For most of the three years it’s existed, the second-largest telehealth abortion provider in the country has operated out of an office not much bigger than some bathrooms. “That is what half a million dollars of mifepristone looks like,” Dr. Angel Foster tells the Tufts University medical students crowded around the conference table, nodding toward the cubicle across the hall. The bins lining the plate-glass windows are filled with Priority Mail packages containing abortion pills, ready to be labeled and shipped. Shelves hold supplies of mifepristone and misoprostol, the two drugs in the gold-standard abortion-pill regimen, all waiting to be packed.
Foster is a leader in the movement that has revolutionized telemedicine abortion care in the post–Roe v. Wade era. The Massachusetts Medication Abortion Access Project, or The MAP, which she co-founded in 2023, is the culmination of a 30-year career on the cutting edge of global reproductive care. Figuring out how to get abortion pills to people who need them, while preparing for a future in which those pills may no longer be legal, is a core part of Foster’s—and The MAP’s—mission.
“We’ve got thousands and thousands of pills with the idea that we’ll be able to provide care for months if we need to weather any storms,” Foster tells the students, her hair pulled into a bun sturdy enough to withstand the harshest of elements. That stockpile is in addition to the more than 3,000 pill shipments The MAP has been sending out every month. “We just want to be able to provide care for as long as possible when there are disruptions,” she adds, knowing a series of Category 5 hurricanes looms on the horizon. Her personal mantra, echoing Timothy Snyder’s On Tyranny, is The MAP’s organizational one: “No anticipatory obedience.”
It’s a Thursday evening in mid-April, and Foster—a professor of medication abortion studies at the University of Ottawa in Canada, as well as The MAP’s head of operations at its Boston-area base—has spent the past week traveling and brainstorming with her abortion access allies about how to innovate and even expand care amid the escalating threats. Although she’s renowned among her colleagues for needing half as much sleep as most people, tonight she seems distinctly tired, not that the rapt students seem to notice. They wolf down dinner—pizza from a neighborhood joint with Oregon pinot and a crisp rosé in plastic cups—as she runs through The MAP’s origin story (thank you, Dobbs), radical philosophy (who needs doctors?), and ever-widening ambitions. Then she asks everyone to clear away their greasy plates for the highlight of the evening: the famous MAP assembly line.
This story will be part of the Reveal episode “The Post-Roe Surprise: More Abortions” on Saturday, August 1. Subscribe to Reveal here or wherever you get your podcasts.
First, they put together Priority Mail cartons, big enough to hold the correct dosage of abortion meds and inconspicuous enough to pass for, say, crafting supplies from Etsy. Then they pass the cartons around the table, each person slipping in something different: orange boxes of mifepristone and white plastic bottles of misoprostol, instruction sheets, information about ectopic pregnancies and patient privacy, and a handwritten card that says, “We wish you the best, [heart drawing] The MAP.” The last student checks the contents, seals the package, and drops it into a plastic bin. Since its launch, The MAP has sent abortion pills to more than 60,000 patients, 95 percent in states where abortion is subject to harsh restrictions and near-total bans. “How are you able to get this amount of volume out?” a dark-haired young woman asks incredulously.
A big part of the answer can be found in work sessions like this one, which happen twice a week. The MAP has a long waiting list of volunteers eager for a chance to help thwart red-state attorneys general and subvert draconian laws. Not only have these events become integral to The MAP’s operations, but they’re a highly effective way of trolling conservative extremists who believed the end of Roe would mean the end of abortion access for much of the US.
Exhibit A for how much Foster has enraged “the antis” (as she calls them) is a blockbuster lawsuit by the state of Louisiana that threatens mail-order mifepristone nationwide. On the gray spring afternoon we were huddled in her office, lawyers for Louisiana were putting the finishing touches on a petition asking the 5th US Circuit Court of Appeals to block Biden-era FDA rules that allow the medication to be prescribed via telehealth and sent through the mail. Although Foster wasn’t a defendant in the case, page 24 of the initial complaint included a photo of her presiding over a pill-packing party in 2024. Describing the gathering as a “scheme,” the lawsuit quoted from the Wall Street Journal article in which the photo appeared, in which middle-aged volunteers “sip[ped] chardonnay in red plastic cups.” (The Journal got that part wrong, Foster insisted later, in mock outrage: “I would never serve chardonnay!”)
The story “infuriated the anti-choice movement,” she tells me, sounding as gleeful as you’d expect from someone whose email signature used to include a drawing of the female reproductive system with the ovaries in the shape of middle fingers pointing up. The article also reached a vital audience for securing The MAP’s future success: progressive donors. The day after it appeared, Foster says, a wealthy retiree in a neighboring state pledged $250,000.
“Even if mifepristone became banned, medication abortion is here to stay. You can’t put this genie back in a bottle.”
Four years after the Supreme Court’s Dobbs v. Jackson Women’s Health decision ended the national right to abortion, Foster and her allies have managed to create an entire healthcare, legal, and financing infrastructure—what The MAP’s medical director, Dr. Maureen Paul, calls a “shadow” system—that has kept abortion pills flowing, with stunning efficiency, into some of the most abortion-hostile parts of the country. In the process, they’ve mainstreamed pills to such an extent that even a nationwide abortion ban, the anti-abortion movement’s No. 1 priority, might be futile. “Even if mifepristone became banned, medication abortion is here to stay,” Foster says. “You can’t put this genie back in a bottle.”
The irony is that while abortion foes see The MAP as an existential threat, many of the patients it serves still can’t quite believe it’s real. Imagine being a woman in an environment where abortion is painted as dangerous, evil, and illegal, Foster tells the students. “You get pregnant, you don’t want to be, you go online, and you find out that there’s this group of clinicians in Massachusetts that will send FDA-approved abortion pills to your home for $5. It sounds absolutely bananas.”
She calls this “the legitimacy challenge,” and it breaks her heart to think of how desperately people want to believe. Several times a week, she says, “we’ll have patients who email us saying, ‘I just paid my last $5. Please don’t be a scam.’ And we email ’em back and say, ‘We’re not—promise.’”
On Friday, May 1, two weeks after my visit, the ultra-conservative 5th Circuit granted Louisiana’s request to suspend FDA rules allowing mifepristone to be prescribed and dispensed via telehealth. It was one of the nightmare scenarios the movement had been dreading since Dobbs: a rogue ruling by an extremist court that could catastrophically disrupt care for tens of thousands of patients. Nearly two-thirds of abortions in the US now involve the two-drug regimen, and almost 30 percent occur via telemedicine; in states with the harshest laws, it’s almost 100 percent.
“There was a tremendous amount of scrambling, a lot of panicked people,” says Susan Yanow, The MAP’s director of community engagement and an abortion access pioneer. The ruling’s timing—just before a weekend and at the beginning of the month—was guaranteed to cause maximum havoc. Hundreds of The MAP’s patients had started ordering pills earlier in the week but were waiting for their paychecks to send in their money. Now they were in limbo.
But the ruling didn’t affect the other medication in the standard abortion-pill regimen, misoprostol. Foster knew from her decades spent working in global settings that misoprostol is a highly effective and safe abortifacient on its own. And because it has so many other uses, from treating ulcers to inducing labor and stopping postpartum hemorrhages, it is relatively easy to obtain and difficult for abortion opponents to control. If the Supreme Court didn’t step in, The MAP and other telemedicine providers had a backup plan. “We’re prepared to switch to misoprostol alone if we need to,” Foster had said back in Boston. “No precompliance.”
That weekend, Yanow deployed volunteers to pack mailers with jars of misoprostol alone. Meanwhile, Foster reached out to patients and answered their frantic questions: If their mifepristone was already in the mail, would the Postal Service still deliver it? Was misoprostol a real abortion pill? New medication instruction sheets had to be finalized, patient consent forms resubmitted, and The MAP’s website revamped. Foster also recognized a rare chance to generate much-needed data about misoprostol-only abortions via telemedicine in the US, so she designed a study that could compare the experiences of a thousand MAP patients on the single-drug protocol with the same number using the two-drug regimen.
“There are people who tend to say, ‘Oh my gosh, the boat’s going down!’” says Yanow, who’s known Foster for more than 25 years. “Angel is one of the people who looks around and says, ‘Okay, where’s the opportunity? How can we fix this?’”
“It made me so happy, when he wrote, ‘They’re undermining Dobbs.’ I was like, yeah, exactly.”
As it turned out, SCOTUS wasn’t ready to take the politically dangerous step of stopping telemedicine abortions—yet. After temporarily pausing the 5th Circuit ruling, the justices issued a one-paragraph order in mid-May that kicked the case back to the lower courts. For the foreseeable future, mail-order mifepristone remained legal. Justice Samuel Alito, the anti-abortion hardliner who authored the Dobbs decision, vociferously dissented, railing about how providers like The MAP had “perpetrat[ed] a scheme” to circumvent the red-state bans that Dobbs made possible.
“It made me so happy,” Yanow says, “when he wrote, ‘They’re undermining Dobbs.’ I was like, yeah, exactly.” As terrifying as the Louisiana case had been, Foster says, it was also confirmation of the abortion access movement’s surprising resilience. (The study could wait for another time.) “I was really proud of the different groups within the [abortion] ecosystem,” she says. “I’m really proud of how everyone rallied to make sure that patients could continue to get care.”
Now 52, Foster has spent decades helping to build and fortify that movement, often behind the scenes as a researcher, strategist, collaborator, and cheerleader, more recently as one of its most visible innovators. Four years after Dobbs, the infrastructure that she and her allies started creating in the 2010s includes mail-order abortion-pill providers, online information clearinghouses, and training initiatives for doctors and community activists. Abortion funds have helped hundreds of thousands of low-income patients pay for care and travel across state lines. Medical and legal hotlines have kept untold numbers out of emergency rooms and jails. New systems have emerged for tracking abortion trends, as well as research initiatives to improve delivery of care. The sum of the parts, another abortion access leader tells me, has been “revolutionary.” Far from buckling under Dobbs, she says, the access movement has created “a whole new way of doing healthcare.”
The “deep irony,” Foster says, is that if the Dobbs ruling had been narrower, “I think we would be in a very different situation.” Had SCOTUS simply upheld the 15-week ban at the heart of the Dobbs case, she suspects Americans—and the mainstream pro-choice movement—would have adapted as they had to all the other incremental restrictions on Roe over five decades.
Instead, the extremism of the decision galvanized “a new kind of creative thinking,” she says—ideas such as shield laws, blue-state statutes that protect abortion providers who deliver care to patients from places where abortion is restricted or banned. Almost every Democratic-run state now has some type of shield law, and eight states explicitly protect telemedicine. By trying to crush abortion in much of the US, conservatives have paradoxically created the conditions for patients and advocates to wrest control of abortion care from the medical and legal systems that have sought to restrict it.
The result, Foster says, is that although abortion rights have been drastically curtailed in much of the country, abortion access has significantly expanded in some of the most unlikely places. Foster’s favorite example is Mississippi, where the Dobbs case originated. In 2022, the state had a single abortion clinic, Jackson Women’s Health Organization, the other party in Dobbs. Women there are among the poorest in the country, and the cost could be prohibitive—an average of $600 for the abortion itself, plus travel, childcare, and time off. (For context, a minimum-wage worker in the state earns $290 a week before taxes.)
Now, with telemedicine and sliding-scale fees, “you can get abortion pills sent to your home for $5,” Foster marvels, “without having to go through all the steps that were required for in-clinic care.” Since April 2022, clinician-supported abortions in Mississippi, as tabulated by the Society of Family Planning’s #WeCount project, have risen a mind-boggling 85 percent—all thanks to telemedicine. Across the US, according to the #WeCount data, abortions are up 16 percent.
None of this is to suggest that the end of Roe has been good for reproductive care, and many people I talked to worried that the abortion access victories of the Dobbs era will be misconstrued or that the herculean efforts required to achieve them will be minimized. For women with uncomplicated pregnancies in their first trimester who have some access to technology, “it’s just not as bad as you thought it was going to be,” says Tracy Weitz, an abortion policy expert who teaches at American University, “and in some ways, in some places, it’s actually better.”
But for the 70 percent of abortion patients who can’t or don’t want to rely on telemedicine—if, for example, they are later in pregnancy or have medical conditions that require clinic-based care—the picture isn’t nearly as rosy. Criminalization of pregnancy loss is on the rise. Harsh laws have wreaked havoc on medical training and emergency obstetric care. “People with wanted pregnancies are at far more risk than people with unwanted pregnancies,” Yanow says. “Because if you want to be pregnant and something goes wrong, you can’t manage it yourself. You have to have somebody empty your uterus. When doctors don’t know how to empty a uterus, pregnant people die.”
“People with wanted pregnancies are at far more risk than people with unwanted pregnancies. Because if you want to be pregnant and something goes wrong, you can’t manage it yourself.”
Foster is the first person to agree with the grim assessments. But she also sees an opportunity to “be the change we want to see in a dysfunctional US healthcare system.” She returns to this theme often. How can the access movement rectify the most glaring social, racial, and economic inequities of the Roe era? “We can use this to build back better,” she says. “What do we want to see this system look like? How can we do this differently?”
![Seen over the shoulder of a volunteer, a handwritten purple note card reads, "Wishing you the best! [Heart drawing] The Map."](https://www.motherjones.com/wp-content/uploads/2026/07/20260801_Post-Roe_g.jpg)
Foster started thinking about abortion access when she was 10. That’s when her mother, Nancy, told her about her own illegal abortion in Mexico in the late 1960s. To pay for the procedure—$300, the equivalent of almost $3,000 today—she had to sell some of her possessions. Then she was robbed at knifepoint by one of the gangs that preyed on American women crossing the border with purses full of cash. She returned to Los Angeles, sold more stuff, and eventually got the abortion. The whole experience “was terrifying,” Nancy tells me, and deeply disturbing to her daughter. “My mom was the most important person in the world to me,” Foster says. “And I thought, ‘I want to be an abortion provider so nobody has to go through what my mom went through.’”
As an infant, she and her mother spent months traveling from Australia, where Foster was born, through Asia and Europe, back to the US. “I can’t tell you how many women around the world held her when she was a baby,” Nancy says. “I can’t help but think that molded her.” In high school in Portland, Oregon, in the early 1990s, Foster won a scholarship to Jordan, where she spent time with Palestinian refugees and orphans and decided she wanted to be a humanitarian as well as a doctor. Her undergraduate studies at Stanford took her to labor-and-delivery wards in Egypt filled with women her own age suffering from sepsis and perforated uteruses—“the consequences,” she says, “of abortion bans.” As a Rhodes scholar at Oxford, her focus turned to Tunisia, an Islamic country that had integrated abortion into its health system, leading to some of the best maternal and infant outcomes in the region. “I was just desperately curious,” she recalls. “How did this happen?”
She had just begun her medical studies at Harvard when, in September 2000, the FDA approved mifepristone for use in the US. Despite the thrilling possibilities that abortion pills presented, the restrictions on its use were disheartening, as was the dearth of medical school training for abortion, “even in blue, blue Boston.” She threw herself into activism and met Yanow, a founder of what was then called the Abortion Access Project (now the Texas-based nonprofit Provide), who was organizing a training with chapters of Students for Choice. “Every year, [the students] would say they would do things,” Yanow recalls, “and our staff did 99 percent of it.” So when Foster volunteered to help, Yanow was skeptical. “But within a week and a half, Angel produces this rock-star list of speakers.” She even came up with tabletop centerpieces made from gourds. Yanow decided, “This is the woman for me.”
When Foster was in her second year at Harvard, she accepted a job—on top of her studies—leading the Middle East portfolio for a new research group called Ibis Reproductive Health, which put her in a global network of researcher-advocates working to make medication abortion more accessible worldwide. Much of that work became the foundation on which The MAP is built. “We don’t usually think of low-resource humanitarian settings as having lessons for the United States,” she says. “But that’s absolutely what’s happened here.”
“We don’t usually think of low-resource humanitarian settings as having lessons for the United States. But that’s absolutely what’s happened here.”
One groundbreaking project took her to a Burmese refugee settlement on the Thai border, where illegal abortions and postpartum hemorrhages contributed to horrific rates of maternal mortality. Her friend Cari Sietstra, founder of Law Students for Choice, had reached out for help figuring out how to train people in the settlement to use misoprostol to bring down maternal deaths. Together, they created a community-based distribution network to get the drug into the hands of 918 abortion patients over three years, then studied how the women fared. More than 96 percent of the abortions were successful, meaning the pregnancy ended without the need for a follow-up procedure. Foster is “fearless,” says Sietstra, who now heads an incubator called Innovations in Reproductive Health Access, “a true ride-or-die.”
When Foster and a different group of colleagues replicated the project in rural Pakistan, the misoprostol-only success rate was 100 percent. Before then, misoprostol’s promise as an abortion drug in crisis settings was undercut by the lack of rigorous studies, but this research proved it could be used safely even where there wasn’t access to backup care.
The findings completely contradicted the American anti-abortion activists’ cherished narrative that medication abortion was so dangerous that it needed to be strictly controlled, if not banned. According to Foster’s research, “demedicalizing” abortion pills—her preferred term vs. the “self-managed” framing often used—didn’t make them unsafe, any more than had demedicalizing Tylenol in 1960. “We began to feel very confident in no-touch, no-test protocols and the idea that routine ultrasound, bloodwork, or physical examinations were not necessary,” she says. Almost more important was the element of patient autonomy.
At The MAP, Foster has returned to one of the key lessons from this time: If this model of care worked in resource-starved villages and refugee camps with minimal medical infrastructure, she knew it would succeed in places with smartphones, paved roads, and functioning postal systems. “If we can trust illiterate and semi-literate women from eastern Myanmar to make decisions about their own bodies,” she asks, “how is it that we can’t trust women in Texas to do the same thing?”
When Foster joined the University of Ottawa health sciences faculty in 2011, Canada presented a fascinating opportunity to help improve access to medication abortion on a nationwide scale. It had a single-payer healthcare system that was the envy of American progressives. On the other hand, it hadn’t decriminalized abortion until 1988, and it still hadn’t approved mifepristone 11 years after the FDA had done so. A major part of Foster’s new job was to help build the research argument for the drug’s acceptance. Canadian authorities finally gave their blessing in 2015.
Foster’s reach expanded in 2020, when she came to rescue of Perspectives on Sexual and Reproductive Health, one of the few journals publishing high-level, peer-reviewed studies on abortion. When the Guttmacher Institute decided to shut it down, “there was a panic” among researchers, says Weitz, a close friend of Foster’s for 20 years, “and of course, people looked to Angel, and she gets the University of Ottawa to take it.” She and Weitz are now the editors, focusing exclusively on abortion-related topics around the world.
The leak of the draft Dobbs decision in May 2022, just as the National Abortion Federation was a winding up its first in-person meeting since the pandemic, was “huge gut punch,” Foster recalls. As a member of the federation’s board, she was in the middle of the planning frenzy that followed: “What do we do? How do we move on this?” The final decision a month later stunned her with its “cruelty.” Not only did it overturn 50 years of precedent, “in so many places, there was an immediate change in policy with no consideration to what was happening to actual people and patients and providers on the ground.”
Then Massachusetts enacted its shield law in July 2022, the first in the country to explicitly protect telemedicine providers, and Foster saw a perfect opportunity to operationalize her middle-finger rage. After kicking around a few ideas with Weitz and others, including for an abortion-pill pharmacy, she settled on creating an organization—that would become The MAP—offering telemedicine nationally, supported by the new Massachusetts law. It would operate within the formal medical system but use a demedicalized model. “It was like, ‘We’ve got this law. It seems strong, but if nobody leans into it, we’ll never show its strength.’”
“It was like, ‘We’ve got this law. It seems strong, but if nobody leans into it, we’ll never show its strength.’”
Foster already had an essential piece of infrastructure in place—Cambridge Reproductive Health Consultants, a research nonprofit she had co-founded with Sietstra years before to do politically sensitive work, including a study on the lack of abortion access for Peace Corps volunteers. She also had an impressive brain trust. Foster’s co-founder was a nationally known abortion provider who needed to stay in the background to protect her family. Yanow, a social worker by training, had spent decades leading initiatives to expand access for marginalized communities around the country, inspired in part by the killing of a young woman she’d been mentoring, in an abortion clinic shooting spree in 1994.
Dr. Maureen Paul, an OB-GYN who had served as the medical director for three Planned Parenthood affiliates across the country, assumed the same role for the new organization. Paul’s passion for abortion access dated to her own experience as a pregnant 18-year-old in pre-Roe Massachusetts, when women hoping for a hospital abortion had to make their case to a special committee. “The social worker came back from the committee hearing and said, ‘They denied your request, but you can go to England or Puerto Rico to have an abortion,’” Paul recalls. “And she might as well have said, ‘You can go to the moon.’” Paul carried the pregnancy to term and gave up the baby for adoption—a heartbreak that, all these years later, remains close to the surface. After Dobbs, when she was looking for a way to channel her fury, The MAP “checked all the boxes.”
Lawyers in the pro-choice mainstream were less enthused, Foster says, fretting that shield laws were untested in the courts and might end up hurting the entire abortion movement. “I finally had to say, ‘We are going to do this, I don’t want to hear about how we can’t,’” she tells me. To get the full protection of the Massachusetts law, Foster and the team decided The MAP would be completely Massachusetts-based, from the doctors prescribing the medication to the malpractice insurer paying the legal bills if anyone got prosecuted or sued. This contrasts with the largest telemedicine provider, Aid Access, which has partner doctors scattered around the US but is based in Europe.
The downside was that The MAP would also have to comply with Massachusetts laws they disagreed with, such as the state’s parental involvement law for patients under 16. The goal was to show the law’s strength without provoking a backlash—to be fearless but not reckless.
As an added layer of protection, the team adopted a distributed-risk model, meaning that every step of The MAP’s operations was performed by a different person—from prescribing pills to packing shipments and lugging them to the post office. Although Foster is an MD, she is not a practicing clinician, nor is she one of the five prescribers. “To the outside world,” she says, “it is really hard to identify an individual person who provided pills to an individual patient.” Crucially, the team was the first in the US to leave doctors’ names off drug and shipping labels, making it much harder for someone in a red state to target them for legal action. If, say, a suspicious boyfriend in Texas finds a mailer and Googles “The MAP,” instead of being directed to abortion-related content, he might be drowned in links to actual maps. Seven states have now adopted similar protections as part of their shield laws.
One of the biggest innovations is the pricing structure. For the first year after its 2023 launch, The MAP charged $250 a patient—enough to more or less break even. Then Foster and the team convinced foundations and abortion funds to finance a bold experiment: dropping the cost of pills to a maximum of $150 per patient with a sliding scale that allows people to pay as little as $5 an order, though if a patient can’t afford even that, The MAP will send pills anyway. “It’s a very feminist vision of empowerment,” Yanow says. The team makes up the difference by constantly fundraising—a business model that requires Foster to be front and center.
The vast majority of patients use the medication immediately to end a confirmed pregnancy. But The MAP offers other options as well. Women who think they might be pregnant but can’t take a test or don’t want to know can pay $75 for “period pills”—the same drugs that induce abortions can be used to “bring down” missed periods. Or for $150, patients can purchase medication to stash away for future use. Orders for “just-in-case” pills tend to spike after seismic events like the 2024 election or the Louisiana-FDA scare. It turns out that bad news about abortion is a form of free publicity, getting the word out to women who might otherwise not have known The MAP existed.
Amid it all, Foster must also contend with the ever-present legal risks. While she has not (yet) been charged or sued by red-state authorities, Cambridge Reproductive Health, as The MAP’s official sponsor, has received cease-and-desist orders from Alabama and Arkansas. Other providers in New York, California, and Delaware have been targeted by authorities in Texas and Louisiana. Massachusetts’ shield laws, though among the strongest in the country, protect Foster only while she’s in the state, so she drastically limits how she moves within the US—her biggest regret about her work. When she travels into and out of the country, it’s always through Canada. The only state where she’ll drive a car is Massachusetts. Everywhere else, her husband of almost 27 years serves as her chauffeur, “which is a little bit of a problem for him but lovely for me, because I can work in the car.”
Travel to red states is too dangerous, which means Foster can no longer visit the woman who inspired her life’s work: her 78-year-old mother, who now lives with Foster’s stepfather in South Carolina. Last year, Foster’s beloved mother-in-law, who was Dutch, died in the Netherlands. “I was able to see her and say goodbye,” she says. “It was very hard and sad and also really beautiful at the same time, and I’m so grateful to have been a part of that.” When she and her husband were getting ready for their flight home, he asked her how she felt about the fact that if this were her mother, she wouldn’t have been able to be by her side when she died. “It was really hard to absorb,” Foster says. “Um, yeah, so I feel sad.”
Increasingly, the anti-abortion movement has been pushing a narrative that the care offered by telemedicine providers is substandard and irresponsible, leaving women to fend for themselves in emergencies and allowing them to be cajoled or tricked into having abortions they don’t want. “We are not just about mailing pills,” Paul counters, “we’re following people from start to finish, trying our best to help them get the care that they need.” She tells a story about a woman in Texas who ordered abortion pills last fall, only to have a pregnancy test after taking them come back positive. After an ultrasound, The MAP sent her a second batch of pills that also didn’t work. When she was around 10 weeks pregnant, the woman traveled to a small town in Mexico for a death in her family. She started bleeding, and a clinic diagnosed her with a type of ectopic pregnancy in which the fetus implants in cesarean scar tissue—a potentially catastrophic complication the clinic didn’t have the capacity to treat.
So the Mexican doctors sent the woman back to Texas with a picture of her ultrasound. “This is where we really bumped up against how broken the healthcare system is for people living in abortion-ban states,” Paul says. “The patient could have died from this. The fetus wasn’t viable.” But doctors at the Texas emergency room “refused to even look at the ultrasound because they said those people in Mexico don’t know what they’re doing,” Paul says. Telling the patient that bleeding during pregnancy was not unusual, they sent her home to “pray.”
Instead, she got back in touch with The MAP’s doctors, who reached out to their network of high-risk providers in the state, eventually finding someone two hours away who was willing to perform the lifesaving procedure. Paul was on the phone with the woman on and off during the long drive. “She was so afraid: ‘What if they won’t see me? Am I going to be arrested?’” The procedure went well, and the woman told them it was the best medical care she’d ever received.
“I have been an abortion provider in different settings for 40 years. I have never heard stories like the ones I hear from my patients now.”
What has surprised Paul the most about her nearly three years at The MAP, she says, is the level of desperation among her patients. “I have been an abortion provider in different settings for 40 years, and I have never heard stories like the ones I hear from my patients now.” In survey this spring, 9 percent of The MAP’s patients said they’d been victims of some type of violence or reproductive coercion in their current pregnancy. Many patients have four or more children. And the stories they share are harrowing. “I need to do this as discreetly as possible,” one woman wrote. “I’m in a relationship that I’m trying to safely get out of, and I can’t be pregnant while I do it. I can’t have a baby with him. I can’t have another baby, period.”
But the story that haunts Paul the most was from a patient in Texas who already had two small children and could afford only $9.22 for her pills. “I read this comment,” Paul says, “and sat there trying to imagine this person figuring out what it took for her to put food on the table and clothes on her kids and pay her rent, and after counting it all up, finally say: ‘I can pay you $9.22.’”
When Foster and her team launched The MAP in September 2023, Foster didn’t consider it to be just a telehealth platform. It was a demonstration project, one she hoped would inspire providers in other shield-law states to follow her lead. One of her long-term goals has been to build redundancy into the US abortion access infrastructure, which is essential to ensuring its resilience. But so far, The MAP is the only telemedicine provider of its kind, with the entire medical practice based in a single state. “I think it’s intimidating for folks to create a new practice,” Foster acknowledges. “It feels like a heavy lift.”
In June, The MAP switched to new computer software designed to streamline the patient intake process and improve protections for confidential information. To Foster’s shock, the number of orders nearly doubled to more than 6,000 patients a month, which has created enormous new pressures—for more inventory, more packing parties, and a lot more money. Instead of the $60,000 to $70,000 The MAP had to raise each month when I visited Boston last spring, it’s now closer to $120,000 a month. “That is the biggest challenge—what it means for us financially. It’s keeping me up a little bit at night, I’m not gonna lie,” she says.
There’s also the impact that comes with being a major player in a resource-starved movement. The MAP’s fee structure has made it the equivalent of a “safety-net facility,” Foster says, helping to fill a gap for low-income women that goes back to the Hyde Amendment, which banned federal funds for abortion care. But most telemedicine providers haven’t had the level of philanthropic support that makes those low prices possible, and clinics are even worse off: They rely on abortion pills—at an average charge of $600 per patient—to subsidize care for people for whom pills aren’t an option. As more patients order pills online, some clinics could be forced to close—a disaster for women who need later abortions and something the entire abortion ecosystem needs to reckon with.
At the end of June, Weitz—who as the former US program director of one of the largest funders of reproductive care, the Susan Thompson Buffett Foundation, knows the landscape better than most—convened a meeting of about 30 abortion access leaders. “It’s time for an honest conversation about what it’s going to take to make a service-delivery sector that makes sense to both the patient and to the providers,” Weitz says.
That conversation comes as the legal and political campaign to restrict mifepristone access has ratcheted up. Abortion opponents have been pressing President Donald Trump’s FDA to rescind a variety of Obama- and Biden-era rules that have made mifepristone more accessible or to overturn approval of the drug entirely. Despite decades of evidence to the contrary, they insist mifepristone is unsafe, and to buttress their case, they have been churning out junk science, claiming abortion pills are sending large numbers of patients to emergency rooms, polluting the water supply, and enabling the coercion of women. The same abortion foes are pushing for the revival of the Comstock Act, a Victorian-era anti-obscenity law that bans the mailing or transport of abortion-related drugs and supplies; it hasn’t been enforced for decades. But if it were, the result would be tantamount to a national abortion ban.
After almost two years of resisting such sweeping measures, the Trump administration has recently taken a series of steps—the nomination of Todd Blanche as attorney general, a stepped-up FDA review of mifepristone’s safety—that could signal a willingness to give conservatives what they want, possibly after the midterms.
Meanwhile, various lawsuits against mifepristone are moving through the federal courts, including the Louisiana case. The 5th Circuit is expected to issue another ruling in the not-too-distant future, and Foster and her colleagues doubt it will go any better than the last time. Until then, Foster says, they are watching, preparing, and serving as many patients as they can. “We try not to get sucked into the noise of all the things that are bad that could happen,” she says, “and just do the work.”
