In states that have banned abortions, some women with unwanted pregnancies are seeking an unconventional approach: they “self-manage” their abortions by seeking the necessary know-how online and obtaining medication without the supervision of a clinic or doctor.
At first glance, the practice may recall the days before Roe v. Wade, when women were too often forced to take risky measures to end an unwanted pregnancy. But the advent of medical abortion — which is performed with drugs rather than in-office procedures — has transformed reproductive care, posing a significant challenge to abortion law.
Even before the Supreme Court overturned Roe v. Wade, medical abortions accounted for more than half of abortions in the United States. Federal regulators have made access to the pill even easier during the pandemic by removing the in-person visit requirement and allowing the medication to be sent to patients after a virtual appointment.
But many states have never allowed telemedicine abortions, and the new laws banning abortions apply to all forms of the procedure, including medication. So women in increasingly restrictive parts of the country are acquiring the pill any way they can, often online, despite state bans.
According to the Guttmacher Institute, which researches and supports abortion access, there are no accurate estimates of the number of women who self-abort.
Abortion has been banned in at least 10 states since Roe v. Wade was overturned, according to The New York Times database. Kansas voters on Tuesday rejected a ballot measure that would have removed protections for abortion rights from the state constitution.
Still, some form of restriction is expected in at least half of the US states, and so both sides of the divide are bracing for an increase in self-administered abortions.
Critics of abortion in any form insist that medical abortions are more risky than claimed, especially without medical supervision. They note that the procedure should not be performed after 10 weeks of pregnancy, or performed without a doctor’s visit, because accurate dating of pregnancy is not always possible.
They say other medical complications can be missed, including an ectopic pregnancy, in which a fertilized egg implants outside the uterus.
Claims that medical abortion is safe “are based on flawed and incomplete data that prioritize convenience and cost over the health and safety of patients,” said Dr. Christina Francis, pro-life chairwoman of the American Association of Obstetricians and Gynecologists. which opposes all abortions except to prevent permanent harm or death to the mother.
Pro-abortion doctors tell a different story: There is overwhelming evidence that medical abortion is safe, and women already perform the procedure virtually alone at home, even if they go to a doctor for medication. Self-government isn’t that different, proponents argue.
“It’s quite safe and effective, based on the research we’ve done, the national data provided by the states and the Guttmacher Institute, and the experience of other countries,” said Dr. Beverly Winnikoff, founder of Gynuity Health Projects, which has done much of the medical abortion research that led to its approval in the United States more than 20 years ago.
Read more about abortion issues in America
The procedure usually involves taking two drugs: mifepristone, which ends the pregnancy by blocking a hormone called progesterone, and a day or two later, misoprostol, which causes the uterus to contract.
Research shows that more than half a million women had medical abortions in the United States in 2020, and less than half of 1 percent experienced serious complications. According to a 2013 review of dozens of studies involving tens of thousands of patients, less than 0.4 percent of patients required medical interventions, such as hospitalization or blood transfusions.
Medical abortion is “non-invasive, doesn’t cause sepsis and doesn’t cause internal organ ruptures” like illegal abortions in the pre-Roe era, Dr. Vinikov said.
“That’s not to say that people can’t have excessive bleeding and need help from time to time, but it’s not as dire a circumstance as people 50 years ago,” she added.
However, the drugs are regulated by the Food and Drug Administration and are meant to be taken under the supervision of a doctor. The agency does not recommend buying mifepristone online because patients would “bypass important security measures,” officials said in a statement.
But the FDA advises against buying misoprostol (brand name Cytotec) online, which is used to treat a number of conditions. Recent studies have shown that misoprostol can terminate a pregnancy on its own.
While no treatment is 100 percent safe, taking the pill “alone at home does not affect the risk of complications,” said Dr. Carolyn Westhoff, an OB/GYN professor at Columbia University and editor-in-chief of the journal Contraception .
But self-management also means that a woman doesn’t have a familiar medical professional nearby to call in the event of an emergency or complications. Dr. Westhoff and other experts worry that women who self-abort may be reluctant to seek medical care in states where abortion is criminalized.
Cassie, 20, who uses the pronouns they and them and asked to use only her first name because they live in Texas, where most abortions are illegal after about six weeks of pregnancy, had her own abortion in January.
Cassie, who had already given birth and was struggling financially, filled out an online form to request abortion pills from Aid Access, based in Europe. The medication took longer than expected to arrive, and when it did, Cassie was already 12 weeks pregnant.
“I just took them and prayed for the best,” Cassie said. They had profuse bleeding, nausea and “the worst cramps I’ve ever had in my life.”
“I cried, curled up in a ball of pain in the middle of the bed,” they said.
When the bleeding didn’t stop, Cassie’s partner took them to the hospital, where the remaining tissue was removed.
“It was my own horrible experience of praying that they wouldn’t find out or suspect that I did it myself,” Cassie said.
Both the know-how and the tools to perform an abortion are becoming increasingly available.
Women who live in states where abortion is legal can turn to US telemedicine providers such as Abortion on Demand and Hey Jane, which offer detailed information to women seeking abortions and deliver pills by mail after a video visit in states where these services are legal.
The MYA network offers doctors to answer questions about self-abortion, and information about the abortion pill provides advice on how to keep online research private.
For women in states where abortion is illegal, Plan C offers a number of workarounds, including a list of online pharmacies that sell abortion drugs that the organization has vetted and tutorials for setting up mail order in another state to receive the medication.
The site also directs people to Aid Access, which screens women online and orders abortion pills from overseas pharmacies, sent in self-addressed envelopes, even to states where abortion is illegal. The group charges $150 or less, depending on income.
Hannah, a 26-year-old woman from Oklahoma, said she had an abortion with Aid Access pills late last year when local clinics overwhelmed with patients from Texas couldn’t take her.
Hanna, who asked not to be identified because abortion is now illegal in her state, said she had suffered from depression at times before the pregnancy, but had sunk to a new low and was suicidal.
“I couldn’t afford the pregnancy and I wasn’t well enough, physically or mentally, to carry the pregnancy,” she said. Her self-induced abortion was “no worse than a normal period for me.”
A medical abortion is indistinguishable from a miscarriage, and traces of pills are undetectable when taken orally, said Dr Rebecca Gomperts, the Dutch doctor who founded Aid Access.
If a woman needs care after taking the pill, “we always tell people to say they had a miscarriage,” she said. “They are exactly the same symptoms and the treatment is exactly the same.”
A study of thousands of women in the United States who received abortion pills from a provider without an in-person visit during the pandemic found the practice was safe.
Complications are a rare exception. Another recent study looked at self-administered abortion in Argentina and Nigeria, where abortion is illegal except to save the life of the mother (and in Argentina, rape).
Twenty percent of the nearly 1,000 women in the study sought hospital care after the procedure, but most only wanted confirmation that the abortion was complete. About 4 percent reported persistent pain, fever, or bleeding. According to a study published in The Lancet Global Health in late 2021, seventeen required procedures to complete the abortion, 12 stayed in the hospital overnight, and six required blood transfusions.
An unexpected finding was that while some women took a combination of mifepristone and misoprostol, the success rate for those who took misoprostol alone—a widely available drug that can be purchased without a prescription in countries like Mexico and is relatively inexpensive— was higher than that of the combination of the two drugs.
Most state laws restricting abortion make it a crime for doctors to perform abortions, not for patients. Only three states—South Carolina, Oklahoma, and Nevada—have laws that make it a crime to terminate one’s own pregnancy.
However, other states have child endangerment statutes or other laws against women suspected of having an abortion.
In 2015, Purvi Patel was sentenced to 20 years in prison in Indiana for self-inflicted abortion; her conviction was overturned in 2016. In Texas, murder charges were filed against Liesel Herrera earlier this year in connection with a self-administered abortion, but prosecutors said they would not pursue the case.
At least six states have introduced legislation that defines a fetus as a person, which would make it easier to prosecute women who terminate their pregnancies, said Dana Sussman, deputy executive director of the National Organization for Advocacy for Pregnant Women.
Both the American Medical Association and the American College of Obstetricians and Gynecologists, which support abortion as an important component of health care, oppose criminalizing self-abortion because they believe it will discourage women from seeking medical care.
According to If/When/How, an abortion rights group, health care providers are not currently legally required to report patients they suspect have self-aborted. But laws change.
“We’re operating in a zone of total uncertainty,” Ms. Sussman said.