In states that have banned abortion, some women with unwanted pregnancies seek an unconventional solution: they “manage” their abortions themselves, look up the necessary know-how online, and obtain the drugs without the supervision of a clinic or a doctor.
On the surface, the practice is reminiscent of 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 drug abortion—achieved with drugs rather than in-office procedures—has transformed reproductive care, posing a significant challenge to anti-abortion laws.
Even before the Supreme Court’s decision to reverse Roe v. Wade, drug abortions accounted for more than half of abortions in the United States. Federal regulators made access to the pills even easier during the pandemic by dropping the requirement for an in-person visit and mailing the drugs to patients after a virtual appointment.
But many states have never allowed telehealth abortion, and new laws banning abortion apply to all forms of the procedure, including medications. So women in increasingly restrictive parts of the country buy the pills by any means necessary, often online, despite state bans.
According to the Guttmacher Institute, which researches and supports access to abortion, there are no reliable estimates of the number of women who perform their own drug abortions.
With the destruction of Roe v. Wade, abortion is now banned in at least 10 states, according to a database maintained by DailyExpertNews. Kansas voters on Tuesday rejected a ballot measure that would have removed protections for abortion rights from the state constitution.
Nevertheless, restrictions of one kind or another are expected in at least half of the US states, so both sides of the divide are bracing for an increase in the number of self-selected abortions.
Critics of abortion in any form insist that drug abortions are more risky than claimed, and even more so without medical supervision. The procedure should not be performed after 10 weeks of gestation, they note, or performed without a doctor’s visit, as it is not always possible to accurately date a pregnancy.
Other medical complications can be missed, they say — including ectopic pregnancy, in which the fertilized egg implants outside the uterus.
Claims that drug abortion is safe “are based on flawed and incomplete data, which prioritize convenience and cost over patient health and safety,” said Dr. Christina Francis, president of the American Association of Pro-Life Obstetricians and Gynecologists, who opposes all abortions except to prevent permanent injury or death to the mother.
Doctors who support abortion tell a different story: There is abundant evidence that drug abortion is safe, and women already perform the procedure almost all by themselves at home, even when they see a doctor to obtain the drugs. Self-management is not that different, argue proponents.
“It’s quite safe and effective based on studies we’ve done, national data provided by the states and the Guttmacher Institute, and the experience of other countries,” said Dr. Beverly Winikoff, the founder of Gynuity Health Projects, who led much of the research into abortion medication that led to its adoption in the United States more than 20 years ago.
Read more about abortion issues in America
The procedure usually involves taking two medications: mifepristone, which stops the pregnancy by blocking a hormone called progesterone, followed a day or two later by misoprostol, which causes the uterus to contract.
In the United States, more than half a million women had drug abortions by 2020, and less than half of 1 percent will experience serious complications, studies show. Medical interventions such as hospitalizations or blood transfusions were required for less than 0.4 percent of patients, according to a 2013 review of dozens of studies involving tens of thousands of patients.
Medication abortion “is non-invasive, does not cause sepsis, and does not rupture internal organs,” like the illegal abortions of the pre-Roe era, said Dr. Winikoff.
“It doesn’t mean people can’t bleed excessively and need care now and then, but those aren’t the atrocious conditions of people 50 years ago,” she added.
However, the drugs are regulated by the Food and Drug Administration and are intended to be taken under a doctor’s supervision. The agency is discouraging internet purchases of mifepristone because patients “bypass important safeguards,” officials said in a statement.
But the FDA does not recommend online purchases of misoprostol (brand name Cytotec), which is used to treat a number of medical conditions. Misoprostol can terminate pregnancies on its own, recent studies have shown.
While no treatment is 100 percent safe, taking the pills alone at home doesn’t affect your risk of complications, says Dr. Carolyn Westhoff, an obstetrician gynecologist and professor at Columbia University and editor-in-chief of the journal Contraception.
But self-management also means that a woman does not have a trusted health care provider nearby to call in case of emergency or complications. dr. Westhoff and other experts fear that women who perform their own abortions will be reluctant to seek medical help in states that have criminalized abortion.
Cassie, 20, who uses the pronouns she and she and asked to only use a first name because they live in Texas, where most abortions are banned after about six weeks of pregnancy, arranged their own abortion in January.
Cassie, who already had a child and was struggling financially, filled out an online abortion pill application form from Aid Access, which is based in Europe. The drugs took longer than expected to arrive, and when they did, Cassie’s pregnancy was already 12 weeks away.
“I just took them and prayed for the best,” Cassie said. They had heavy bleeding, nausea, and “the worst cramps I’ve had in my entire life.”
“I was crying, curled up in a ball of pain in the middle of my bed,” they said.
When the bleeding did not subside, Cassie’s partner took them to the hospital, where the remaining tissue was removed.
“That was his own horrible experience of praying that they wouldn’t know or suspect I caused it myself,” Cassie said.
Both the know-how and the tools to perform an abortion are increasingly accessible.
Women living in states where abortion is legal can turn to U.S. telehealth providers such as Abortion on Demand and Hey Jane, who provide detailed information to women seeking abortions and mail pills after video visits in states where these services are legal.
MYA Network provides doctors answering questions about elective abortion, and Abortion Pill Info provides tips for keeping online research private.
For women in abortion-banned states, Plan C offers a number of solutions, including a list of online pharmacies that sell abortion drugs that the organization has tested and tutorials on setting up mail forwarding in another state to receive the drugs.
The site also references Aid Access, which screens women online and orders abortion pills from foreign pharmacies to ship in return-address envelopes, even to states where abortion is illegal. The group charges $150 or less, depending on income.
Hannah, a 26-year-old in Oklahoma, said she arranged her own abortion with Aid Access pills late last year when local clinics, overrun with patients from Texas, were unable to accommodate her.
Hannah, who asked not to be identified because abortion is now banned in her state, said she suffered from occasional depression before becoming pregnant but had plunged to new lows and was suicidal.
“I couldn’t afford a pregnancy and wasn’t well enough physically or mentally to carry a pregnancy,” she said. Her self-selected abortion was “no worse than a normal period for me.”
A drug abortion is indistinguishable from a miscarriage, and traces of the pills cannot be detected when taken orally, says Dr Rebecca Gomperts, a Dutch doctor who founded Aid Access.
If a woman needs care after taking the pills, “we always tell people to say they’ve had a miscarriage,” she said. “It’s 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 health care provider without a face-to-face visit during the pandemic found the practice to be safe.
Complications are the rare exception. Another recent study looked at self-managed abortions in Argentina and Nigeria, where abortion is banned except to save the mother’s life (and, in Argentina, in cases of rape).
Twenty percent of the nearly 1,000 women who took part in the study sought care in hospitals after the procedure, but most just wanted to confirm that the abortion was complete. About 4 percent reported persistent pain, fever, or bleeding. According to the study, published in The Lancet Global Health in late 2021, it took 17 procedures to complete the abortion, 12 stayed overnight in the hospital and six required blood transfusions.
The surprising finding was that although some women took the mifepristone-misoprostol combination, the success rate for those taking misoprostol alone — a common drug that can be bought over the counter in countries like Mexico and is fairly cheap — was higher than that of the combination of two drugs.
Most state laws restricting abortion make performing an abortion a crime for doctors, not patients. Only three states – South Carolina, Oklahoma and Nevada – have laws that explicitly make it a crime to terminate one’s own pregnancy.
However, other states have enacted child endangerment statutes or other laws against women suspected of terminating their pregnancies.
In Indiana, Purvi Patel was sentenced to 20 years in prison in 2015 for inciting a self-selected abortion; her conviction was quashed in 2016. A murder charge against Lizelle Herrera was filed in Texas earlier this year in connection with a self-selected abortion, but prosecutors said they would not pursue the case.
At least six states have passed legislation identifying a fetus as a person, making it easier to prosecute women who terminate their own pregnancies, said Dana Sussman, the deputy executive director of National Advocates for Pregnant Women.
Both the American Medical Association and the American College of Obstetricians and Gynecologists, which support abortion as an essential part of health care, oppose criminalizing self-monitored abortion, saying it will deter women from seeking medical attention.
Currently, health care providers are not legally required by any state to report patients they suspect have performed an abortion themselves, according to If/When/How, an abortion rights advocacy group. But laws are in flux.
“We operate in an area of complete uncertainty,” Ms Sussman said.