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In states where abortion has been banned, some women with unwanted pregnancies are seeking unconventional solutions: They “self-manage” their abortions, seek the necessary knowledge online and obtain medications without the supervision of a clinic or doctor.
At first glance, this practice may recall the days before Roe v. Wade, when women are too often forced to take risky actions to end unwanted pregnancies. But the advent of drug abortion – performed with drugs, not an in-office procedure – has transformed reproductive care, posing a significant challenge to anti-abortion laws.
Even before the Supreme Court’s decision to overturn Roe v. Wade, drug abortion accounts for more than half of abortions in the United States. Federal regulators are making access to pills easier during the pandemic by scrapping requirements for in-person visits and allowing drugs to be delivered to patients after virtual appointments.
But many states have never allowed telehealth abortions, and new laws banning abortions apply to all forms of procedures, including medications. So women in increasingly stringent parts of the country buy pills any way they can, often online, despite state bans.
There are no reliable estimates of the number of women who have their own drug abortions, according to the Guttmacher Institute, which researches and supports abortion access.
With the cancellation 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 remove abortion rights protections from the state’s constitution.
Limits of one kind or another remain expected in at least half of US states, and both sides of the split are bracing for an increase in self-administered abortions.
Abortion critics of all kinds insist that drug abortion is riskier than claimed, and even more so without medical supervision. This procedure should not be performed after 10 weeks of gestation, they note, or be carried out without a doctor’s visit, as it is not always possible to accurately determine gestational age.
Other medical complications can be missed, they say — including an ectopic pregnancy, in which a fertilized egg implants outside the uterus.
The claim that drug abortion is safe “is based on flawed and incomplete data, which prioritizes convenience and cost over patient health and safety,” said Dr. Christina Francis, chair of the American Association of Pro-Life Obstetricians and Gynecologists, is against all abortions except to prevent permanent harm or death of the mother.
Doctors who support abortion tell a different story: There is ample evidence that abortion pills are safe, and women already perform the procedure almost entirely alone at home, even if they see a doctor for medication. Self-management is not so different, proponents argue.
Read More about the Abortion Problem in America
“It’s fairly safe and effective based on the research we’ve done, national data provided by the state and the Guttmacher Institute, and the experience of other countries,” said Dr. Beverly Winikoff, founder of the Gynuity Health Project, which did much of the research on drug abortion that led to its approval in the United States more than 20 years ago.
This procedure usually involves the use of two drugs: mifepristone, which stops 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 have drug abortions in 2020 in the United States, and less than half of 1 percent have serious complications, studies show. Medical interventions such as hospitalization or blood transfusions are required by less than 0.4 percent of patients, according to a 2013 review of dozens of studies involving tens of thousands of patients.
Medicinal abortion is “non-invasive, does not cause sepsis and does not cause internal organ rupture,” like illegal abortions in the pre-Roe era, said Dr. Winikoff.
“It’s not that people shouldn’t bleed profusely and need to get occasional treatment, but it’s not a terrible state of affairs for people from 50 years ago,” he added.
Medicines are regulated by the Food and Drug Administration, however, and are meant to be taken under a doctor’s supervision. The agency banned the purchase of mifepristone over the internet because patients would “pass important protections,” officials said in a statement.
But the FDA does not recommend buying misoprostol (brand name Cytotec) online, which is used to treat a number of medical conditions. Misoprostol may end a pregnancy on its own, recent research shows.
While no treatment is 100 percent safe, taking the pill “alone at home does not affect the risk of complications,” says Dr. Carolyn Westhoff, an obstetrician and professor at Columbia University and editor-in-chief of the journal Contraception.
But self-management also means a woman doesn’t have a familiar health care professional nearby to call in case of an emergency or complication. Dr. Westhoff and other experts worry that women who perform abortions themselves may be reluctant to seek medical help in states that have criminalized abortion.
Cassie, 20, who uses the pronouns they and they and asks that only first names be used because they live in Texas, where most abortions are prohibited after about six weeks of pregnancy, had an abortion herself in January.
Cassie, who already has children and is struggling financially, filled out an online abortion pill request form from Europe-based Aid Access. The drugs took longer to arrive than expected, and when they did, Cassie was already 12 weeks pregnant.
“I just took it and prayed for the best,” Cassie said. They had heavy bleeding, nausea and “the worst cramping I’ve ever had in my entire life.”
“I was crying, curled up in pain in the middle of my bed,” they said.
When the bleeding didn’t subside, Cassie’s partner drove them to the hospital, where the remaining tissue was removed.
“It was a terrible experience praying that they wouldn’t know or suspect that I myself caused it,” Cassie said.
Both knowledge and tools for performing abortions are increasingly accessible.
Women living in states where abortion is legal can contact US-based remote healthcare providers such as Abortion on Demand and Hey Jane, which offer detailed information to women seeking abortions and deliver pills by mail after video visits in states where this service is legal.
The MYA network provides doctors who answer questions about self-administered abortion, and Abortion Pill Info offers tips for keeping online research confidential.
For women in states with abortion bans, Plan C offers a number of solutions, including a list of online pharmacies selling abortion drugs that the organization has tested and tutorials on setting up mail forwarding in other states to receive the drug.
The site also refers people to Aid Access, which screens women online and orders abortion pills from overseas pharmacies that are delivered in envelopes without a return address, even to states where abortion is illegal. Groups charge $150 or less, depending on revenue.
Hannah, 26, in Oklahoma, said she administered her own abortion with pills from Aid Access late last year, when a local clinic, overwhelmed with patients from Texas, couldn’t accommodate her.
Hannah, who asked not to be named because abortion is now banned in her state, said she suffered from depression several times before she became pregnant but had fallen to rock bottom and committed suicide.
“I was unable to conceive and not healthy enough, physically or mentally, to conceive,” she said. Her self-administered abortion “was no worse than a normal period for me.”
A drug abortion is indistinguishable from a miscarriage, and traces of the pill cannot be found if it is taken orally, says Dr. Rebecca Gomperts, a Dutch doctor who founded Aid Access.
If a woman needs treatment after taking the pill, “we always tell people to say they had a miscarriage,” she says. “The symptoms are exactly the same, and the treatment is exactly the same.”
A study of thousands of women in the United States who received abortion pills from providers without an in-person visit during the pandemic found the practice to be safe.
Complications are a rare exception. Another recent study looked at self-administered abortion in Nigeria, where abortion is prohibited except to save the mother’s life, and in Argentina (which legalized abortion for up to 14 weeks at the end of 2020).
Twenty percent of the nearly 1,000 women who participated in the study sought hospital care after the procedure, but most just wanted to make sure that the abortion was complete. About 4 percent reported ongoing pain, fever or bleeding. Seventeen procedures were required to complete the abortion, 12 stayed in the hospital overnight, and six required a blood transfusion, according to the study, published in The Lancet Global Health in late 2021.
The surprising finding was that while some women took the mifepristone-misoprostol combination, the success rate for those taking misoprostol alone — a widely used drug that can be purchased in countries like Mexico without a prescription and reasonably priced — was higher than that. of a combination of two drugs.
Most state laws that restrict abortion make abortion a crime for doctors, not patients. Only three states – South Carolina, Oklahoma, and Nevada – have laws that explicitly state that it is a crime to terminate a pregnancy on your own.
Other states, however, have used child harm laws or other laws against women suspected of terminating their pregnancies.
In Indiana, Purvi Patel was sentenced to 20 years in prison in 2015 for encouraging self-administered abortion; her conviction was overturned in 2016. In Texas, a murder charge was filed against Lizelle Herrera earlier this year in connection with a self-administered abortion, but prosecutors said they would not pursue the case.
At least 11 states have laws with broad personality language that apply to fetuses, said Dana Sussman, deputy executive director of the National Advocates for Pregnant Women. At least six — Kentucky, Louisiana, Ohio, South Dakota, Texas, and Wyoming — define a fetus as someone throughout the Criminal Code, making it easier to sue women who terminate their own pregnancies.
Both the American Medical Association and the American College of Obstetricians and Gynecologists, who support abortion as an essential component of health care, oppose criminalizing self-administered abortion, because they say it will deter women from seeking medical attention.
Currently, healthcare providers are not legally required by any state to report a patient they suspect of having an abortion themselves, according to If/When/How, an abortion rights advocacy group. But the law is changing.
“We operate in an area of uncertainty,” said Sussman.
Audio produced by Kate Winslett.