Why so many American women are ordering abortion pills online

A number of groups are helping American women access safe medical abortions at home, and as abortion rights are threatened their work is becoming even more vital.

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If Roe v. Wade is overturned, and anti-abortion fanatics in states such as Georgia and Alabama succeed in implementing their abortion bans, American women won’t stop having abortions.

Research by the Guttmacher Institute suggests that abortion rates are similar in countries in which abortion is highly restricted and those in which it is legal (in fact, countries that restrict abortion seem to have slightly higher abortion rates.)  The main difference is that when abortion is illegal, women are more likely to have unsafe abortions. According to the World Health Organisation, each year between 4.7 – 13.2 per cent of maternal deaths can be attributed to unsafe abortions.

There is, however, a safe way for women to self-administer abortions, one that was pioneered by Latin American women seeking to circumvent strict anti-abortion laws in the 1980s and that has since entered the medical mainstream in many countries. For women who are up to 10 weeks pregnant, a medical abortion, commonly using two drugs – misoprostol and mifepristone – is over 95 per cent effective at terminating a pregnancy, and the risk of serious complications is extremely low. 

Medical abortions, though heavily regulated in the US, are a popular choice for women seeking abortions in clinics, used by around a third of American women who terminate their pregnancy within the first twelve weeks.

Now, thanks to a network of women’s organisations, abortion pills are also offering women who are already feeling the impact of state-level restrictions a safe way to terminate their pregnancy.

In the US, abortions can be prohibitively expensive, depending on a woman’s healthcare coverage and how advanced her pregnancy is, costing anywhere from a few hundred dollars to tens of thousands. Around 90 per cent of US counties do not have an abortion clinic, in part thanks to state-led efforts to defund family planning clinics and impose onerous restrictions on abortion providers. This means women often have to budget for considerable travel costs, time off work and childcare arrangements.

Some states have introduced mandatory counselling sessions and waiting periods, which means women are burdened with still more travel costs, more time off work, more childcare to arrange. In states that require minors to obtain parental consent before an abortion, this too can block a vulnerable teenager from terminating her pregnancy.

This all means that low-income women, who make up around three-quarters of women seeking abortions in the US, are already being hard hit by abortion restrictions.

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Last October, a charity called Aid Access began providing American women with online medical consultations and abortion pills by mail to enable them to safely terminate their pregnancies at home. Aid Access is an offshoot of a non-profit called Women on Web, founded by the Dutch doctor Rebecca Gomperts, which since 2006 has been prescribing and sending abortion pills to women in countries where abortion is illegal.

Gomperts told the Guardian that between October 2018 and March 2019 21,000 women requested abortion pills from Aid Access, and around a third subsequently received them. Around three quarters of the women lived in states that are hostile to abortion, and some told Aid Access that they had been considering drastic and dangerous measures to end their pregnancies, such as getting someone to punch them in the stomach.

In March 2019 the US Federal Drugs Administration issued a warning letter ordering Aid Access to stop sending women abortion drugs. The charity is currently challenging the FDA ruling.

Meanwhile, another American non-profit, Plan C, which was founded in 2015 by two public healthcare experts, Elisa Wells and Francis Coeytaux, is also trying to plug the gaps in American abortion provision by providing women the information they need to obtain an abortion with pills.

It directs women who live in Georgia, Washington State, Maine, Oregon, New York, New Mexico, Hawaii and Colorado to a pilot “TelAbortion” project, which will mail abortion pills to a woman’s home following an online medical consultation.

For others, it offers information on how to safely self-administer a medical abortion. Knowing that many women have already tried to order abortion pills online, without knowing whether they are being scammed, Plan C compiles and regularly updates a “report card” that rates different websites from which you can buy abortion pills.

Wells told me that traffic to Plan C’s website keeps increasing, too. They now average around 40,000 hits a month.

“If the worst-case scenario happens [and Roe v Wade is overturned], there will be more need than ever for groups like Plan C, that are providing information for people to make their own decisions about the medical care they need, and to gain access to that medical care,” says Wells. “There’s no stopping people from accessing information and medications, we have a global economy and a global information system.”

Restrictive policies can make life harder for women, but they cannot make abortion impossible. And it is fitting, perhaps, that the history of medical abortion has long been entwined with the history of abortion restrictions and the female-led resistance.

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In the eighties, Brazilian women learned that misoprostol, a drug used to treat ulcers, also worked as a safe and effective abortifacient. As misoprostol became an increasingly popular way for women to terminate their pregnancies despite the country’s strict anti-abortion laws, Brazil experienced a drop in the annual mortality rate from illegal abortions. Knowledge of misoprostol’s off-label use spread among women in Latin America, and indeed across the globe, and other countries too noticed a drop in the number of women dying each year from unsafe abortions.

On its own, and when taken correctly, misoprostol is about 75-85 per cent effective at inducing abortion during within the first ten weeks of pregnancy. But when used in combination with another drug, mifepristone, which was developed in France in the 1980s, the effectiveness rises to over 95 per cent.

Overall, the risk of complications is extremely low: according to the US FDA only 2 in every thousand women experience an adverse reaction to mifepristone – making it significantly safer than other widely-used drugs, such as Tylenol (known as Ibuprofen in the UK) or Viagra.

These two abortifacient drugs revolutionised reproductive healthcare. While surgical abortions can only be safely performed by qualified doctors, medical abortions can be administered by other health workers or, under the right circumstances, by women themselves.

The combination is so safe to use that World Health Organisation guidelines suggest that women can manage most stages of the process without visiting a medical professional, provided they are given adequate guidance. (It recommends more research is conducted into whether women can reliably self-assess their eligibility for the drug.)

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When mifepristone was approved for use by the Federal Drugs Administration (FDA) in 2000, Wells hoped that it would transform abortion provision in the US, too, by drastically increasing the number of abortion providers and reducing the barriers to accessing abortion.

It didn’t happen that way, however.

Even though you’re less likely to an experience an adverse reaction to Mifepristone than an over-the-counter painkiller (each year around 100 Americans die from an inadvertent Tylenol overdose), the abortion drug is part of a drug safety programme known as Risk Evaluation and Mitigation Strategies (or REMS) which limits the number of medical professionals licensed to dispense the drug and means its distribution is strictly monitored.

At the same time, anti-abortion legislators have repeatedly tried to restrict the use of non-surgical abortions. Eighteen US states require that doctors are in the same room as women seeking abortion care, which prevents women from using telemedicine services to have their abortion at home, with medical guidance.

“In the US, access to abortion drugs is restricted by politics, not by medical science,” Wells observed.

This all means that at present, the biggest risk faced by women who self-administer abortions seems to be legal, rather than medical (though any woman who experiences complications such as excessive bleeding or a fever after taking abortion bills should seek medical attention.)

At least 21 women have been prosecuted in the US for self-inducing an abortion, and it’s believed still more have been arrested. The group If/When/How has set up a free, confidential hotline for women with questions about their legal rights in regards to self-managed abortion.

There’s no doubt that should Roe v. Wade be overturned, it will represent an immense setback for women’s reproductive freedoms in America – but there is also a network of women-led organisations that are already preparing for the worst.

After all, if Plan A and Plan B don’t work out, there’s always a Plan C.

Sophie McBain is North America correspondent for the New Statesman. She was previously an assistant editor at the New Statesman.