This article is part of a larger series titled “The End Of Roe.” Head here to read more.
There’s a new war on drugs looming. But it won’t involve addictive narcotics or S.W.A.T. teams banging down doors. Instead, the approaching battle will be over medication that is safer than Tylenol and approved by the Food and Drug Administration: abortion drugs.
Medication abortion is the most common method of abortion in the country, accounting for about 60% of all abortions in the U.S. Abortion drugs were approved by the FDA in 2000, and are safe, effective and widely prescribed for miscarriage and abortion care before the 10-week mark.
If Roe v. Wade falls in the coming weeks, rolling back the constitutional right to abortion care, about half of the states will immediately ban or severely restrict abortion ― leaving a small patchwork of blue states to cover care for the rest of Americans. The country is staring down a historic moment that will irrevocably change the political and cultural face of the U.S. But medication abortion can ensure we don’t go back to the pre-Roe days of back-alley abortions and desperate women dying on tables in dingy motel rooms.
Many people don’t know that abortions can now, in many cases, be done from the comfort of their home. And anti-choice lawmakers and other abortion opponents are banking on you not knowing about medication abortion.
Many have already started explicitly attacking access to abortion pills: In the first three months of 2022 alone, more than 100 measures attempting to restrict medication abortion were introduced in red states across the country ― in addition to dozens of other extreme abortion restrictions that have gone into effect this year.
“It’s critical to remember that medication abortion is incredibly safe, incredibly effective and in high demand ― and the states hostile to abortion rights know this,” said Elisabeth Smith, the director of state policy and advocacy at the Center for Reproductive Rights. “That’s why they are trying to increase stigma around medication abortion… and create additional liability for those trying to access the pills.”
With or without Roe, anti-choice lawmakers know the next chapter in abortion care will center on medication abortion. And they’re starting to quietly wage a war, hoping to cut off access to a safe and effective abortion method before most Americans even know about it.
The Huge Disconnect In Understanding Modern Abortion
Medication abortion is a two-drug regimen ― one mifepristone pill, usually followed by four misoprostol pills ― that’s commonly used in the U.S. and around the world. Misoprostol alone can also be used to induce an abortion, and is widely used in countries outside of the U.S., but only a combination of mifepristone and misoprostol has FDA approval. When used together, they are more than 95% effective. Misoprostol used alone is also extremely safe, but only about 80% to 85% effective.
“For the longest time, everyone’s imagined abortion in a pre-Roe way ― a physical procedure that you must have,” said Christine Matthews, a veteran pollster who focuses on gender and voting. “Most voters don’t know that about half of abortions these days are done with pills.”
Some experts argue that the lack of common knowledge around medication abortion is by design, and overregulation has deliberately stifled the full potential of abortion pills in the U.S. In some countries, both mifepristone and misoprostol are available over the counter. In others, just misoprostol is available at pharmacies. Neither drug is available over the counter in the U.S., and mifepristone can only be prescribed and dispensed by certified prescribers.
“Anti-choice lawmakers know the next chapter in abortion care will center on medication abortion. And they’re starting to quietly wage a war, hoping to cut off access to a safe and effective abortion method before most Americans even know about it.”
Medication abortion can be obtained in a few different ways, but typically people set up an appointment at their local abortion clinic and are sent home with a bag of pills to be taken over the next 72 hours.
Leigh was recently one of those people, making the 20-minute drive to a clinic in Washington, D.C., to come home with a handful of abortion pills and Netflix their way through the abortion from the comfort of their bed.
“I was thankful I didn’t have to be in a clinic, that I could be at home in familiar surroundings and just try to relax as best as I could,” they said. (Leigh, who is nonbinary, is using a pseudonym for privacy reasons.)
But obtaining abortion pills in a clinic setting is becoming increasingly more difficult depending on where you live.
In the last few years, anti-choice lawmakers have ramped up their efforts to restrict access to in-person clinic care by using targeted regulation of abortion providers, also known as TRAP laws, and other medically unnecessary restrictions, such as state-mandated waiting periods between the consultation and getting the pills prescribed, required counseling that’s not based in science or laws that force people to listen to fetal activity before accessing an abortion. In states like Oklahoma and Texas, which have extreme abortion bans, people are forced to take multiple-day journeys out of state just to access a handful of abortion pills.
Since in-clinic access has all but disappeared in many red states, some providers have moved online, allowing people in certain states to access abortion pills by mail. States including California, New York and Colorado allow telehealth for abortion before the 10-week mark, through online pharmacies like Hey Jane and Abortion On Demand. This means that a physician can virtually prescribe and send abortion pills right to your doorstep, allowing you to manage your abortion from the comfort of your home.
And it’s clear there’s a growing interest in accessing abortion pills from these online pharmacies. Before the Supreme Court draft decision leaked in early May, Elisa Wells, co-founder and co-director of Plan C, an advocacy organization that provides people with information on how to obtain abortion pills, told HuffPost her website averaged around 2,500 visitors every day. The night the draft decision leaked, Wells said her website saw 16,000 visitors. The next day, it had 56,000 visitors.
But with more awareness of the benefits of and easy access to abortion pills, comes more attacks from abortion opponents. Heavyweight anti-choice groups like Susan B. Anthony List and Americans United For Life stated at the start of this year that restricting abortion drugs is a top priority in 2022. Already, 19 states have banned prescribing medication abortion via mail or by virtual telehealth visits.
This year alone, Missouri lawmakers introduced bills that would equate mailing abortion pills to drug trafficking. In Kentucky, lawmakers created a public database that lists the name of medication abortion providers so that people can anonymously report any purported violations of the state’s abortion laws. Tennessee lawmakers passed a bill making it a felony to mail medication abortion, punishable by a $50,000 fine or up to 20 years in prison ― a similar law passed in Texas last year. And all of the draconian abortion bans in places like Texas, Oklahoma and Idaho apply to both procedural and medication abortions.
“In the face of these unjust laws and unjust court decisions, this is what we want people to know: There is something you can do,” Wells said. “We’ll tell you where to find these pills, how to use them, how to get support and what you need to know about the landscape around using pills for self-managed abortion, including the potential legal risk.”
Self-Managed Abortion In A Post-Roe Reality
As access to in-clinic and telehealth abortion dwindles in red states, some women and birthing people will prefer self-managing their own abortions because it’s easier than navigating the ever growing list of barriers. And many will simply be forced to self-manage their abortions because they don’t have any other options.
Thankfully, self-managing your own abortion with medication looks very similar to one done in a clinic or via telemedicine. A self-managed abortion is done outside of a traditional health care setting, often when a person obtains abortion pills not from a physician and undergoes an abortion without medical assistance. Because medication abortion is extremely safe and effective, it will ensure that we don’t go back to the pre-Roe days of botched abortions that left so many dead.
There are several ways to to get abortion drugs outside of the traditional health care setting, including in Mexico, where misoprostol is widely available over the counter. People can also go through Aid Access, an Austria-based nonprofit that prescribes medication abortion via mail to all 50 states.
Aid Access can offer telehealth abortion anywhere in the U.S. despite specific state restrictions because their provider is based in Austria. This allows the group to circumvent U.S. regulations that penalize providers, and prescribe medication free of legal risk. Obtaining abortion pills through Aid Access is not technically characterized as a form of self-managed abortion because patients are guided through the process by a physician. But most people who need to go through Aid Access are likely navigating state restrictions or bans on abortion.
Managing an abortion outside of traditional health care settings brings with it certain legal gray areas.
“People have been targeted for criminalization for self-managed abortion in this century in numerous states where prosecutors misapply laws that were never intended to be used against somebody for ending a pregnancy,” said Sara Ainsworth, the senior legal and policy director at If/When/How: Lawyering for Reproductive Justice.
“One of the reasons we understand that that happens is, in addition to the political opposition to abortion, is that there’s so much stigma that surrounds abortion generally,” she added. “The idea that it must be illegal if someone is managing an abortion on their own is unfortunately very pervasive.”
“The more stigmatized and banned abortion is, the more people will be forced to self manage and the more likely it is that politically motivated prosecutors will look to other laws to try to go after the people who self-manage their care and investigate, prosecute or criminalize them in some way.”
Lizelle Herrera is a perfect example of how the law can be misunderstood and incorrectly applied when it comes to self-managing abortions. Herrera, a 26-year-old Texas mother of two, was arrested and charged with murder in April for allegedly self-inducing an abortion. Many of the details around Herrera’s case are unknown, but she likely used medication to terminate her own pregnancy. She was held in a jail with a half-million-dollar bail.
But self-managing your own abortion is not illegal in Texas. It’s actually not illegal in any of the 50 states except Nevada, South Carolina and Oklahoma ― and legal experts caution that it’s unclear if those laws would even stand up in court if challenged today.
The charges against Herrera were eventually dropped, but her story is emblematic of what could come if Roe falls and half of the states ban abortion.
“The more stigmatized and banned abortion is, the more people will be forced to self manage and the more likely it is that politically motivated prosecutors will look to other laws to try to go after the people who self-manage their care and investigate, prosecute or criminalize them in some way,” Ainsworth said.
Many pro-choice lawmakers in blue states, however, are preparing for a post-Roe world where prosecutors misunderstand or misapply the law to people self-managing care. Washington state just passed a law that bans the criminal legal system from investigating or prosecuting people who self-manage their abortions or anyone who helps them. California and Michigan are also debating similar measures, including ballot initiatives to ensure people are not criminalized for their pregnancy outcomes.
While abortion pills will revolutionize access and allow people to self-manage their abortions in a post-Roe world, there are glaring limits. Dr. Christie Pitney, a provider at Aid Access and the CEO of Forward Midwifery, cautioned that there will always be people who don’t know their options or are too afraid of presumed legal risks to attempt to self-manage. Or people who are simply past the 12-week point and will need a procedural abortion.
“Medication abortion will absolutely not be enough of a stop-gap. It will help to an extent, but it won’t be the end all be all,” Pitney said. “The ideal situation would be that folks can choose between community care, getting a medication abortion or procedural abortion at a clinic in their area, or choosing telehealth. It shouldn’t be that politics is forcing us to choose one option over the other.”
More Surveillance, More Mistaken Criminalization
Every single abortion restriction that has passed into law in modern history excludes one person from being punished: the pregnant person. Most measures target physicians; other laws, like those in Texas and Oklahoma, also penalize anyone who aids and abets someone looking to get an abortion. But never the person getting an abortion.
This is important because it avoids criminalizing people for any pregnancy outcome, including a miscarriage of a wanted pregnancy, and ensures that women cannot be thrown in jail for self-managing their own abortions with abortion drugs. At least for now.
Louisiana recently tried to pass a law that would allow prosecutors to charge women who got abortions with criminal homicide. Although the bill drew immediate criticism and never made it to a vote, it’s emblematic of what could come ― especially if Roe falls.
“We know that criminal law penalties and sanctions fall hardest on historically marginalized communities who are already subject to racism in so many systems,” said Smith, from the Center for Reproductive Rights.
“When we think about a future where abortion is unavailable in potentially half of the states and we think about people exerting their bodily autonomy by self-managing their abortions,” she added, “there is an anticipation that the racialized prosecutions we’ve seen in the history of prosecutions based on pregnancy outcomes would likely accelerate.”
It’s hard to truly understand the many ways the fall of Roe will impact people across the country. But a few things are definitive: There will be delays in care and an onslaught of misinformation. Many will be forced to self-manage their own abortions, and many more will simply be forced to carry unwanted pregnancies to term.
To get a glimpse of a post-Roe future, just look to Texas, said Rep. Veronica Escobar (D-Texas).
“On a number of levels, Texas represents the dystopian vision that Republicans have for Americans,” she said. “The Republican Party has become an extremist movement and when you have politicians who are angling for that extremist base, they will stop at nothing. So, Texas absolutely does give us insight into the kind of future that Republicans want for women and healthcare professionals.”
If you or anyone you know needs assistance self-managing a miscarriage or abortion, please call the Miscarriage + Abortion Hotline at (833) 246-2632 for confidential medical support or the Repro Legal Helpline at (844) 868-2812 for confidential legal information and advice.