication abortion. Now that number has grown to two-thirds, with no signs of slowing down, said Mareisa Weil, vice president of development.

Overall, however, the number of abortions performed in both Maine and the U.S. continues to decline.

“Every abortion story is unique,” Weil said. “Some people want a clinic. They want a doctor’s care, to know they’re not going to leave the building pregnant. Others want privacy, the convenience of a pill. That’s why we need pills in our hands and clinics in our communities. We deserve both.”

Color designer Aleisha Reynolds of Portland opted for a medication abortion 20 years ago. “A lot of it was just to lessen trauma,” she says. Brianna Soukup/Staff Photographer

Aleisha Reynolds, a 43-year-old color designer who lives in Portland, got an early medication abortion from a Planned Parenthood clinic in Worcester, Mass., in 2001. RU-486 had hit the U.S. market a year earlier, and the then-22-year-old Clark University art student didn’t know anything about it.

“It was an easy decision for me to get an abortion – I was in an unhealthy relationship, no good for kids – but I walked into the clinic not knowing what I was going to do about it exactly,” Reynolds said. “A pill just seemed easier, faster to make happen, and less invasive.”

It also meant she could avoid coming back on a weekend, when all surgical abortions took place and the clinic would be surrounded by angry protesters yelling at young women who went inside, Reynolds said. And she didn’t want to have to wait weeks to book an appointment for a surgical abortion.

“A lot of it was just to lessen trauma, from the people outside, the wait, the procedure itself,” she said.

She thought medication abortion was going to be easy, but it wasn’t. She endured heavy bleeding and cramping, which was normal but still painful. She didn’t talk about it for a long time, even though she has never regretted it, because she didn’t want to have to deal with the judgment of others.

“I love my life right now,” said Reynolds. “I had the opportunities I had because I made the decision. I recognize it was more than a pill, that I made a choice that changed my life, and I’m fine with it. It was my choice. I am kinda pissed that other people don’t have that.”

MEDICATION ABORTION RULES EASE

The modern version of what started off as RU-486 consists of an initial dose of mifepristone, which stops production of the hormone needed to grow a pregnancy, followed by misoprostol, which causes the uterus to contract and expel its contents.

These are both drugs that have uses outside of an abortion clinic, Pelletier notes – mifepristone is used to help women who have suffered a miscarriage, while misoprostol can be used to induce labor and prepare the cervix for biopsy and IUD insertion and can be obtained with a prescription at a pharmacy.

A 2015 study found that medication abortion used in the first nine weeks of pregnancy was effective 99.6 percent of the time, with a .04 percent chance of major complications – safer than having a wisdom tooth extracted, Pelletier said. The effectiveness dips after nine weeks, but goes back up with a second dose.

Ten years ago, Mainers had to go to an abortion clinic to get screened for eligibility, get an ultrasound to date their pregnancy to gauge how much medication to take, pick up the medication and take the first of the two-dose regimen inside the clinic, under the watchful eye of clinical staff.

But the rules around medication abortion have been relaxed. Research has shown ultrasounds aren’t needed if a patient knows the date of her last menstrual cycle. Telehealth practices put into place for a pandemic setting are now being used to conduct abortion eligibility screenings.

Patients used to be required to take the first dose of the abortion pill, the mifepristone, inside the clinic, but the FDA waived that requirement during the pandemic, equating it to an over-the-counter medication. It has since made that change permanent.

It also opened the door to mailing the kits to telehealth-screened and counseled patients, creating a truly no-touch abortion – something Maine Family Planning has been doing for years as part of a government-approved patient-managed abortion study, said Lindsey Piper, Maine Family Planning’s lead clinician.

Planned Parenthood will now mail abortion pills to eligible patients. Mabel Wadsworth still requires all patients to pick up their abortion pills in person, and take the first one in the clinic, but it’s exploring the possibility of take-home and mail-order medication for the future, said lead clinician Bonnie Case.

It has embraced telehealth abortion counseling when possible, and has dropped its requirement for the follow-up ultrasound in favor of a simple urine-based pregnancy test to confirm the abortion pills have worked, Case said.

These extra patient protections, or what some may consider restrictions, may explain why the abortion pill accounts for a smaller percentage of the overall number of abortions at Mabel – about half – than at Maine’s other two abortion providers, Family Planning and Planned Parenthood.

Patients must live in Maine and agree to take the abortion pills in Maine, where abortion is still legal, to pick up the medication at the clinic or arrange to have it mailed to them, Piper said. But many of Piper’s patients don’t want to wait for the mail and prefer to drive to the clinic on the day their plan is approved.

It would be illegal to mail the pills to someone intending to end a pregnancy – theirs or someone else’s – in a state that has outlawed abortion, Piper said. Also, Maine abortion providers are not allowed to practice medicine or prescribe medicine in a state where they are not licensed.

The increasing preference for medication abortion has drawn the fire of abortion foes. Conservative states are passing laws to make it less convenient and affordable by requiring a patient to take pills inside the clinic, requiring a doctor to dispense them instead of a nurse, or banning the practice outright.