Foes and defenders of abortion rights are preparing for seismic shifts in the abortion landscape.

Voters in Alabama and West Virginia on Tuesday approved "trigger" measures that could pave the way for state abortion bans if the U.S. Supreme Court overturns Roe v. Wade — a possibility raised by the appointment of Justice Brett Kavanaugh to the high court.

Even while Roe's constitutional right to abortion remains in place, abortion has become so hard to get in many parts of the country that a new online service called Aid Access quietly launched during the summer to provide prescription abortion pills by mail-order to U.S. women. Founder Rebecca Gomperts, a Dutch physician and activist, has for years run Women on Web, which ships abortion pills to women in countries where abortion is illegal.

Meanwhile, the Self Induced Abortion (SIA) Legal Team last month unveiled a helpline and website to provide information and attorney referrals for people who have ended their own pregnancies and fear they will be arrested or prosecuted.

"We know of at least 21 people who have been arrested, and some prosecuted, either for ending their own pregnancy or helping others" since 1973, said Jill E. Adams, a Berkeley, Calif., lawyer who founded the SIA team. "Now that we have the helpline, we expect we'll learn about more."

Tuesday's midterm elections illustrated the ever-deepening divide over abortion.Voters in Oregon overwhelmingly opted to preserve public funding for abortion, while Alabama passed a state constitutional amendment that recognizes "the sanctity of unborn life and the rights of unborn children." West Virginia amended its constitution to declare no right to abortion.

If Roe's legal framework is abolished, 20 other states already have laws that could be used to further restrict or ban abortion, according to the Guttmacher Institute, a research center that supports abortion rights. (Pennsylvania and New Jersey are not among the 20.)

No matter what happens, activists expect demand will only grow for medication-driven terminations, which now account for a third of all U.S. abortions. The regimen involves two drugs: Mifepristone, sold in the U.S. by Danco Laboratories and branded Mifeprex, disrupts the pregnancy, then misoprostol triggers uterine contractions that expel the grape-size fetus.

Mifepristone, branded as Mifeprex, is made by Danco Laboratories.
Danco Laboratories
Mifepristone, branded as Mifeprex, is made by Danco Laboratories.

In 2016, the Food and Drug Administration updated mifepristone's labeling to lower the dose and let women use it through nine weeks of pregnancy. But women still have to make two visits to the doctor, and they can't get the drug from pharmacies. It can only be dispensed in clinics or medical offices by specially certified health-care providers.

By contrast, Women on Web, which uses mifepristone made by an Indian company, provides pills after the woman consults online with the prescribing doctor and gets a blood test. An ultrasound is recommended, but not required. Instructions explain how to use the drugs, what to expect, and when to see a doctor if problems occur.

Gomperts did not respond to a request for an interview. But the Atlantic reported last month that Gomperts created Aid Access because she had been deluged with pleas from U.S. women. She said 600 women had so far gotten pills through the website. "She claims that every step of the Aid Access process is legal," the article said.

Whether the FDA will agree that it is legal remains to be seen. In an emailed statement, the agency said it is "evaluating the allegations to assess potential violations of U.S. law," and it "warns consumers not to buy Mifeprex online because doing so bypasses important safeguards."

The purported safeguards that limit dispensing are excessive, said Susan Wood, former director of the FDA's Office of Women's Health.

"There's been a lot of [scientific] data and experience with this medication," said Wood, now a health-policy professor at George Washington University's School of Public Health. "It's more and more clear … the restrictions should have been removed when it was relabeled a few years ago."

As part of that relabeling, the FDA's own review concluded that "medication abortion has been increasingly used as its efficacy and safety have become well-established by both research and experience, and serious complications have proven to be extremely rare."

Americans United for Life, an anti-abortion law firm, contends that the Aid Access model is not only unsafe, but in violation of U.S. postal and other regulations.

"An ultrasound should be administered before the abortion pill because otherwise, you can't rule out an ectopic pregnancy, which is very dangerous," said AUL chief legal officer Steven H. Aden.

"We're also talking to senators on Capitol Hill," he said, about federal intervention against the new web-based service.