Given the many obstacles facing reproductive rights in our current political climate, we as physicians are seeing some people take abortion into their own hands. No, I’m not talking about coat-hanger abortions or any of the other infamous and tragic methods that people in the past (and, sadly, even some in the present) have explored.
Specifically, I’m talking about those who are self-managing medication abortions, meaning that they’re getting and taking abortion medications without going through a health-care provider at all.
To be clear, neither SELF nor I advocate self-managing a medication abortion for a variety of safety and legal concerns which we’ll go over in more detail here. However, the reality is that some people may end up in this situation, and for those people, I want to provide accurate and responsible information on all of the potential risks and alternatives.
How surgical abortions and medication abortions work
Surgical abortions are in-clinic procedures using suction or other medical tools to remove a pregnancy from the uterus. According to the Guttmacher Institute, nearly one in four U.S. women (about 24 percent) will have an abortion by age 45, and the majority of those abortions are surgical. Surgical abortions can take anywhere from 5 to 20 minutes and they are a safe, effective, and common medical procedure. The vast majority of surgical abortions occur in the first trimester; this is the most common abortion option available after 10 weeks of pregnancy.
Medication abortions (also referred to as “medical abortions”—but we’ll use “medication abortion” to be totally clear) generally include taking two pills—mifepristone and misoprostol—to terminate a pregnancy. With a medication abortion, you take the first pill (mifepristone) either at a physician’s office or at home (depending on the laws in your state) and then you take the second pill (misoprostol) 6 to 48 hours later. (The FDA-approved regimen states that you should take misoprostol 24 to 48 hours later, but many abortion providers actually have patients administer the second pill as early as six hours later, as evidence has shown this is effective when administering misoprostol vaginally.) Together, these medications are approved by the FDA for abortion purposes up to 10 weeks (70 days) gestation, and the regimen is known to be about 95 percent effective.
Cramping and bleeding typically start within a few hours of taking the second medication. Nausea, vomiting, cramping, heavy vaginal bleeding, and diarrhea are all common side effects of a medication abortion. As many as 5 percent of people may not completely pass the pregnancy, which is why follow-up is key. Most clinics will have you return for another ultrasound appointment to make sure the abortion is over, but as of March 2016, the FDA guidelines changed and no longer explicitly state that an in-clinic follow-up is always necessary, so a follow-up may also take place over the phone.
As you can imagine, various obstacles can make it difficult to access a medication abortion. In fact, the first pill, mifepristone, cannot be distributed to or dispensed at pharmacies. There is something called a Risk Evaluation and Mitigation Strategies (REMS) program in effect with mifepristone, which is used by the FDA to lessen the risk of adverse events happening in relation to certain medications, as the FDA explains. But we abortion providers near universally agree that, with mifepristone, this is unnecessary and interferes with abortion access, as the medication is very safe.
As the Guttmacher Institute states: “Anyone seeking a medication abortion must locate a registered provider who has a supply of mifepristone—a task made more difficult because the stringent registration and stocking requirements [that] limit the number of providers willing and able to offer mifepristone. That much regulation can delay—and ultimately prevent—an individual from accessing a medication abortion altogether, especially in underserved communities such as those in rural areas.”
The reality of self-managed abortions
For the purpose of this article, I’m using the terms “self-induced” or “self-managed” abortions to mean abortions involving medication that’s sourced by a person on their own, via an online site or alternative route—in other words, without going through an abortion provider or telemedicine service to obtain the medications.
A self-managed abortion could theoretically take many forms, but it most likely goes something like this: A person has an unwanted pregnancy and either cannot access an abortion or doesn’t know how to access one. They search the Internet for answers and find random websites or anonymous forums offering questionable, anecdotal information about how to induce a miscarriage or terminate a pregnancy on your own. This person might then stumble upon nonregulated pharmaceutical sites that claim to sell and deliver real abortion medication (misoprostol and mifepristone) to buyers directly.
This person might feel desperate, then wonder: Is this safe? Is this legal?
It’s difficult to estimate how many people self-manage medication abortions in the U.S., but we know that it happens. With a slew of abortion laws in the current political conversation as well as potential punishments for any violators, not to mention a lot of confusion and misinformation about abortion access, it’s not hard to imagine how a person might find themselves in a situation where ordering abortion medication online seems like their only option.
In 2012, the Texas Policy Evaluation Project found that 7 percent of abortion patients in Texas had taken or done something on their own before coming to the clinic, and that upwards of 4.1 percent of women of reproductive age had attempted to self-induce an abortion. (This study was evaluating the impact of one of the most restrictive abortion bills in history, Texas House Bill 2, which required all Texas abortion facilities to have hospital-level standards.) By applying that rate to the 5,949,149 women aged 18 to 49 in Texas at the time, they estimated that somewhere between 100,000 and 240,000 women had attempted a self-induced abortion.
A 2017 study published in Contraception surveyed 1,235 people who had searched for information surrounding self-managed abortions (using medication or other methods, like alcohol, drugs, or supplements) to assess whether people had interest in learning more about self-managed abortion on the Internet. The research found that 10.6 percent of respondents reported having taken or used something on their own (meaning without any medical assistance) to try to end an unwanted pregnancy. Of this group, 8.1 percent said they used the “abortion pill,” while 54.8 percent reported trying to use herbs and/or vitamins.
Out of the 1,200-plus respondents, 52.4 percent said they weren’t sure whether there were any abortion providers in their area (and 19 percent said there actually weren’t any). Interestingly, 10.7 percent said they’d already had an abortion at a health care facility.
In a separate study published last summer in BMC Medicine that looked at abortion-related emergency room visits in the U.S. from 2009 to 2013 by women ages 15 to 49, an estimated 1.4 percent were potentially a result of self-induced abortion attempts (though the research did not indicate whether any of these cases involved the use of proven abortion medications or other methods/substances). The rate was also slightly higher in the South compared to other parts of the country.
It also appears some people are motivated to self-source abortion meds for privacy or convenience purposes: In a small, peer-reviewed study published last year in Perspectives on Sexual and Reproductive Health, researchers at the University of Texas at Austin interviewed 32 people who had self-sourced abortion medication online (without assistance from a health care professional) between January and June of 2017. They found that some people did cite access barriers (such as expensive costs for clinical care in states with restrictive laws) as a reason behind self-management, but also privacy or comfort issues, like wanting to be at home or fearing harassment from protesters if they traveled to a clinic.
The in-between option: telemedicine abortion services
There is an option that lies somewhere in between a physician-assisted medication abortion and ordering medication online. This option is telemedicine, which is legal in some areas though also increasingly restricted and politicized.
A telemedicine abortion goes something like this: A person living, say, in one of America’s 27 “abortion deserts” (large U.S. cities with the closest abortion provider being over 100 miles away) has a clinic visit via a video chatroom with the doctor, who then orders the prescription for mifepristone and misoprostol (which then gets sent either to a pharmacy, satellite clinic, or directly to the patient) and then the patient manages the abortion on their own, with on-call medical support at the ready. (So while in a way this is a self-managed abortion, the telemedicine aspect means it still involves a health-care provider.)
At first glance, it’s a simple solution to an access problem, especially given that we essentially do the same thing with in-person clinic visits for medication abortion. There are even variations that include having the video chat at an actual clinic where an ultrasonographer or nurse first performs the ultrasound to ensure the correct gestational age of the pregnancy.
The latest reliable research, published in 2017 in Obstetrics & Gynecology, found that telemedicine abortions are no less safe than in-person medication abortions. Of the 8,765 telemedicine abortions and 10,405 in-person medication abortions studied, only 0.18 percent of telemedicine patients and 0.32 percent of in-person patients experienced adverse outcomes (hospitalization or emergency room treatment, for example). There were no deaths or complications requiring surgeries reported in the study.
Despite the safety and success of telemedicine abortions, several states still have obstructionist laws on the books. Thirty-four U.S. states require that clinicians who perform medication abortions are physicians, not nurse practitioners; and 19 states require that the clinician providing a medication abortion be physically present during the visit, thereby prohibiting telemedicine entirely.
Still, the safety of telemedicine abortions may cause some to wonder: Is a self-managed abortion using medication obtained online really so different?
The safety and efficacy of self-managed abortions
While medication abortion is generally very safe, that assumes you’re under the care of a licensed provider. An obvious complication of a medication abortion is that it simply might not work and the pregnancy continues. In that case, your medical provider can determine whether a repeat dose or surgical intervention is appropriate. But as with any medical procedure, other side effects and complications can occur, too. Side effects may include heavy or prolonged bleeding, feeling nauseated, abdominal cramping, infection, and/or fever. A self-managed medication abortion would come with these same risks—but on top of that, you have to consider that you’d be navigating these risks without any guidance and support of a medical provider.
In addition, you carry the risk of not being totally sure what you’re actually taking if you obtain medication from an unverified source, and whatever is in that medication could carry additional unknown risks. And if complications arise, the solution is the same as after a clinic-induced medication abortion: You would need to go to the emergency room.
The point is, while medication abortions are generally very safe under some amount of supervision by or contact with a medical provider, the same cannot be said when you’re going at it completely alone with unverified drugs.
So the next question to address is, are online abortion medication providers trustworthy, meaning do they provide actual, untainted abortion medication? In one groundbreaking study published last year in Contraception that explored the feasibility of buying these medications online, researchers used chemical assays and found that, by and large, the products ordered were in fact the products delivered. When they did find differences in medication concentrations, it was only such that the misoprostol pills came in doses slightly lower than what they ordered, not higher. To clarify, this doesn’t mean that hypothetically you’d want to take even more of the medication—it just reinforces the fact that you have no idea what you’re getting (and at what dose) when you buy pills like this online.
Ultimately, the researchers of that study concluded that obtaining abortion medications from online pharmaceutical websites is feasible in the United States, and very likely a growing reality. But even though this study seemed to suggest that going the online route might not be harmful to your health, the reality is that you cannot know for sure what you’re getting when you order these pills online. It’s possible that you’re getting more or less of the recommended dose, or it’s also possible that you’re getting and taking a medication that could be harmful to you. We just don’t know. For that reason, providers still cannot recommend this option. Given that there’s no absolute, 100 percent guarantee that the medication will be safe, and that you won’t put yourself at added risk by flying solo should things go south, the FDA still clearly warns not to buy these medications online or bypass important safeguards already in place via in-clinic abortions.
The FDA has also recently taken steps to crack down on the selling of unapproved abortion medication directly to patients online, issuing warning letters to multiple online retailers this past month with the requirement to immediately stop selling the “violative” drugs. “Unapproved new drugs do not have the same assurance of safety and effectiveness as those drugs subject to FDA oversight,” the letters read. “Drugs that have circumvented regulatory safeguards may be contaminated, counterfeit, contain varying amounts of active ingredients, or contain different ingredients altogether.”
The legality of self-managed abortions
Currently, there are several state laws criminalizing self-induced medication abortion directly, laws criminalizing harm to fetuses, and misapplied pre–Roe v. Wade laws that criminalize abortion in general. Six U.S. states have laws that include language that directly criminalizes self-induced abortion: Arizona, Delaware, Idaho, Nevada, Oklahoma, and South Carolina. (New York previously had a ban, but it was repealed under the Reproductive Health Act that was signed into law in January.)
While there is nothing in the Constitution that says the state can punish people for performing their own abortions, at least 20 people in the U.S. to date have been arrested for ending their own pregnancies, which is a widely cited estimation, reported by the SIA Legal Team. Of course, the specifics of each case varies depending on the circumstances and jurisdiction under which it fell, and not all situations have resulted in convictions. The main thing to keep in mind is that the language of these laws can be interpreted in ways that criminalize the act of using unapproved abortion drugs, terminating a pregnancy after a certain point, or doing so outside of a clinical setting. It’s important to know that this is a risk you would be taking in these circumstances.
Interestingly, these restrictive state laws criminalize the act of carrying out the abortion, not actually having the medication on your person, as there are other medical reasons for having both mifepristone and misoprostol. Enforcing and reporting these events also varies widely and often come from the medical providers who care for women if complications arise.
The bottom line is that self-managing a medication abortion may be illegal in your area, and it’s very difficult to know what the legal repercussions may be for attempting it. The aforementioned SIA Legal Team (short for Self-Induced Abortion) has made it their mission to help people better navigate these laws. (If you ever have questions about your rights, their confidential legal helpline is available here.)
It’s also important to point out that criminalizing abortion does not prevent people from attempting to end their own pregnancies. In many parts of the world where abortion is illegal, abortions still happen—and abortion medication is largely cited in these cases. For instance, in a small qualitative study involving college students in Chile (where abortion is illegal, save for in cases of rape or when the mother’s life is at risk) published last year in Contraception, researchers did interviews with 30 women who had a medication abortion between 2006 and 2016. The conversations touched on the realities that young women still pursue medication abortion even illegally, by obtaining information from the web or through their friendship networks and by posting on anonymous forums for health advice during the process.
Some of the women in the study, like many women in other areas of the world with restrictions to abortion access, reported using Women on Web (WoW), which is an organization that aims to help women access abortion medication through telemedicine services. (Note: Women on Web delivers abortion pills to people in ways that reportedly do not violate customs regulations in most countries. But while having the medication on you may not be illegal, depending on the legislation in your country, it may be illegal to use the medication for the purpose of terminating a pregnancy. So it’s important to be familiar with the laws in your location, as a legal risk of using this service could still exist.)
My role as an abortion provider
As an abortion provider, I’ve come full circle with my own feelings about self-induced medication abortion. Ultimately, while I do not recommend a self-managed medication abortion, I understand why this happens; and if someone ends up in this situation, I will always work to support them and keep them safe.
Clinic-based abortion care is an essential component of full-spectrum reproductive health care, and my role as an ob/gyn is to protect and support this right. So to legitimize abortions outside the clinic initially seemed akin to admitting defeat by anti-abortion legislators and erasing the message that abortion is a safe and legal medical procedure. An abortion doula can’t do my job, nor should they, but I also acknowledge the reality of the situation.
A person’s access to clinical abortion is dependent on several factors: their ability to navigate local laws; their financial situation (affordability is a major barrier to abortion access in the U.S., where the average cost of an early medication abortion in 2014 was $ 535); and, simply put, their zip code. So the reality is that for a large number of Americans, abortion is already inaccessible, and for some, self-induced medication abortions might feel like the only immediate solution.
My epiphany regarding self-induced medication abortion, however, came when I saw it as a harm-reduction strategy aimed at eliminating the gruesome self-induced abortion tactics I mentioned earlier. There is also undoubtedly a racial and economic justice narrative here, whereby criminalizing self-induced medication abortion disproportionately affects immigrants, LGBTQ people, and people of color.
So while it’s tempting to create a hierarchy of “good” or “bad” methods of abortion, I’d argue there is no such thing. Safety and accessibility are the real values we should be talking about. One thing is clear: Self-managed medication abortions are one of many components of abortion care, and we as providers and advocates would be remiss to ignore that.
My advice for anyone in this situation
So, what do I recommend if you are someone who can’t get to a provider in person, or can’t afford the necessary medications? My answer would be to first familiarize yourself with the abortion restrictions in your state if you’re in the U.S. (this Guttmacher chart is a useful starting point). Then, consider these options:
Call your local Planned Parenthood. Even if your local Planned Parenthood clinic does not offer medication abortions, they can help direct you to a health center closest to you that does. Some Planned Parenthoods can also help arrange telemedicine services.
Look into financial/logistical aid. A few organizations exist that might be able to help with the cost of an abortion, such as the National Network of Abortion Funds (NNAF), as SELF reported previously. Members of these orgs work to help with the costs of abortion for people who need it but may also offer things like transportation and/or childcare to make the logistics less complicated.
Reach out to the SIA Legal Team helpline here. As the organization’s website explains, the team of lawyers behind the SIA Legal Team can help explain (free and confidentially) how self-managed abortion legislation may apply to your specific situation/location. While they cannot actually give you legal advice, they can help you find a lawyer in your area if you think you need one.
Also, beware of “crisis pregnancy centers,” which are clinics that provide family counseling from an anti-abortion position. These centers (some of which don’t even have trained medical personnel on staff) generally have the goal of persuading people out of getting abortions. It can be challenging to tell them apart from real clinics, but this Planned Parenthood guide can help.
If all is said and done and you’ve ordered abortion medication online anyway, remember this: The absolute safest way to perform a medication abortion is with the guidance of a doctor or nurse. If you bought pills online from a random website, there is no surefire way to guarantee that you’re getting the right kind of medication or the right dose. And depending on where you live, there may be significant legal ramifications to self-managing an abortion, including being arrested.
But if you still chose to go it alone, without any amount of care from a medical provider, please heed these words of caution:
- Go immediately to the nearest emergency room if you experience any sort of complication like fever, severe pain, or heavy bleeding.
- When you go to the emergency room, there may be questions about where and how you got the medication. You do not need to disclose where you got the medication, but please disclose what you took and when you took it. I will point out that hospital personnel or a social worker could report your situation if they believe you broke the law in your area (although many medical personnel do not report these cases). But if you need medical attention, that should be your first priority—not avoiding potential legal consequences. Read more here.
- The most common scenario following a self-managed medication abortion is that the online pills don’t work and you’re still pregnant. If you are suspicious that this is happening, take a home pregnancy test. If positive, call your provider to follow up if you have one, or contact your local Planned Parenthood right away for further assistance.
Jennifer Conti, M.D., M.S., M.Sc., is a clinical assistant professor of obstetrics and gynecology at Stanford University School of Medicine and cohost of the V Word podcast. Follow her on Twitter at @doctorjenn.