Several years ago, an abortion rights activist got in touch with Dr. Suzanne Poppema, a reproductive rights leader retired from her Seattle-area practice. As states were passing abortion restrictions, plans were in the works for an offshore internet service that would supply abortion pills to women who couldn’t get them at home.

Would Poppema get involved?

“People tried to talk me out of this,” Poppema recalled. “You better be careful,” they told her. She could lose her license.

“You know, I’m retired,” she said last week in her home overlooking Puget Sound. “I’m about to be 74. Oh God, take my license? I don’t care.”

Poppema began acting as a consultant to Aid Access, founded by a Dutch doctor known for providing abortions on ships in international waters near countries that outlaw the procedure.

With Roe v. Wade seemingly about to be overturned, as a leaked U.S. Supreme Court draft opinion suggests, increasing numbers of women are certain to look to discreetly mailed abortion pills to get around laws seeking to stop them from ending their pregnancies. Such pills, meanwhile, could be a way doctors in Washington and other states with strong abortion protections serve these patients.

The anti-abortion movement is trying to prevent that from happening, however. Nineteen states require a provider to be physically present when dispensing abortion pills, according to the Guttmacher Institute, and an end to Roe would likely spur further limitations.

Advertising

That puts Poppema in the middle of one of the hottest ongoing abortion debates, albeit in a behind-the-scenes role: She’s not named on Aid Access’ website and doesn’t write prescriptions. Out of reach of American authorities, the Dutch doctor has handled many of the 30,000 prescription packets Aid Access has dispensed so far, according to Poppema.

More about the Supreme Court and abortion

Dr. Sarah Prager, a professor of obstetrics and gynecology at the University of Washington and a onetime intern at Poppema’s clinic, Aurora Medical Services, said she isn’t surprised by her former mentor’s involvement in Aid Access. It’s a great example, Prager said, of how Poppema has for decades been on the forefront of abortion access, asking: “What’s the next step?”

Poppema was one of the nation’s first female abortion providers soon after Roe became law in 1973, wrote a book called “Why I Am an Abortion Doctor” in which she revealed her own abortion, helped found Physicians for Reproductive Health, and trained a generation of abortion providers.

Younger doctors may not know Poppema’s name, said Deborah Oyer, medical director of Cedar River Clinics, but “she has somehow impacted every provider in Seattle’s ability to do abortions.”

Vitriol has also come her way. After the 1996 publication of her book, written with Seattle-area journalist Mike Henderson, one anti-abortion website called her “hardened and callous” and accused her of “tearing apart developed babies limb by limb.”

Advertising

After a spate of violence against abortion doctors and clinics began in the 1990s, Poppema bought a bulletproof vest.

“It crossed my mind that she might get murdered,” said her husband, Dr. John Cramer, a retired critical care physician. He said their two sons would ask: “Mom, are you going to come back OK?”

Treating ashamed patients

Once so shy that a teacher told her mother she never opened her mouth, Poppema had a feminist awakening while a student at Harvard Medical School. She enrolled in 1970, the same year the feminist women’s health book “Our Bodies Ourselves” was released, among what she said was then the largest female class ever admitted.

Roughly two dozen of her 150 classmates were women.

Poppema moved to Seattle in 1974 for a residency with a clinic providing abortions. A man ran the clinic, Poppema said, but “Seattle was a perfect place to be a budding feminist.”

Women were forming self-help groups of various sorts, and Washington voters had passed a referendum legalizing abortion through the first four months of pregnancy three years before the Roe decision.

Then, shortly after moving to Seattle, Poppema became pregnant herself.

“I could see my career plans crashing at my feet,” Poppema wrote in her book. “I was terrified at the thought of being a single mother, especially given the fact that I had always believed that having two parents is the best way to grow up.”

Advertising

The doctor who performed her abortion told her: “Suzanne, you will be such a better family physician because of this.”

Telling the story almost 50 years later, Poppema got a catch in her voice. “It meant a lot.”

Later, caring for ashamed patients, Poppema said she would tell them: “You’re making a decision that is right for you at this time in your life. That doesn’t make you a bad person.”

Poppema went to France in 1989 to observe patients being given mifepristone, an abortion drug just approved there. Five years later, her clinic started participating in U.S. trials.

“I thought this is it. This is going to change the face of the abortion world,” she said.

Providers don’t need surgical skills, and patients can take mifepristone and a second drug given up to 48 hours later, misoprostol, at home. The effect is the same as a spontaneous miscarriage.

Sponsored

The U.S. Food and Drug Administration in 2000 approved the use of mifepristone, which blocks a hormone needed for the pregnancy to continue and causes fetal tissue to detach from the uterine wall, up to the 10th week of pregnancy.

Misoprostol, which causes contractions, was already widely available for various uses, including the treatment of miscarriages in cases where the tissue isn’t fully discharged.

But the FDA put restrictions on the use of mifepristone. Among them: a specially certified health provider had to give the pill to patients in person.

“It really dashed our hopes,” Poppema said.

Still, medication abortion gradually grew in use. In 2020, it accounted for 54% of U.S. abortions, according to the Guttmacher Institute, a research organization focusing on reproductive health.

Surging demand

Serving on a part-time, volunteer basis for Aid Access, Poppema looks over lengthy online intake forms to spot cause for caution: medication allergies, for instance, or health risks. If none exist, Aid Access offers the pills for a sliding-scale fee that tops out at about $100.

Poppema said she insisted Aid Access give this instruction: “If you seek emergency care, do not say anything about taking pills. No one can detect them. And you will be treated much more nicely.”

Advertising

There is no reason to mention the drugs because the complications and treatment are exactly the same as a spontaneous miscarriage, she said. Drs. Oyer and Prager both agree.

“There is absolutely nothing to gain if a patient divulges this information, and in many states, that disclosure could put the patient, and possibly health care providers, at risk for prosecution,” Prager said.

Aid Access also tells patients about a hotline, staffed by Poppema and other volunteer doctors, they can call if they need help.

The FDA in 2019 ordered Aid Access, which uses an Indian drug company, to stop selling Americans pills that aren’t approved in the U.S.

The FDA hasn’t enforced its order but said it “remains very concerned about the sale of unapproved mifepristone.”

Such drugs, the agency said in an email, “are not subject to FDA-regulated manufacturing controls or FDA inspection of manufacturing facilities.”

Advertising

Last year, with COVID-19 raging, the FDA lifted its requirement that mifepristone be given in person, clearing the way for mailing the pills. More American doctors got involved with Aid Access and several new online medication abortion providers, Poppema said.

But the FDA left other contested restrictions in place, most notably that providers have to be specially certified to prescribe mifepristone.

The decision set off a firestorm, with anti-abortion activists saying it opened the door to dangerous, unsupervised abortions, and those on the other side contending the FDA was clinging to unnecessary obstacles.

States continued erecting their own obstacles, like outlawing telemedicine for medication abortion and effectively requiring providers be locally licensed.

Still, demand has surged at Aid Access, which now sends out 1,200 to 1,600 pill packets a month — more than it used to distribute in an entire year, according to Poppema.

Initially, she said, patients came largely from Texas, which allows private citizens to sue anyone who helps facilitate an abortion after about six weeks of pregnancy. But now patients come from everywhere, including Washington, Oregon and California.

Advertising

Between 5% and 10% of requests to Aid Access over the last several months have been from women who want to have pills on hand just in case they get pregnant and face abortion restrictions triggered by the end of Roe, according to Poppema. Aid Access serves these women too.

Poppema, who expects an increase in Aid Access patients if Roe is reversed, sees abortion advocates’ next step as persuading the FDA to drop restrictions preventing all health care providers and pharmacies from dispensing abortion pills.

Then, she said, providers throughout the country could call in prescriptions to states with abortion bans under the guise of “miscarriage management.”

Poppema said pharmacists couldn’t ask questions because of the federal patient privacy law. As for people who might sue because the pills were used for abortion, she asked, “How the hell would they prove that? Just curious.”