In countries where abortion is illegal or more heavily restricted than it is in the U.S., external women’s-health organizations often try to fill in the gap. There’s Women on Waves, the Dutch group behind a semi-famous “abortion boat” offering medication-facilitated abortions to women in international waters a few miles off the coast of their own countries. (It anchored near Mexico last week.) Its sister organization, Women on Web, mails abortion pills to women in places where the procedure isn’t legal or safe and counsels them to administer the medicine themselves. Safe2Choose and Women Help Women do the same.
But women in the U.S. have been largely excluded from efforts to make abortion medication available by mail. Some of these organizations focus their work on countries where abortion is least accessible and least safe; the U.S., where abortion is a constitutional right offered at well-regulated clinics, doesn’t qualify. Other groups, like Safe2Choose, do send pills to women in countries with legal abortion, but fear of legal repercussions keeps them from mailing them to people in the U.S.
That doesn’t stop U.S. women from trying to figure out how terminate their pregnancies confidentially, without a doctor’s assistance. A Safe2Choose executive told the New York Times it gets tens of thousands of monthly visitors to its site from the U.S., and Women on Web gets multiple emails from U.S. women a day. Last year, economist Seth Stephens-Davidowitz reported that Google searches for “how to self-abort” and “how to have a miscarriage” spiked in times and places that saw an increase in abortion restrictions. In those states, rates of legal abortion fell, but birth rates didn’t rise. It appeared that there were thousands of missing births—or missing abortions—unaccounted for in public health data.
Recognizing that even women in a country with legal abortion might need help getting one, Women Help Women is introducing a U.S.-specific online counseling service for women who are trying to terminate their own pregnancies at home. At abortionpillinfo.org, women who’ve gotten misoprostol—one of two drugs usually taken as a pair to end a pregnancy—through a means other than a doctor can contact a counselor for personalized advice and instructions for how to take it and whether to seek further medical attention. The service is called Self-managed Abortion; Safe and Supported (SASS).
SASS is a direct response to the current wave of abortion restrictions coming through state houses and the hostility the White House has shown to women’s health in recent months. “WHW has been providing information and support to thousands of women around the world since 2014,” said Kinga Jelinska, Women Help Women’s executive director, in a statement. “We are now expanding this information service to the U.S. because the new Trump administration and anti-abortion legislatures in many states are moving swiftly to push abortion out of reach.”
Abortion restrictions—which require women to wait longer, make multiple trips to the clinic, and travel obscene distances to get, in some cases, a blister pack of pills—are just one of many reasons why a woman in the U.S. might need a self-induced abortion. Cost is a big one. The Hyde Amendment bars women on Medicaid, the Indian Health Service, federal-employee health care plans, or any other federally funded health plan from getting insurance coverage for abortion. Republicans in Congress have been trying to dismantle private insurance coverage for the procedure, too. Confidentiality may figure into some young women’s desire to manage their own abortions: In all but a handful of states, minors must notify their parents (or in some cases, get explicit permission) if they don’t want to carry a pregnancy to term and need an abortion.
As the New York Times reported on Thursday, it’s pretty easy to find misoprostol, with or without its usual pairing of mifepristone, for sale online. Plan C, an organization that educates women about how to get misoprostol and campaigns to get it sold over the counter, recommends buying it on pet-medicine sites (it’s used for stomach ulcers in dogs). But the procedure is a little more complicated than swallowing an aspirin—multiple pills must be held under the tongue for 30 minutes—and since messing up could mean an incomplete abortion, taking the pills correctly is important. Women Help Women’s online consultation service could help women complete a successful termination with a lower risk of needing medical intervention.
Abortion by medication already carries a very low risk, about the same as having an uninduced miscarriage, and only 2 to 3 percent of patients will need additional medical care. This low complication rate would support any future campaign to make abortion medication available over the counter. New research published Thursday in BJOG: An International Journal of Obstetrics and Gynaecology lays out the additional research needed and likely obstacles that would face such a campaign.
Women would have to be able to determine the length of their gestation based on their last periods, or get a separate ultrasound to determine their eligibility for medication abortion, since it’s only safe and effective through about the 10th week of pregnancy. The FDA would also need to see a “label comprehension study” that proves patients can understand and properly self-administer the drugs; researchers cite multiple studies that have found women able to self-administer misoprostol at home after taking mifepristone at a clinic with “similar effectiveness and greater satisfaction” compared to those who had to take both at the clinic. To get FDA approval for over-the-counter sales, assessments would have to show that women don’t fare far worse with medical abortion complications at home, on their own, than with a doctor’s instructions, and that they know when to seek medical attention. The authors of the new research found studies that show women are “nearly as accurate” as clinicians at determining whether the abortion was successful by filling out a symptoms questionnaire.
The most difficult obstacles to FDA over-the-counter approval may be political, not scientific. Right-wing opponents of women’s health care in general and abortion in particular are prevalent in the federal government right now, and they won’t look kindly on giving women yet another way to take their reproductive decisions into their own hands. Then again, the FDA has defied over-restrictive GOP-backed legislation on the abortion pill before. Just over a year ago, the agency changed and expanded the on-label usage of mifepristone, making it available further into a pregnancy, at lower doses, and without three trips to the doctor’s office. This displeased state-level Republicans who’d legislated that doctors can only prescribe the pill in strict accordance with the FDA label. Of course, we have a new head of the Department of Health and Human Services now, and he’s not a friend to abortion access. But when the “religious rights” advocate at the head of the Justice Department is defending Obamacare’s contraception mandate against religious employers, you never know what might come out of this administration.
n any case, it’s a good time to start on that additional research—in four years, these guys might be out of a job, clearing the way for better access to safe medication when women need it.