Maggie Mayhem knows when she decided to become a reproductive rights activist. At around 13 she discovered two conditions in her southern California Catholic girls school’s manual:
If a student was found to have had an abortion, they would be expelled, because abortion was against the teaching of the Catholic church.
At the same time, the school would not accommodate a student who became pregnant.
“It taught me my reproductive system was something I should be afraid of, that it could have negative consequences for my life,” Mayhem says. “I saw: ‘there will be no sympathy for you. And anyone that you talk to about this poses a risk.’”
She also saw beautiful things: friends helping friends to the abortion clinic. Teenagers taking care of teenagers, keeping grownups at bay. That solidarity led her to her current line of work.
Mayhem – a pseudonym – is just one of many US activists vouching for self-managed abortions outside the gaze of the medical establishment. With a growing slate of abortion restrictions and the recent leak of a supreme court draft opinion indicating justices have already voted to overturn the constitutional right to abortion, activists like Mayhem say such measures aren’t just necessary, they are also better than what’s currently on offer. They are saying: abortion is your right – and you don’t need to depend on doctors or the state for it.
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When most people think of self-managed abortion, they think of back alleys, coat hangers or throwing oneself down the stairs; of last resorts, despair, shame. But that is no longer the reality. Today, self-managed abortion often means taking pills that are available over the counter in many countries, with little risk of death or serious complications. Other times, it means using herbs, or vacuum aspirators, like the Del-Em (a homemade suction device created by activists in the 70s), under the watchful eye of somebody experienced – like a midwife or a doula – who can advise if things go wrong.
Self-managed abortion is not a silver bullet. It carries with it the risk of prosecution, even though it is not illegal in most states. In April, a Texas woman was charged with murder for a self-induced abortion, even though there was no legal basis for the charges – as the district attorney admitted when he dropped the case. And not everybody wants to turn to a clandestine market for their abortion care. Some people feel more comfortable with a licensed practitioner. People want options. But for many, options are fast receding.
Those who look outside the medical establishment will find, often through word of mouth, an underground movement of doctors, midwives, doulas and activists – some trained by formal institutions, others by practitioners in the network. They will find those who mostly undertake legal work – sharing information from the World Health Organization about how to use medication to induce an abortion, for example. They’ll also find some who do not – assisting with abortions later down the line, or giving medical advice when things go wrong.
“It is not a practitioner’s or a government’s job to give people power,” says Samantha Zipporah, an educator who refers to herself as a traditional midwife – Zipporah is not credentialed. Zipporah says she rejects state regulation of pregnancy care. To her, home-centered abortion care is far from a last resort or a reaction to a changing policy landscape. It’s simply not something that should be dependent on an outside authority.
“Throughout history, we have a much greater tradition of our fertility and reproductive capacities being social, spiritual and ecological rather than medical or political,” she explains.
“The medical-industrial paradigm, the church, the state – these institutions are set up in a way that requires obedience and submission,” she says. “Our power was never theirs. Our bodies have power.”
The advent of medication abortion has made the work of these activists easier – because it is easily available. Medication abortion is safer than Tylenol – resulting in a successful termination 99.6% of the time when used appropriately, with less than a 1% risk of complications, according to the Kaiser Family Foundation. The safety of other means used outside a clinical setting hasn’t been sufficiently studied, but broadly speaking, existing data from recent years does not show elevated fatality rates from self-managed abortion.
The FDA recently allowed people to receive abortion pills by mail, without needing to first visit a medical facility. But states seeking to restrict abortion have required in-person visits or have banned abortion telehealth services outright.
That’s just one reason activists want to cut out the middle man.
Although the majority of abortions are completed with medication, only 21% of the US public know these pills exist. People can order them online but scam sites are common. So activists use in-person and virtual grassroots networks to share where to buy the pills, how to safely ingest them, what a normal response to them looks like and when to seek help. Crucially, they can explain the legal landscape – after all, if you turn up at the emergency room admitting you tried to cause your own abortion, you could face legal risk. But because medication abortion and complications from it look exactly the same, medically, as a miscarriage – people need not disclose they tried to induce their own abortion.
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Self-managed abortion can eradicate barriers, even in a world where in-clinic abortions aren’t under attack. It offers privacy: the ability to have an abortion at home, away from protesters, or your community. It may offer cover from an abusive partner. And it means that people who live far away from a clinic, or can’t afford to make the trip, can still access the procedure.
“It all comes down to someone assessing their own situation, and being able to make a decision about how to manage their reproductive care. There’s simply no medical reason that abortion pills shouldn’t be over the counter,” says a spokesperson for Mountain Access Brigade, a group that runs an abortion hotline in Appalachia and the south-east. “To make people jump through these hoops: to go to appointments, to have a mandatory ultrasound – these things are designed to humiliate, shame and coerce them into changing their mind,” she adds.
“These pills are safer than aspirin. They’re safer than Viagra. We let people manage very complex conditions at home – such as diabetes. And yet these pills are so restricted,” says reproductive rights activist Susan Yanow. “People are afraid of them.”
Of course, some doctors worry about self-managed abortions. The abortion pill is considered safe only until 10 weeks. People can still use it effectively up to 14 weeks, but the risk of complications goes up.
Doctors worry about people estimating the wrong date of conception; that they may still be pregnant after taking the medication without realizing; or they will experience complications and end up in need of urgent help.
“I absolutely worry about people self-managing their abortions,” says Dr Mark Rosing, an obstetrician gynecologist who works in the Bronx, New York. “A patient could hemorrhage, develop a severe infection and even die,” he adds.
Rosing was in training in New York in the early 2000s, when he noticed patients in the emergency room talking about taking a “star pill” before miscarriage. They were referring to misoprostol, one of the drugs used to induce a medical abortion, which was not widely available for abortion uses then. He presumes many people used the medication successfully and didn’t end up in the emergency room. But those who did were panicked, scared of how much they were bleeding and sometimes hadn’t successfully evacuated the pregnancy.
He understands that in a landscape that looks increasingly likely to overturn the constitutional right to abortion, leading to bans in 26 states, people might not have a choice. “I wouldn’t blame them. People aren’t going to stop trying to get what they need,” he says.
Rosing was trained by many doctors who practiced before Roe v Wade, the seminal supreme court decision which established the constitutional right to abortion. His mentors and teachers told him about cases involving self-managed abortion, and the gruesome complications which haunted them.
“People came in with perforated uteruses, hemorrhage and severe infections. People lost their uterus and all kinds of things,” he says. “I’m really afraid we’re going back there.”
The reality is that self-managed abortions don’t look the same now as pre-Roe. There were 19 deaths related to “illegal” abortions – those not performed by a licensed clinician – in 1973, the year Roe v Wade was decided, according to CDC data. In the last two decades, two people have died from an illegal abortion, while 103 have died from a legal abortion. The comparison is not like-for-like – hundreds of thousands of legal abortions take place every year in the US, whereas the full scale of self-managed abortion is unknown – but the dangers of self-managed abortion may be overstated.
“We are more capable of being able to understand our reproductive selves – and to manage that effectively and safely – than we’ve been led to believe,” says Vienna Farlow, a holistic healthcare practitioner. “But the system is set up to say, you’re too dumb to do any of this. And not only are you too dumb, your body doesn’t matter enough for us to even care to tell you how to do it,” she expands.
Activists believe much of the stigma around self-managed abortion was caused, in part, by a campaigning technique by the pro-choice movement – when abortion activists would hand out small coat hangers, defending the right to abortion by evoking images of dangerous procedures that are no longer the norm.
“That may have been very necessary or appropriate for the time, but it increased the fear of abortion and added a lot more abstract ideas of danger rather than demystifying what abortion is,” Mayhem says.
Between 2017 and 2020, researchers from the University of California, San Francisco, tried to understand the prevalence, effectiveness and dangers of self-managed abortions – the first ever such study to do so. They asked a random sample of 7,022 women if they had self-managed an abortion in their lifetime and 1.4% responded that they had, leading researchers to predict that something like 7% of all women in the US will self-manage an abortion in their lifetime.
The researchers were surprised by the methods women use to induce their own abortions – booze, herbs, pills, even asking a partner to hit them in the abdomen. They thought medication abortion would be more prevalent. These methods were largely ineffective, but also largely not life-threatening. Of 92 participants who said they had tried to manage their own abortions, 27 were effective. Twelve said they experienced complications (defined as something requiring “treatment by a doctor or nurse”). Nobody experienced severe complications.
For one in five participants, not being able to locate an abortion clinic, or having to travel too far to get to one, was the reason the person attempted self-management.
Forebodingly, the researchers pointed out: “Unprecedented levels of new state-level abortion restrictions … and the potential for a Supreme Court decision that could reshape federal Constitutional protections on abortion, suggest an urgent need to pay close attention to trends in [self-managed abortion] … in the coming years.”
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While fears over medical difficulties abound when discussing self-managed abortion, incarceration is the bigger threat in the US. At least 17 people have been arrested in the US for charges connected to self-induced abortion. They include Jennifer Whalen, who served jail time for buying pills online for her 16-year-old daughter to have an abortion, after they couldn’t access an appointment at a clinic. Some, like Purvi Patel in Indiana and Regina McKnight in South Carolina, were given decades-long sentences. Both were overturned, but not before each spent years in jail.
But what are the risks of not getting an abortion? First, a lot more people will die during childbirth – which is 14 times more deadly than abortion.
“Abortion is a very safe procedure. And in the United States, staying pregnant is relatively deadly, because we have such an abysmal rate of pregnancy-related mortality and morbidity,” explains Dr Amanda Stevenson, who conducted research predicting how many more people will die if Roe v Wade is overturned solely because of the greater mortality risk of continuing a pregnancy.
Her study found that, in the event of a nationwide abortion ban, pregnancy-related deaths would increase by 21% within two years. The numbers would be worst for racial minorities. Black people would experience the greatest rate of increase in deaths (33%), followed by Hispanic people (18%).
Denying women access to abortion also increases their chances of life-threatening complications, financial hardship and prolonged domestic violence. But if more people know how to manage their own abortions, risks would be reduced, surmises Dr Stevenson. “If the alternative is self-managed abortion, and that’s because clinic-based care isn’t accessible, then that’s a whole lot safer than staying pregnant,” she says.
Another midwife, who supports abortions outside a clinical context, points out the dangers associated with in-clinic abortions. She says she has supported people who have gone for an abortion in-clinic, and then found themselves with complications – like hemorrhage, or incomplete removal – who did not want to go back to the doctor. “There’s so many people that are sent home with pills, without any education about what [their experience should look like],” says the midwife, who did not want to be identified for legal reasons.
“I have supported people who have had incomplete abortions, and needed to go back to the clinic for a repeat suction a number of times, or have had infections and retained tissues, who did not go back to the clinic because the clinic was abusive … because the clinical care was so impersonal,” she says.
As Zipporah puts it, it’s not about placing one treatment over the other, it’s about giving people a choice.
“I am not demonizing medical care providers or medical care. I don’t think that abortion should be only always in the clinic with a doctor or only always at home with a midwife. I believe that people need to have the education and support to do whatever the fuck they want. And to realize that they have options,” says Zipporah.
