Mother Jones
Dobbs Didn’t End Abortion. It Ignited a Movement.
After spending more than four decades studying abortion in American social, medical, and political culture, Carole Joffe was fully prepared for the Supreme Court to overturn Roe v. Wade in 2022. “Dobbs itself wasn’t that scary to me,” she says. “It was upsetting and politically outrageous, but because of our work, we knew abortion wasn’t going to go away.”
What she did find frightening was a Louisiana lawsuit last month challenging the Food and Drug Administration’s rules allowing the abortion pill mifepristone to be prescribed via telemedicine and sent through the mail. In the end, the justices kicked the case back to the lower courts, but abortion advocates were reminded of how much patients around the country still have to lose. “Things since Dobbs have gone better than many of us thought, but so much of that access has been dependent on telehealth,” says Joffe, a sociologist and professor at the University of California, San Francisco. “So yes, the case felt scary, but then I got back to business as usual. ‘Abortion is still happening. Who do I want to interview?’”
Joffe’s mission is to try to understand the American abortion ecosystem through the people who populate it, including patients, providers, and fellow advocates. Her most recent book, After Dobbs_: How the Supreme Court Ended_ Roe But Not Abortion, co-written with Drexel University legal scholar David S. Cohen, tracked how that ecosystem adapted in the aftermath of the landmark ruling: the surge in abortion protections in blue states, the mobilization of activists to help patients in red states, the rage donations—and just rage—fueling it all.
Four years post-Dobbs, the right-wing legal and legislative attacks have been relentless, and the risks from the courts and the Trump administration are dire, but the abortion-access movement has proven to be more resilient than even Joffe foresaw. She points to new data from the #WeCount project showing that clinician-managed abortions approached 1.13 million in 2025, with the monthly average up 14 percent from April 2022. By the end of last year, almost 9,000 women a month were accessing care in states where abortion is banned. “David and I knew that there would still be abortions happening in the blue states, but we did not anticipate the [nationwide] numbers going up to the degree they have,” she says. “That has been astonishing.”
“Things since Dobbs have gone better than many of us thought, but so much of that access has been dependent on telehealth.”
Much of the movement’s strength is due to legal and medical innovations that have made abortion pills more accessible than ever before, including telemedicine and blue-state shield laws that protect providers in those states who care for patients from places where abortion is illegal. Cohen is one of the masterminds behind shield laws, which have been embraced by Democratic-run states. But when he and Joffe were working on their book, the laws had barely taken hold. Now, she says, “their impact can’t be emphasized enough.”
Still, those innovations have largely benefited women seeking what one recent law review article calls “everyday abortions”—those occurring for non-medical reasons, usually in the first trimester. For other segments of the population—women suffering from life-threatening pregnancy emergencies, those seeking abortions later in pregnancy, immigrants—the Dobbs era has been precarious indeed, and sometimes deadly. Nor is it clear why more abortions are happening, with some advocates worrying that women are choosing to end their pregnancies because their economic and social circumstances are so bleak. Another major fear: Self-managed abortions without sufficient medical or legal support is increasing women’s risk of being criminalized.
I reached out to Joffe by phone for an update on how Dobbs has remade the US abortion landscape—and how it hasn’t. Our conversation has been edited for length and clarity.
Let’s start with the numbers. According to the Guttmacher Institute, the last time the number of US abortions surpassed 1 million was back in 2012.
And those are just the clinician-managed abortions counted by the #WeCount project in the formal healthcare system. There are also a lot of self-managed abortions not being counted that are happening with the help of underground community networks and overseas pill-providers. If someone goes to their computer and orders from a website in India, that’s not counted. If someone gets their pills from one of those grannie expats living in Mexico who are bringing in [medication] over the border, that’s not counted.
A lot of the increase in the WeCount numbers seems to be because of shield laws.
Even though my co-author was one of the legal theorists behind them, I didn’t expect shield laws to happen so quickly and so effectively. It’s not just that shield laws and telemedicine mean women don’t have to travel, so abortion doesn’t cost as much money, and they can have privacy. There’s a provider in Massachusetts—The MAP—that offers pills for $150 but accepts as little as $5. So shield laws have also brought down the price of pills, which makes them even more accessible. I didn’t see that coming.
I was really worried that the criminal justice system in red states would go after providers, but so far, there has been remarkably little of that. I’m aware of only three criminal cases: two against shield law doctors in California and New York, and one against a midwife in Texas. There have also been some civil cases. I really hope things work out for the people being targeted. But that is not the massive wave of cases I was afraid of.
From what I hear from other advocates, the patients who have benefited most from these post-Dobbs improvements in access are women in their first trimester. Many telemedicine providers will only prescribe abortion pills through the 11th or 12th week of pregnancy, so patients who are further along may lie to get their pills or find another source, like an underground network. Who else is being left behind?
The people I most worry about are those with pregnancy emergencies—serious complications. These are not people who could get on a plane and travel from Texas to Illinois or Colorado for emergency abortion care. These are really sick women.
“Can you imagine living in Louisiana, going to your boss and saying, ‘I’m going to be gone for several days because I need to get an abortion?’ No.”
There are also patients whose social circumstances make it impossible to access telemedicine or travel out of state. Maybe you’re a single mother with several kids, and you can’t take time off work. Can you imagine living in Louisiana, going to your boss and saying, “I’m going to be gone for several days because I need to get an abortion?” No. I remember when Dobbs first happened, reading about a doctor in Texas who told his patient, “Well, you could go to New Mexico,” and the patient said something like, “If you sent a limo for me, I couldn’t leave.” Think of a woman living in her car, or someplace in the Mississippi Delta—if she doesn’t have a computer, how does she even know?
Back in 2024, you and your UCSF colleagues published a report about how doctors in Texas and other abortion-ban states were being forced to delay abortion care for pregnancy emergencies that could endanger the life of the mother. How common are those kinds of situations today?
This is something that a colleague and I are studying now. I had thought that, four years after Dobbs, these kinds of questions would be resolved. Doctors who don’t know whether they’ll be arrested if they perform an abortion while there’s still fetal cardiac activity, and wondering: How sick does a patient have to be? Some state legislatures have taken some action to clarify medical exceptions for abortion care—when women die, it’s not good publicity. So in aggregate, the situation has seemingly improved somewhat for women suffering from ectopic pregnancies and PPROM [when the amniotic sac ruptures before the fetus is viable]. But there are still too many unforgivable instances of care withheld and delayed. We won’t know the full impact of Dobbs for some time, but we do know that rates of maternal and infant mortality in Texas have significantly risen since Dobbs.
Telemedicine only accounts for 30 percent of all abortions in the US, which means that more than two-thirds of patients are still getting their care in person. But abortion pills from a clinic can cost hundreds of dollars. How can clinics compete with a shield-law provider who charges much less? And that doesn’t even take into account the cuts in federal funding for Title X and Planned Parenthood.
I am worried about the viability of the brick-and-mortar clinic. Many clinics in red states have had to close after Dobbs. Some have been able to relocate to blue states, but not all. Many clinics operate on a tight budget. While the great majority of abortions in the US occur in the first trimester, one of the most important functions that some clinics provide is abortions in the second trimester or later. As more and more patients order pills and avoid clinics, the clinics may eventually have to close, leaving the minority of patients who require later abortions in a very dire spot.
While I applaud the creation of these new models that make abortion more accessible, I mourn the possible loss of the clinic-based model of abortion care, because what I have learned from my 45 years of studying this issue is that abortion is not one-size-fits-all. Many women are fine doing it themselves. They order the pills online, they take the pills at home, and they go on with their lives. Other women need more. For example, a very religious woman who believes, “God will punish me for getting an abortion—I am a murderer,” can really benefit from talking to someone who will reassure her that she’s not going to hell. Dr. George Tiller [the Kansas abortion provider who was murdered in 2009] had a chaplain on his staff. The best clinics deliver the kind of care that some women, often very young ones, really need.
And not everybody is a suitable candidate for pills. Some people have bleeding disorders, some may have ectopic pregnancies, and some will be past the gestational age at which the pill is offered. Many of the most serious fetal anomalies are only discovered around 18 weeks. I worry that these people will get lost. Some women need to be in a clinic for the abortion experience to feel real. Some women are afraid— “I’m talking to a disembodied voice on the phone, she sounds nice, but I don’t know. My friend had a really bad reaction when she took a pill that somebody sent her.” Even though the shield laws and telemedicine have been an enormous success, there are still people going to be left out.
There’s a narrative out there that people don’t care about abortion as much as they did four years ago, or during the 2024 elections. One measure of this supposed lack of engagement is the big drop in donations to abortion-related organizations over the past couple of years. What do you make of that?
I always expected the so-called rage spending would drop off. After Roe was overturned, people were furious, and the money came pouring in. So much of that immediate mobilization we describe in After Dobbs was dependent on millions and millions of dollars in donations—for airplanes, hotels, abortion procedures or pills. I knew it couldn’t be sustained. I knew other very important issues would arise, like immigration, although I didn’t predict the savagery we’ve seen under the Trump administration. I knew that decent people giving their money to abortion would feel it was important to give it to other things as well.
That said, I think about what happened to make sure that women in red states could access abortions—the volunteer networks, the people who are willing to drive strangers to get care. The participation of everyday people. I read a touching account that almost sounded like the Underground Railroad: “Someone has to get the patient from Texas to Illinois—this person will drive her to here, and then somebody else will drive her to there.” I think of this as part of the larger resistance we’ve been seeing in the Trump era.
When you think about the future of abortion in the US, what keeps you up at night?
We don’t know what’s going to happen politically. The midterms will be really important, but even if the Democrats win the House and Senate, the courts will be the ones calling the shots. What keeps me up at night is: Will they try to enforce the Comstock Act [the 19th-century obscenity law that would amount to a national abortion ban]? Will the FDA withdraw its approval of mifepristone or get rid of the rule allowing abortion pills via telemedicine? I am terrified of shield laws going before the Supreme Court. That’s really my biggest worry.
What if there’s a crackdown on providers to the extent we haven’t yet seen? I always worry about clinic violence, but I worry more now because the anti-abortion movement is furious: “We got Dobbs, so how in the hell have abortions gone up?” I worry that Republicans and the Department of Justice will figure out how to do surveillance on people who get abortion pills: “Why does this little town in Mississippi have somebody getting a package from India?” I am a Class A worrier, so I am worried about everything that one can possibly worry about.