Some Women ‘Self-Manage’ Abortions as Access Recedes

Information and medications needed to end a pregnancy are increasingly available outside the health care system.



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.

ImageBags 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/Reuters


Medication 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.

 

 

Kansas rattles the nation, and the midterms, with its abortion vote.

Voters in deep-red Kansas delivered a loud warning shot to Republicans across the country, signaling that abortion has the potential to energize voters who the G.O.P. had hoped would remain disengaged. Democrats are likely to use the vote to try to build momentum and depict Republicans as out of step with the majority of Americans on the issue.

The vote in Kansas, which resoundingly rejected a ballot referendum that would have removed the right to abortion from the State Constitution, was the first test of Americans’ political attitudes on the issue since the Supreme Court overturned the Roe v. Wade decision. It revealed that from the bluest counties to the reddest ones, abortion rights outran Joseph R. Biden Jr.’s performance in the state in 2020.

 

3 common myths about the abortion debate that many people get wrong

July 22, 20225:00 AM ET

JULIE ROVNER

Even though Democrats had bigger majorities in Congress under Democratic Presidents Bill Clinton and Barack Obama, large numbers of anti-abortion Democrats in both chambers meant abortion protections could not be codified.

Mark Wilson/Getty Images

In the wake of the U.S. Supreme Court's decision to overturn the federal right to abortion, things are more than a little confused.

As lower courts grapple with rapidly changing state laws, patients wonder from day to day if abortion is still legal, and even if legal, whether it is still available in their states. Health professionals in states with abortion bans fear prosecution by state authorities for performing abortions or by federal authorities for not performing them in life- or health-threatening situations.

Even employers are caught between conflicting state and federal rules about what can, cannot, and must be covered by insurance.

But amid all the confusion, there are some things that are simply not true. Here are three myths going around about the abortion debate:

MYTH 1: Only people seeking abortions are affected by the Supreme Court's action.

The huge changes and uncertainties wrought by the Supreme Court's erasure of 49 years of largely settled federal policy most directly affect pregnant women. But they are far from the only people whose medical care is being disrupted.

As abortion providers pack up and leave states with bans, they may take with them expertise in managing high-risk pregnancies as well as routine deliveries, particularly in less-populated areas, plus access to long-acting birth control and screening and treatment for cancer and sexually transmitted diseases.

Similarly, medical students and medical residents may not want to train in states where they can't learn abortion techniques, which are often the same as care for miscarriages. That could lead to shortages of people trained to help patients give birth safely just as more people are being forced to carry pregnancies to term.

Also affected, at this point as much by accident as intent, is birth control. In Missouri, a hospital system temporarily stopped distributing the "morning after" birth control pill, which is a contraceptive that does not cause abortion, before reversing the decision.

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That is its own sub-myth — that the Plan B morning-after pill is the same as the abortion pill mifepristone. Plan B is a high dose of regular birth control that prevents ovulation but does not interrupt an existing pregnancy. Mifepristone ends a pregnancy if used in approximately the first 10 weeks.

And it's not just pregnant women who are affected by the uncertainty. People with severe psoriasis, lupus and other autoimmune disorders are already reporting difficulty obtaining methotrexate, a first-line medication for those ailments that can also be used as an abortion medication.

MYTH 2: The Democratic Congress could have codified abortion protections long before now, but chose not to.

The House on July 15 voted — for the second time by this Congress — for a bill that would effectively codify the federal abortion protections of the 1973 Supreme Court decision Roe v. Wade. Ever since the court overturned that decision last month, Democrats on social media and elsewhere have complained that this is a bill Congress should have passed years ago, when the Democrats had firmer control of the House, the Senate and the White House.

This story was produced in partnership with Kaiser Health News.

But even though Democrats had bigger majorities in Congress under Democratic Presidents Bill Clinton and Barack Obama, large numbers of anti-abortion Democrats in both chambers effectively meant there was not a majority for such legislation, much less the 60-vote supermajority that would have been required in the Senate.

It was not, contrary to some revisionist historians' views, for lack of trying. In 1992, Democratic leaders promised to bring the "Freedom of Choice" act to the floor, a bill that would have written the right to abortion into federal law, if only to embarrass then-President George H.W. Bush right before the GOP convention. (Here is a very old clip of me explaining the situation on C-SPAN.) In the end the bill did not make it to the floor of either the House or the Senate, as Democratic leaders could not muster the votes.

In fact, since the Roe ruling, the House has been more anti-abortion than the Senate, in part because so many Democrats from Southern and/or conservative districts opposed abortion (most have now been replaced by Republicans), and because the Senate has long had at least a handful of Republicans who support abortion rights. Today that is limited to Sens. Susan Collins (R-Maine) and Lisa Murkowski (R-Alaska). The House got its first abortion-rights majority only in 2019, when Donald Trump was president.

MYTH 3: Congress could simply eliminate statutory abortion restrictions now.

With Democrats in charge of both Congress and the White House, they can just change the existing laws limiting abortion, advocates claim. Indeed, President Joe Biden's budgets in 2021 and 2022 proposed eliminating the so-called Hyde Amendment, named for its sponsor, the anti-abortion crusading Rep. Henry Hyde (R-Ill.), which has barred most federal abortion funding since the late 1970s. But while the House voted in 2021 for the funding bill for the Department of Health and Human Services without the abortion rider for the first time in decades, Senate Republicans forced the restrictions back into the final measure. The same is expected later this year. Democrats hold only 50 seats in the Senate and need at least 10 Republicans on any bill that is threatened with a filibuster.

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The Hyde Amendment could also keep the federal government from allowing abortion clinics to operate on federal land, as many progressives have been calling for. But other, more complicated federal-state issues would more likely doom that scenario.

Complicating things still more, the Hyde language in the HHS spending bill is far from the only abortion restriction embedded in federal law. While abortion-rights backers have successfully fought off most efforts to make such restrictions permanent, various other spending bills annually include limits on abortion in the military, in federal prisons, by the Indian Health Service, and as an insurance benefit for federal workers. Congress has also limited the ability of the District of Columbia to spend local tax dollars on abortion.

It is possible the reversal of Roe could lead to the reversal of some of these restrictions. But with Democrats' paper-thin majority in the Senate, it's not likely, at least not in 2022.

 NPR

Women who are denied abortions risk falling deeper into poverty. So do their kids

May 26, 20225:00 AM ET

Heard on Morning Edition

JENNIFER LUDDEN

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Abortion-rights advocates demonstrate in front of the Supreme Court last December as it heard a case that could strike down the constitutional right to abortion. Economists say decades of research show that doing so would limit women's economic prospects.

Jose Luis Magana/AP

Like most women seeking an abortion, Brittany Mostiller already had children when she unexpectedly got pregnant again. "I had two young daughters both under the age of 5, sharing a two-bedroom apartment with my sister," she says.

She'd also just been laid off from her overnight job as a greeter for Greyhound buses. Her unemployment benefits were less than her wages there, and nearly all of them went toward rent and utilities. "I'm not even sure I had a cellphone at that time," she says. "If I did, it was certainly on and off," to save money.

Mostiller worried about finding another job while pregnant and then being able to take time off to care for a newborn. But mostly, she knew how expensive it was to have a baby, and she didn't want to sacrifice the well-being of her two children by having a third she simply could not afford.

As it turned out, she couldn't afford an abortion either. And in Illinois at that time 15 years ago, abortion was not covered by Medicaid.

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Mostiller went ahead with the pregnancy and had to be hospitalized at 32 weeks and then induced a week later. Not long after giving birth to a third daughter, she started work as a cashier but could get only 20 hours a week. Her financial hardships began to multiply.

"I defaulted on student loans that I was navigating," she says. She'd been studying to be a paralegal but had left without a degree. Within about a year, she also defaulted on credit card payments, which eventually led to her meager checks being garnished. At one point, she juggled three jobs — one of them full time — trying to make it all work. "It was certainly rough."

Since then, Mostiller has managed to improve her situation, ironically through another unplanned pregnancy. The second time, she discovered a local group that helps poor women pay for abortions, and she now works with the National Network of Abortion Funds. But her worries about falling further into poverty are widely shared among women seeking abortions. And a large body of research proves them right.

Roe v. Wade provided a natural experiment on the economic impacts of abortion

Before the Supreme Court legalized abortion with its Roe v. Wade ruling in 1973, five states and the District of Columbia had already allowed abortion for several years. Caitlin Myers, an economist at Middlebury College, says this provided researchers a natural experiment through which to study the demographic and economic outcomes of women in those states compared with others and then to look at what happened after Roe as well.

Myers says they found profound impacts and were able to document that they were discrete from all the other changes happening in society at the time.

First, legalizing abortion dramatically reduced the number of women and girls who gave birth — and got married — as teenagers. Access to abortion also offered a major boost to women's economic prospects, "allowing them, in turn, to obtain more education, to enter more professional careers, to avoid poverty," Myers says. "And also providing those same economic advantages to the children that they parented later."

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ROE V. WADE AND THE FUTURE OF REPRODUCTIVE RIGHTS IN AMERICA

Much of the United States could criminalize abortion. But how will those laws be enforced?

In the Mississippi abortion case before the Supreme Court, Myers spearheaded an amicus brief by 154 economists. But she says their findings seem to have been ignored.

During oral arguments in the case in December, Julie Rikelman of the Center for Reproductive Rights argued against Mississippi's law to ban nearly all abortions after 15 weeks. At one point, she said, "The data has been very clear over the last 50 years that abortion has been critical to women's equal participation in society." As she continued, Chief Justice John Roberts interrupted her to ask, "What kind of data is that?" And then interrupted again to say, "Well, putting that data aside ..." and asked why 15 weeks was an inappropriate cutoff.

In his leaked draft opinion, Justice Samuel Alito notes that Roe's supporters say without access to abortion, "women will be unable to compete with men in the workplace." He then cites abortion-rights opponents' "countervailing arguments about modern developments." These include, he writes, changed attitudes toward unmarried pregnant women, federal and state laws banning discrimination on the basis of pregnancy and "that leave for pregnancy and childbirth are now guaranteed by law in many cases."

But Myers says this is just not true for most women seeking abortions, who are disproportionately poor and women of color.

"This population of women ... lacks access to paid parental leave, lacks access to affordable child care," she says. And even many who can get child care face challenges scheduling it because "a lot of these women work in what's called shift work, with very irregular schedules."

The financial fallout extends to the next generation

Sen. Tim Scott, R-S.C., speaks as Treasury Secretary Janet Yellen testifies before a Senate committee hearing May 10. He told her it was "harsh" to talk about abortion access as an economic issue for women. "As a guy raised by a Black woman in abject poverty, I'm thankful to be here," he said.

Tom Williams/AP

Of course, abortion-rights opponents see all this differently. When Treasury Secretary Janet Yellen told a recent Senate panel that overturning Roe would "set women back decades," she drew a rebuke from Republican Sen. Tim Scott of South Carolina.

"Did you say that ending the life of a child is good for the labor force participation rate?" he asked pointedly. He called it "callous" and "harsh" to frame the "painful reality" of abortion that way.

"As a guy raised by a Black woman in abject poverty," he said, "I'm thankful to be here, as United States senator."

But Scott's success story is not the norm when those who seek an abortion are denied one. Economist Jason Lindo, with Texas A&M University, says the financial fallout extends well into the lives of such women's children.

"There's a huge empirical literature showing that there are detrimental effects on these kids' outcomes," he says. "When they grow up, they're less likely to attain higher education themselves, they're more likely to be involved in crime, have lower adult earnings."

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Research into abortion's economic fallout continues. The landmark Turnaway Study followed women for a decade and found that those denied an abortion were four times as likely to be living in poverty years later.

And economists have gotten more opportunities for "natural experiment" studies as Texas and a growing number of other states have strictly limited abortion in recent years. One analysis by the Institute for Women's Policy Research calculates that such measures cost state and local economies $105 billion annually by reducing women's labor force participation and earnings.

Still, Middlebury professor Myers says if Roe is overturned, "it's not going to be a return to 1971."

Based on what has happened so far, she estimates that if half of states impose various abortion bans, about three-quarters of women seeking abortions in those states will still find a way to travel and access abortion in another state. But it will largely be women with means, resulting in "a dramatic increase in inequality of access." Her own research last year found that even an increase in travel distance of up to 100 miles could prevent 20% of women from reaching a provider.

Myers calculates that in the first year after Roe was struck down, about 100,000 lower-income women would not be able to get an abortion. She says that number could be higher if more places restrict medication abortion by mail and if a backlog of women seeking help in other states leads to long delays.

And again, she and economist Lindo stress that the consequences don't stop there but extend to the children whom women already have or will have later. They say it's empirically clear that cutting off abortion access for more women would mean widening already stark economic and racial disparities for generations to come.