In states that have banned abortion, some women with unwanted pregnancies are pursuing an unconventional workaround: They are “self-managing” their abortions, seeking out the necessary know-how online and obtaining the medications without the supervision of a clinic or a doctor.
At first glance, the practice may recall the days before Roe v. Wade, when women too often were forced to take risky measures to end an unwanted pregnancy. But the advent of medication abortion — accomplished with drugs, rather than in-office procedures — has transformed reproductive care, posing a significant challenge to anti-abortion legislation.
Even before the Supreme Court's decision to overturn Roe v. Wade, medication 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 allowing the drugs to be mailed to patients after a virtual appointment.
But many states never allowed telehealth abortion, and new laws prohibiting abortion apply to all forms of the procedure, including medications. So women in increasingly restrictive parts of the country are procuring the pills any way they can, often online, despite state prohibitions.
4:38From Mexico to the U.S., an Underground Abortion Pill NetworkAs more U.S. states move to criminalize abortion, activists in Mexico have been inundated with calls from women seeking abortion medication. Our cameras went inside their distribution effort.CreditCredit...Miguel Tovar for The New York Times
There are no reliable estimates of the number of women who undertake their own medication abortions, according to the Guttmacher Institute, which researches and supports abortion access.
With the overturning of Roe v. Wade, abortion is now banned in at least 10 states, according to a database maintained by The New York Times. Voters in Kansas on Tuesday rejected a ballot measure that would have removed abortion rights protections from the state constitution.
Limits of one sort or another are nonetheless expected in at least half of U.S. states, and so both sides of the divide are bracing for an increase in self-managed abortions.
Critics of abortion in any form insist that medication abortions are riskier than claimed, and even more so without medical supervision. The procedure should not be undertaken beyond 10 weeks gestation, they note, or performed without a doctor’s visit, because dating a pregnancy accurately is not always possible.
Other medical complications can be missed, they say — including ectopic pregnancy, in which the fertilized egg implants outside the uterus.
Claims that medication abortion is safe “are based on flawed and incomplete data, which prioritize convenience and cost over the health and safety of patients,” said Dr. Christina Francis, chair of the American Association of Pro-Life Obstetricians and Gynecologists, which opposes all abortions except to prevent permanent harm or death to the mother.
Physicians who support abortion tell a different story: There is plentiful evidence that medication abortion is safe, and women already carry out the procedure almost entirely alone at home, even if they do see a doctor to obtain the drugs. Self-management is not so different, supporters argue.
“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 performed much of the research on medication abortion that led to its approval in the United States more than 20 years ago.
The procedure typically involves taking two drugs: 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.
More than half a million women had medication abortions in 2020 in the United States, and fewer than half of 1 percent experience serious complications, studies show. Medical interventions like hospitalizations or blood transfusions were needed by fewer than 0.4 percent of patients, according to a 2013 review of dozens of studies involving tens of thousands of patients.
A 2018 review by the National Academies of Sciences, Engineering and Medicine found that abortion medication ended pregnancies 96.7 percent of the time in gestations of up to nine weeks. The World Health Organization endorses self-managed abortion and says it can be used up to 12 weeks gestation.
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Bags of medical abortion medication and follow-up instructions for patients were readied at the Trust Women clinic in Oklahoma City in December.Credit...Evelyn Hockstein/ReutersMedication abortion “is noninvasive, doesn’t cause sepsis and doesn’t cause ruptures of internal organs,” like the illegal abortions of the pre-Roe era, Dr. Winikoff said.
“It doesn’t mean people can’t have excessive bleeding and need to get care occasionally, but those are not the dire circumstances of people from 50 years ago,” she added.
The drugs are regulated by the Food and Drug Administration, however, and are intended to be taken under a doctor’s supervision. The agency discourages internet purchases of mifepristone because patients will be “bypassing important safeguards,” officials said in a statement.
But the F.D.A. does not advise against online purchases of misoprostol (brand name Cytotec), which is used to treat a number of medical conditions. Misoprostol can terminate pregnancies by itself, recent studies have shown.
While no treatment is 100 percent safe, taking the pills “on your own at home does not affect your risk of complications,” said Dr. Carolyn Westhoff, an obstetrician gynecologist and professor at Columbia University and the editor in chief of the journal Contraception.
But self-management also means a woman does not have a familiar health care professional nearby to call in case of an emergency or complications. Dr. Westhoff and other experts fear that women performing their own abortions may be reluctant to seek medical help in states that have criminalized abortion.