Editor’s Note: This piece was originally published on January 26, 2018. It was updated with new research compiled by the New York Times on September 27, 2019.
According to the New York Times, researchers think that while in-clinic abortions have declined, at-home abortions are on the rise. As abortion becomes harder to access, more and more women are taking matters into their own hands with self-managed abortion—buying abortion pills on the internet and using them without medical supervision.
The recently-launched Self-Managed Abortion. Safe and Supported (SASS), a project of Women Help Women, provides information about the safe use of abortion pills to end an unwanted pregnancy without a clinician, including access to skilled bilingual counselors in English or Spanish through a secure portal.
Boston-based Susan Yanow, spokesperson for the project and co-founder of Women Help Women (WHW), which is working to make medication abortion available around the world, answered some questions for us about self-managed abortion and where activism intersects with this burgeoning movement.
What are the advantages of self-managed abortion?
For one thing, it minimizes the chance that those unable to go to a clinic will use a harmful method – punching themselves in the stomach, throwing themselves down the stairs, using something caustic, using something sharp. But beyond that, Women Help Women frames self-managed abortion in the human rights feminist context of empowering people to take control of their own healthcare. So we don’t see self-managed abortion as a less good alternative to clinic-based medicine, even though we know that in the U.S. some people are probably choosing to self-manage because they can’t get to a clinic given the incredible restrictions and rate of clinic closures. We now have seven states where there is only one clinic. So we actually envision self-managed abortion as a legitimate alternative.
Why might somebody who has access to healthcare choose to use self-managed abortion?
That’s a great question and let me put that to you, whom I assume is a very busy person. I’m going to give you the option: you can go down the street, you can pay $500, you can go through protestors, you can spend a lot of time in the waiting room – all of which is to take one medicine, the mifepristone, in front of a clinician and be given the misoprostol, which you will take 24 hours later at home anyway. So you’ve essentially spent a good part of your day to have somebody watch you swallow a pill. You might feel confident that you can do this without being supervised.
Another reason is that clinics may not have a clinician available at a time that is best for the person seeking an abortion pills — they may only be able to administer the mifepristone, say, on Tuesdays or Wednesdays which forces you to take the misoprostol 24 hours later and bleed on schedule. If you are self-managing your abortion, you might choose to use the mifepristone (which causes no side effects) on a Friday and do the bleeding and cramping on a Saturday, which just might be more convenient for you in terms of arranging for child care, taking time off work, not having to give people at work a reason that you need to take a day off, etcetera.
The final reason is cost. For first trimester abortion before 10 or 11 weeks, whether one is using medicines or having an aspiration abortion, the cost is between $500 and $700. These abortion pills are available in a range of places in a range of prices, but always at lower prices than that.
How much do they cost and where might people get them?
If a person is seeking mifepristone plus four misoprostol, which is 95 to 98 percent effective in the first 10 or 11 weeks of pregnancy, studies show that quality medicines are available on the internet. A study by Gynuity Healthcare tested the mifepristone/misoprostol combination medicines purchased from 18 different internet sites and found they were of high quality and ranged in price from $110-360.
The World Health Organization has also established a protocol for using misoprostol alone. Women in Brazil actually figured that out by looking at the label which said “Don’t use if your pregnant. Could cause cramps.” They actually identified it as a way to have a safe abortion. The World Health Organization, after much research, has created protocols which describe how to use 12 misoprostol pills alone for a safe abortion up to 12 weeks. Misoprostol is used to treat arthritis and ulcers. It’s used in hospitals to induce labor. And it’s used to treat arthritis in dogs. It’s over the counter in many Latin American countries and African countries. And for all of those reasons people may have an easier time finding misoprostol. Misoprostol is 80 to 85 percent effective in ending an unwanted pregnancy.
Are abortion pills medically safe?
Yes, in fact, safer than aspirin. More people die in the U.S. each year from penicillin than from these medicines. They are very, very safe. They’re actually on the World Health Organization list of essential medicines. If a person is concerned or has signs of a complication, they should seek medical treatment, but understand that the symptoms are exactly the same as a miscarriage, that there is no test for mifepristone and misoprostol in blood or urine, and that one need not reveal that one took these medicines. In fact, in many states, one might be at legal risk if one reveals that one used abortion pills on their own.
Is self-managed abortion legal?
That’s a difficult question. State laws differ and many states have laws that criminalize self-managing one’s abortion. The SIA Legal Team is a UCSF group that has tried to map the laws around the country. In many states, managing one’s own abortion is specifically criminalized. For example, Massachusetts prosecuted a woman in 2007 under a state law that says it is a felony to procure your own miscarriage. This was the first known case of 17 women to be prosecuted in the US for using these pills on their own. The wording of the laws differs in every state and not every state has laws on the books that explicitly criminalize this practice. However, in every state there are laws that could be used to prosecute a person doing this. And similarly, if a district attorney learns that a person has used these medicines without medical supervision, there are a whole range of possible laws that could be used against them, from practicing medicine without a license to illegal use of medicine, even if there’s nothing specific in the criminal code.
Are there any efforts to change state laws to legalize self-managed abortion?
Yes, there are efforts in some places. In New York, there’s an effort to take abortion out of the criminal code totally and to frame it as a healthcare procedure—which makes sense, because why should a healthcare procedure be in the criminal code! I don’t know of any specific attempts to legalize self-managed abortion and, frankly, in this political climate I understand that this strategy would not be effective.
How does your organization support those who seek to manage their own abortions?
SASS is a website located on servers overseas with information about self-managed abortion and a secure portal through which people can access counselors who are based overseas. Through this secure portal, they can ask any question. After a person asks a question, they will get back a web link which is randomized letters and numbers; when the person clicks on that link, the answer shows up. The information disappears in seven days. The reason for setting it up this way is that part of the evidence against two of the women who were prosecuted for self-managed abortion was taken from their cell phones. So as SASS was being created, WHW wanted to be sure that there was nothing that incriminated women.
With an online-based approach to spreading information regarding self-managed abortion, how does SASS and Women Help Women do outreach to marginalized communities and make this information accessible to them?
The challenge of reaching those in vulnerable communities is one that all public health information disseminators face. When SASS was launched, there were over 40 stories about the project in mainstream media. But we know that many people, particularly those in vulnerable communities, don’t read the New York Times, The Washington Post, Bustle or Glamour. And so SASS is piloting some strategies to try to reach some of those communities. We are currently fundraising to try some social marketing approaches, as well as building a social media team to get into some of the smaller Reddit groups and other media that might reach more of those people. But we are very much in a pilot phase for that outreach.
Are you working to connect to grassroots organizations in these communities and form partnerships?
To the extent that we have the capacity to do that, yes. Women Help Women has 26 staff members based in 14 countries, but very limited staffing in the USA. SASS representatives have presented at the SisterSong conference, at Nursing Students for Sexual and Reproductive Health, Medical Students for Choice and the National Abortion Federation. We understand that community-level education is critical. We are trying to find innovative ways to do that with a train the trainer model.
The mainstream movement for abortion rights has largely shaped a narrative that centers formal medical settings and access to those spaces. While this is key, what sort of tensions with the larger reproductive rights movement arise in advocating for informal means of reproductive control and care?
I think many of the service providers understand that they are seeing people in their clinics who have already tried to end their abortion because women might come in bleeding or they might tell the provider. While there is a tension around clinics needing a certain volume to be viable, and certainly first trimester abortion is the bulk of all abortions, there’s also a recognition that communities have gotten out in front of advocates and service providers on this issue. We don’t know how many are using abortion pills on their own, but we know that this is not a new phenomenon. If one starts from the assumption that there’s a certain sized pie and self-managed abortion is taking away from that pie, it’s a very different conversation than to say perhaps the pie has always been larger than we imagined and how can service providers support people who perhaps have always been doing this but now are showing up at the clinic in larger numbers.
How does bringing information about self-managed abortion to the surface of conversations about reproductive rights and access also start larger conversations about our larger cultural attitudes and images of abortion, as well as the culture of mainstream activism around abortion rights and access?
First of all, self-managed abortion changes the definition of abortion provider. It’s the woman herself. And while some look at self-managed abortion from a harm reduction framework, Women Help Women is working to inform that harm reduction frame with a human rights and feminist lens that destigmatizes abortion, that says information about abortion pills needs to be more widely disseminated to everybody as part of basic healthcare information, including to people who will choose a clinic. Harm reduction includes reduction of harm from overmedicalized health care and from punitive and restrictive state policies.
Many people in the US don’t even know there is such a thing as an abortion pill. It should be part of basic sexual health education, just like information about how to handle menstruation or positive sexuality, consensual sex and contraception is a basic part of human rights and bodily autonomy. How to handle an unwanted pregnancy should be part of that. It isn’t, but should be. We see the conversation on self-managed abortion as an opportunity to break through stigma and begin to use a feminist empowerment model. Not every woman who is taking pills on her own feels particularly empowered—she may feel disempowered and frightened and scared and alone and wish she had a clinic she could go to. But some of that fear is socially and culturally generated because of the stigma, shame and misinformation that has been spread both about abortion and the safety of abortion. SASS hopes to begin to shift that.
How is creating access to knowledge about the option of self-managed abortion a radical act in this particular moment?
Framing abortion without medical supervision as a right is a departure from how abortion has been talked about in our communities. Women Help Women has used this as complementary to all the work that is going on in reproductive rights and justice in the US and as something of a gadfly from the left, if you will, to provoke our movements to think more radically about how we perhaps have been complicit in over-medicalizing and over-regulating the practice of abortion.
In reading about your organization, I think about Our Bodies, Ourselves. I think about the Jane Collective—of the long history in the women’s movement of attempting to understand and take control of our bodies. How do you see what you’re doing as fitting into that tradition?
It very much fits into that tradition. In fact, I have had many conversations with Judith Arcana, who was one of the Janes in Chicago, about how abortion pills are the new Jane. The difference is that people don’t have to travel and the technology is so much easier. Obviously, the Jane Collective taught us that doing an aspiration abortion can be learned, but that’s very different from a very simple set of instructions on how to take a pill, so it builds on that philosophy, but the technological change is that taking a medicine is simply easier. We see the SASS project and Women Help Women as building on the foundation that the self-help movement and the Jane Collective created. We’re very linked to them personally and politically.
Sometimes the abortion pill is called Plan C. Can you explain that?
There are groups that call the abortion pill Plan C because Plan B is when you don’t use contraceptives and have unprotected sex, so Plan C should be when your contraceptives fail. We chose the term “self-managed abortion’ because we see it as more empowering and as capturing more of the human rights and feminist lens. Plan B is a medicine and a medical approach—it’s great. “Plan C“ frames abortion as a backup to contraception and places abortion on the continuum of family planning, which is also great. But we prefer the more active term of self-managed because it implies agency. Not everyone—or most people—who self-manage their abortions feel empowered, but our work is to make them feel empowered and to help break the stigma and the fear and the misinformation. I want to say we work very closely with the folks who have the Plan C website. We’re very collaborative. We just are taking a slightly different approach.
So how can readers of the Ms. Blog support the work of SASS?
Information sharing is critical. On the SASS website, there is art to create stickers and flyers. People can take them, rearrange them, print as many as they want, put them anywhere. People can take the information from the website and educate themselves about these pills and share that information with others just the way people chat with their friends about the best birth control method. We know from studies that people certainly listen to their medical provider when choosing a birth control method, but they listen way more to their girlfriends, so spreading that information is key.
People are also certainly welcome to donate to support the more formal outreach efforts and people are always welcome to contract SASS through the website with their ideas about how they might be able to help. We had a graphic artist who donated her skills to create our stickers, for example. We have our social media team that’s blogging, and anybody can take those blogs and put them on their own social media to spread the word.
The more people that spread the word, the more chances there are that that a rural, vulnerable person in a state with limited access will learn about SASS. We have training manuals and materials on the website. People can learn this themselves. This is not complicated. The instructions are right on the website. That’s part of the demystification. One doesn’t need to be an expert to share this information any more than the Jane Collective. People across Latin America have been self-managing abortion since the ’80s.