With the Supreme Court likely to soon strike down Roe v. Wade, abortion rights activists, researchers and providers are pointing to “self-managed abortion” — ending a pregnancy on one’s own, without a doctor — as the likely future of abortion access in states that ban or heavily restrict the procedure.
And in particular, they are emphasizing the power of medication abortion, a two-pill regimen that can be used to safely end a pregnancy without a doctor’s supervision, as a way for people to access care, even in states where abortion is outlawed.
The research is clear that medication abortions can safely be done from home, and, as of last year, medication abortion is the most common method of ending a pregnancy. The pills are most effective for patients within the first trimester. Some providers — most famously the Austria-based Aid Access — are already prepared to distribute abortion pills to people in the United States who cannot access them in their home states.
Advocates have been working for years to raise awareness. But researchers and some abortion providers still worry that patients may not know about pills as an option, or have the resources in place to safely access them — citing a knowledge gap that could disadvantage many of the people who seek abortions in heavily restrictive states. Raising awareness, they said, is now a critical priority for reproductive health providers.
“Information is probably the biggest hurdle,” said Ushma Updadhyay, an associate professor at the University of California San Francisco who has studied self-managed abortion extensively. “First, a lot of people still don’t know you can have an abortion with pills. Second is the knowledge that it is safe and you can order them online. And Aid Access is really the only game in town.”
Both awareness and interest appear to be climbing. After the draft of the Supreme Court’s decision leaked, traffic soared at the websites for Aid Access and Plan C, another organization that helps people find medication abortion pills. Research from Texas shows that after major abortion restrictions took effect — in 2020, when Gov. Greg Abbott cited the COVID-19 pandemic to temporarily ban abortion provision, and again this past fall, when the state’s six-week abortion ban took effect — more people in the state turned to Aid Access in particular.
But it’s not necessarily clear who knows that those resources exist. Plan C’s website, for instance, saw a surge in visitors from Texas and California, even though California is unlikely to ban or restrict abortion access in the near future.
“I’m hopeful more folks will get the information,” said Anna Bernstein, a health care policy fellow at The Century Foundation, a progressive think tank. “But whether that will get to the folks who need it the most — I don’t know if we can say that.”
There is little research on who are the people most likely to find medications as a means of self-managing. Geography can help: Studies have suggested that in Texas, people who live near the border — and are able to cross over and buy pills from Mexican pharmacies – are more likely to find at least misoprostol, one of the two pills used in medication abortion. (Misoprostol can be used by itself to induce an abortion, but is more effective when paired with the other pill, mifepristone.)
But still, some abortion clinic staffers said they worried that people with lower incomes might be disadvantaged in finding medications.
“Some people will be able to access more resources than others or their community will be able to refer them to places like Aid Access,” said Andrea Gallegos, the executive administrator for Tulsa Women’s Clinic, in Oklahoma, and Alamo Women’s Reproductive Clinic, in San Antonio. “Whereas someone who is in a poorer community may not receive those resources.”
Researchers and health care providers point out that even now, medication is not the only way people are trying to self-manage their abortions. As recently as 2017, the majority of people who attempted to end pregnancies on their own were doing so without pills.
Many, research shows, were using methods that weren’t dangerous but simply didn’t work — herbs, supplements and vitamins, for instance. Others were attempting to induce abortions through dangerous, potentially life-threatening methods, such as physical self-harm. Upadhyay’s study, which uses 2017 data, found almost 1 in 5 patients who were attempting to self-manage abortions used “abdominal or physical trauma.”
“Self-managed abortions with pills is extremely safe. But we have reports — we have it in our research in the past couple of years that people are attempting self-harm,” Upadhyay said. She worries that will only continue when Roe is overturned, and states outlaw or heavily restrict access to abortion.
It’s not clear what the breakdown of how people self-manage abortion currently looks, and it has likely changed at least somewhat since 2017. Aid Access only began delivering pills to the United States in 2018, just four years ago. There is no research using data from 2018 or later to show how many people in the United States are currently using medication to self-manage versus other methods.
Some scholars and abortion providers told The 19th that they still worry about a persistent knowledge gap — and that those who don’t know how to access pills, or who aren’t plugged into the right communities, could be at risk of harm. Pills from Aid Access also take two to three weeks to ship for patients in states that have banned mailing medication abortion pills. And the price tag — around $100 — can be a barrier for some patients.
Texas, whose six-week ban has been in effect since September, offers a case study.
This past fall, “we were seeing patients coming from Texas, that were afraid to not only seek care for a pregnancy test — but we were seeing a lot of patients coming to Oklahoma, because they were septic because of trying to perform a home abortion,” Ginger Thomas, a Planned Parenthood nurse who recently worked in an Oklahoma hospital, told The 19th last month.
That will grow, some clinic staffers worried.
With the end of Roe looming, some abortion clinics and funds are pivoting to direct patients toward resources about self-managed abortion. Katie Quinonez, who runs a clinic in Charleston, West Virginia, said that she plans to inform more patients about the possibility of self-managed abortion — which isn’t outlawed in West Virginia, though non-medical doctors have to be careful in the language they use in discussing the option. The Roe Fund, Oklahoma’s sole abortion fund, now direct patients on its website to Plan C, though self-managed abortion is explicitly outlawed in the state. (Oklahomans who visit the Plan C web page are informed that self-managing brings legal risk.)
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In states like Oklahoma, the legal concerns are greater.
“Is [medication] the only means of self-managed abortions that patients are going to try? No. I think there’s more dangerous methods that patients will try, like they did pre Roe passing,” Gallegos said. “And you know patients died from those things. I think we will see that as well, unfortunately, especially if we overturn Roe.”
Oklahoma is one of three states that criminalizes self-managed abortion. South Carolina and Nevada also have laws making it a crime to induce an abortion on one’s own.
Those are not the only states where self-managing brings legal risk. The Louisiana legislature recently scuttled a proposed bill that would have equated abortion to homicide. That measure represented a break from what the anti-abortion movement has long avoided: explicitly criminalizing the pregnant person.
And even in states that don’t outright ban self-managed abortion, local prosecutors have historically sought to charge people who end their own pregnancies with other crimes.
“It seems like there are options for legal harm to come to those who self-manage,” said Elizabeth Nash, who tracks state policy for the Guttmacher Institute, which researches abortion rights across the United States. “There are a lot of unknowns at this point around what could happen, and whether or not we will see many more arrests. Clearly this is on the table.”