The callers wanted to know how to end their pregnancies without going outside. Many were afraid to travel for fear of contracting the coronavirus, which spreads through contact with others. Some didn’t have the financial resources to make an arduous, often multi-day trip to an abortion clinic. Others were stuck in states where abortions were temporarily halted by Republican leaders exploiting the crisis to erode access.
Faced with dwindling options, callers to the helpline run by the reproductive rights group If/When/How, were considering “self-managed abortion,” loosely defined as ending a pregnancy without the formal supervision of a health care professional. Calls to the confidential helpline have more than doubled in the past two weeks, according to Jill Adams, the group’s executive director.
“People are unable to leave their homes, and yet they still need to have abortions,” Adams said. “While we practice social distancing to maintain public health and flatten the curve, people must be allowed to safely end pregnancies at home without the fear of arrest.”
The idea of women attempting abortions on their own conjures up a painful history in the U.S., epitomized by the image of a coat hanger, the enduring symbol of the dangerous methods women used before Roe v. Wade. The coat hanger is not, however, an accurate representation of what self-managed abortion looks like in 2020.
Nowadays it is safe and easy to induce an early abortion at home thanks to the advent of medication abortion, also called “the abortion pill.” (The term is a misnomer, as medication abortion actually involves two different drugs, usually taken about 24 hours apart, which cause a miscarriage.) Almost 40% of abortions in the U.S. are done via this method, which is approved for use up to 10 weeks of pregnancy.
These abortions take place in the privacy of one’s home. But due to current federal regulations on mifepristone, the first of the two drugs used to end a pregnancy, patients are required to physically show up at an abortion clinic to retrieve the medicine. Unlike virtually every other medication, it can’t be dispensed at a local pharmacy or through the mail.
To get around this, some women have been turning to the internet to buy the pills without a prescription. Now, reproductive health experts expect to see a rapid increase in such purchases as people are stuck indoors and can’t travel to clinics. Ultimately, the pandemic may expose the fact that current restrictions on medication abortion aren’t actually necessary at all.
“This is a really unique opportunity to say, ‘What are the things that we’re doing that are not grounded in medical evidence, that are actually limiting access to care?’” said Jamila Perritt, an OB-GYN and reproductive health advocate. “It may be that we have an opportunity to de-medicalize the way abortion care is provided in this country.”
Managing It Alone
It is difficult to know the extent to which people are self-managing abortion, as it occurs outside the formal health care system.
A recent study in Texas, where abortion access has been eroded dramatically since 2012, found that almost 7% of patients seeking an abortion tried to end a pregnancy on their own. That’s about three times higher than the national average. Most bought pills in Mexico.
“The good news is that self-managed abortion methods like pills are safe and effective when taken according to directions,” Perritt said. “Research shows that when people have accurate information about what to expect and a way to get their questions answered, they can use these tools safely and effectively on their own.”
A 2018 study of 18 websites that sold abortion pills online found that the drugs were generally what they said they were and often cost less than from an abortion clinic.
“The harm is not safety or medical,” Perritt said. “It’s a legal risk.”
Only five states explicitly criminalize self-managed abortions ― Arizona, Delaware, Nevada, Oklahoma and South Carolina. But even in states where it is not a crime, prosecutors have sometimes used interpretations of other criminal statutes to punish women who try to end their own pregnancies.
Still, it remains uncommon for women to be charged with self-inducing an abortion, according to Adams of If/When/How. To date, she said, there is no known example of someone in the U.S. being arrested or investigated based just on the act of ordering abortion pills online.
“Importation of drugs is technically prohibited under federal law, but in practice it is not enforced against individuals for personal use,” Adams said. “However, we know of three cases where people who ordered abortion pills online were later charged with crimes for having an abortion, and in their trials, the fact that they had ordered abortion pills online was used as evidence against them.”
She urged women with questions about their legal rights regarding self-managing an abortion to contact If/When/How’s helpline.
Changing The Status Quo
Given the pandemic and the need for people to stay at home, a growing chorus of voices is calling on the Food and Drug Administration to change its restrictions on mifepristone so that patients can access the drug without having to leave their houses.
The U.K. temporarily changed its abortion policy to allow women to receive abortion pills at home without having to travel to a clinic.
“It doesn’t make any sense from a medical perspective why they have to come in at all,” said Daniel Grossman, an abortion provider and professor of obstetrics and gynecology at the University of California, San Francisco. “It would be so much easier and safer and reduce the risk of transmission of coronavirus to patients and health care workers to just mail the medications directly to patients.”
Grossman noted that mifepristone has been on the market for almost 20 years in the U.S. and has a good safety record. At this point, it’s safe, effective and easy enough to use that it should be available over the counter, he said.
He harbors no false hope of that happening anytime soon. But he said he was optimistic that this crisis would provide a chance to critically reexamine how people can access abortion in 2020.
“After the pandemic, the way we deliver medical care will have changed in America,” he said. Across all areas of medicine, he predicted broader use of telemedicine ― which allows providers to see patients over the computer or on the phone, eliminating the need for transport and extended child care.
In the meantime, Grossman urged policymakers to do everything possible to expand access to early medication abortion, including allowing the drugs to be sent to women in their homes.
“That is the safest way of expanding access to and maintaining access to abortion care during the pandemic,” he said.
Are you trying to self-manage an abortion during the coronavirus outbreak? We want to hear from you. Email Melissa Jeltsen at firstname.lastname@example.org.
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