With the confirmation of Justice Brett Kavanaugh, the U.S. Supreme Court now has the votes it needs to completely undermine or overturn Roe v. Wade, the landmark case legalizing abortion that turns 46 next week. In response to the likelihood of Roe’s demise, reproductive rights advocates have mounted campaigns raising awareness of the safe and effective use of the drug misoprostol as an option for those who want to self-manage the termination of their pregnancy at home. Self-managed abortion can be an ideal option for immigrant women currently in the crosshairs of the Trump administration’s anti-immigrant, anti-choice administration, but the risk of imprisonment is especially high for low-income women of color who obtain the medication through illegal means.

Although there is little to no data on arrests of undocumented women tied to self-induced abortion in the United States, National Latina Institute for Reproductive Health (NLIRH) Executive Director Jessica González-Rojas told Rewire.News undocumented immigrants are “absolutely more criminalized” and fundamentally experience the criminal justice system differently.

“Imagine being undocumented and considering self-managed abortion in this environment. Even though there is so much evidence proving how safe medication abortion is, an undocumented person has a lot to consider, including the risk of deportation. More than that, they’re also worrying about how getting criminalized might not just rip them from their children, but it might shine a spotlight on their family and put them in danger too. Every choice that’s made is compounded by being undocumented in this increasingly hostile environment,” González-Rojas said.

In her work, González-Rojas has come across immigrant women who carry unwanted or unintended pregnancies to term only because the other options seemed too risky and scary. Widely reported cases like Blanca Borrego’s in Texas do not help quell panic among these communities.

The 44-year-old undocumented immigrant from Mexico had been living in the United States for more than a decade in 2015 when she used a fake driver’s license at a women’s health-care clinic run by Memorial Hermann. Staff immediately called the Harris County Sheriff’s Office, which sent deputies to the clinic where Borrego was waiting to see a gynecologist. Borrego was arrested in front of her daughters and taken into custody. (Shortly after Borrego’s arrest, Memorial Hermann defended its actions in a press release that included Borrego’s name without her consent, a violation of the Health Insurance Portability and Accountability Act.)

Borrego’s experience illustrates how access to all forms of health care, including reproductive health care, is dangerous for undocumented people. González-Rojas said that just getting to the clinic can be overwhelming. Undocumented women in states like Texas have to risk going through Border Patrol checkpoints in order to access care. Worse, at clinics that do offer abortion services, protesters have been known to take patients’ pictures, take pictures of their cars and license plates, and harass them as they make their way inside.

“This has happened to me when I was just going to the clinic for birth control,” González-Rojas said. “If you’re already on edge because you’re undocumented and you’re worried about Border Patrol checkpoints and you don’t know if you’ll have the resources to access care, this is another layer to face when you’re already feeling so vulnerable. Clinic escorts are wonderful and doing amazing work, but they can only shield someone so much from this barrage of attacks.”

Limited data

A November 2018 report from the Guttmacher Institute only confirmed what immigrant communities in the United States already know: Immigrant women “face significant challenges obtaining comprehensive and affordable health insurance coverage and care—including sexual and reproductive health services—compared with U.S.-born women, because of myriad policy and systemic factors.” Undocumented people in particular have been barred from accessing insurance coverage in the United States, but, according to Guttmacher, there is also “no research on the characteristics of immigrant women who seek abortion services or the barriers they face.”

NLIRH’s executive director said even less is known about undocumented immigrants who choose to self-manage their abortion. Part of the problem is where the data is collected, which is often at clinics after a person has self-induced and the approach either wasn’t successful or they were unsure. It can be difficult to research this population to gain a better perspective on their needs because many clinics are already out of reach for undocumented communities, and there is a lot of fear around accessing health care and health services, explained González-Rojas.

“It’s generally difficult to get undocumented people as research studies because of these barriers, and our communities just may not feel safe being part of studies if they don’t know how the information will be used, if it will be used against them, or if it may harm their ability to remain in the U.S. There is a lot of legitimate fear, but sadly this also means that our data is not being collected and our needs aren’t understood,” González-Rojas said.

Jill E. Adams, the strategy director for SIA Legal Team, which protects people who self-induce abortions, told Rewire.News about current efforts underway to collect more ethnographic data about who is self-managing. She said that, at least anecdotally, immigrants are among the groups of people who practice self-managed abortion.

“Anecdotally, we know some immigrants come from countries where self-determined health care, including self-managed abortion, are the norm, so that is what is comfortable and familiar. We also know that people may want to incorporate a cultural practice or spiritual tradition into their abortion. These are just some of the reasons that may motivate immigrants to end their own pregnancies outside of the conventional medical system. Immigrants, particularly undocumented immigrants, have to grapple with a double dose of fear seeking medical care because of instances in which people attempting to access medical care were instead turned over to ICE,” Adams said.

According to one study, 39 percent of undocumented Latinas reported that they were afraid of seeking health care out of fear of deportation. This percentage was higher in more rural areas.

These systemic barriers and fears of being detained and deported for seeking care are reasons that self-managed abortion may seem particularly attractive to undocumented communities, but González-Rojas said all pregnant people should have choices regarding self-managed or clinic-based care.

“Deciding to self-manage could be an empowering decision for folks who want to have their abortion where they feel most comfortable and on their terms, but it should not be the only choice accessible to certain communities and it should not replace access to care in clinics or diminish our fight for abortion rights for all,” González-Rojas said. “In border communities in Texas, where it’s like ground zero for government surveillance and hostility toward immigrants that sits at the crux of hatred for women, hatred of abortion, and institutional oppression, there is still a lot of confusion around abortion and its legality—and that’s intentional.”

A recent survey using Google AdWords to target people googling phrases related to self-managed abortion found that one-third of respondents did not know abortion was legal in their state.

“There is a legal right to abortion in the U.S. that is protected by the Constitution and state constitutions,” said Adams. “Nevertheless, some people have been arrested and even imprisoned for ending their own pregnancy or helping others do so.”

González-Rojas said what is desperately needed is more education around self-managed abortion, including what people’s rights are.

This is where groups like Reproaction and the SIA Legal Team come in.

Raising awareness

Well before Brett Kavanaugh was a twinkle in President Trump’s eye, the abortion rights organization Reproaction created a campaign about misoprostol. Advocates consider the medication among a group of self-induction practices that can encompass medication, herbs, or manual aspiration, though some methods are safer and more effective than others. After Kavanaugh’s confirmation, the campaign received an overwhelming response, said Reproaction’s co-director, Erin Matson. “It was almost instantaneous. We were being inundated by requests, it was like a 100 percent increase in public interest. Thankfully, we already had the infrastructure in place to share the information,” Matson said.

Reproaction’s website has a complete breakdown of self-managed abortion with pills within the first 12 weeks of pregnancy, focusing on the use of misoprostol, a safe drug that is 85 percent effective in terminating a pregnancy. The website also features information about taking misoprostol, based on World Health Organization (WHO) guidelines, and provides other resources for those who want to self-manage.

In October, the SIA Legal Team launched a free, confidential legal helpline (844-868-2812) and website to help people understand the legal rights and risks surrounding self-managed abortion. Intended for those who have already self-managed, the helpline provides information, support, and attorney referrals to callers who have been questioned by police about an abortion or fear they may be.

The way that it works is that callers leave a voicemail, detailing information about their situation and contact information where they can be reached. A member of the SIA Legal team returns the call and provides legal information that may be beneficial to them.

The organization does not collect any statistics about the calls; the information shared is kept confidential, and members of the SIA legal team do not ask callers about their immigration status.

“We care deeply about immigrants in our work for many reasons, and they are a very important group to focus on in self-managed abortion advocacy because they are more likely to self-manage and be criminalized,” Adams said. “On rare occasions, there are complications [with self-administered abortions]. Someone who has self-managed may want to be checked out to make sure everything is OK. They deserve to be able to seek medical care without fear of being arrested or deported. It is reckless and inhumane for a society to put people in a really untenable position to have to choose between their health and their freedom.”

“It’s an extreme violation of the Hippocratic Oath that doctors take to do no harm because let’s be clear: Turning a person over to law enforcement and maybe even ICE in this situation subjects them to great harm,” Matson said. “We saw that in the case of Purvi Patel. It was a doctor who called the police on her, and he identified as ‘pro-life.’ At Reproaction we’re clear that identifying as ‘pro-life’ means you’re OK with sending people to jail.”

Purvi Patel lived in South Bend, Indiana, in a conservative Hindu household, when she took herself to the emergency room for heavy vaginal bleeding. She initially did not admit that she had been pregnant, but eventually acknowledged she had miscarried, telling doctors the fetus was stillborn and she had put it in a bag in a dumpster.

Police questioned Patel and searched her cellphone, finding a series of text messages that the prosecution in the case later claimed showed Patel admitting to ordering drugs online to terminate her pregnancy. In 2015, an Indiana jury found the 33-year-old Indian American woman guilty of the contradictory charges of feticide and felony neglect of a dependent after experiencing a miscarriage, or an illegal abortion as prosecutors put it. She received a 20-year sentence, which a later judge reduced to 18 months after her appeal.

As Patel’s case shows, feticide laws designed to protect pregnant women from violence are now used to punish them for the termination of a pregnancy. Patel actually wasn’t the first woman of color in Indiana charged under the state’s feticide law. Rewire.News reported that state prosecutors brought similar charges in 2011 against Bei Bei Shuai, a pregnant Chinese woman who attempted suicide. When her fetus did not survive, the state charged her with attempted feticide and held her in prison for a year until a plea agreement was reached.

These cases have a chilling effect on communities of color. The National Asian Pacific American Women’s Forum said in a statement that despite Patel’s release in September 2016, the “work is not over.”

“[Asian Americans and Pacific Islander] women, low-income women, and all women are stigmatized for their abortion decisions. And our communities face numerous barriers in accessing health care and other essential rights,” the statement read.

Matson, Reproaction’s co-director, said that before making the choice to self-induce abortion, it’s important for people to be aware that they can be prosecuted. In its educational work, a critical thing the organization stresses is that the management for self-managed abortion is no different than the management of a miscarriage. Meaning, if a person needs to go to the doctor after self-managing, there is no reason to tell a doctor they took abortion medication, which would only expose them to risk.

“You will get the same standard of care as you would for a miscarriage because the complications are the same,” Matson said. “If the medication is taken properly, by placing it in the cheek or under the tongue for the appropriate amount of time, it will not show up in the bloodstream. There is no way a medical professional can take a blood test and say, ‘This person took an abortion-inducing drug.’”

Some people have placed misoprostol in their vulva, and Matson said she could not say with the same certitude if this method will go undetected because it is possible that crumbs of the medication may leave traces in the vagina. So long as the medication is taken using the protocol of placing it in the cheeks or under the tongue, it will not appear in the bloodstream, she said.

Language barriers

It was only in the past few years that reproductive rights and justice organizations began to specifically focus on resources for those who choose to self-manage, but these services may not get a lot of traction from immigrants until they become more accessible to those who do not speak English.

Information on SIA’s site and on Reproaction’s site are currently only available in English. There are a few bilingual members on SIA Legal Team’s staff, and SIA intends to add more in the future. Elsewhere, people can access information about abortion in Spanish at websites like Planned Parenthood’s, and the recently launched website and hotline Self-managed Abortion, Safe and Supported (SASS) for English and Spanish speakers. Offline, people can visit a community clinic, which typically staff based on the needs of the community they serve. This looks different in each of the clinics that are part of the Abortion Care Network, for example. Many clinics have staff members that are bilingual or multilingual. Some clinics ask people to bring a translator, while others subscribe to a translation service or even use Google translate.

Meanwhile, the international organization Women on Waves offers information about abortion in 20 languages.

Even with these resources, there remains a lot of work for reproductive rights and justice organizations to make information about self-managed abortion more accessible to more people, particularly those who do not speak English or Spanish, in the United States, as Matson noted. She also hopes that moving forward, self-managed abortion doesn’t continue to get conflated with emergency contraception, labeled as “coat hanger abortions,” or otherwise framed as “radical.”

“Times have changed dramatically since the pre-Roe v. Wade era when self-managed abortion was quite dangerous. Now self-managed abortion with pills is extremely safe and extremely effective, and it’s an important frontier in abortion access now and moving into the future,” Matson said. “Sadly, self-managing might feel like the only option for people who experience barriers accessing abortion in a clinic, like restrictions that bar them from accessing care, fears surrounding deportation, or because they are trans or non-binary and fear mistreatment in the reproductive health-care setting. But there are also people who just want to have an abortion at home on their own terms. No matter what the determining factor, we want people to know there are resources available to protect them if and when they choose self-managed abortion.”