In June 2020, Carol’s life changed.
“I found out I was pregnant, and then my husband, who is an alcoholic, left very soon after,” said Carol, 33, whose name is a pseudonym for privacy reasons. “He left; disappeared. I have three kids already.”
It was several months into the COVID-19 pandemic in the United States, and uncertainty was at an all-time high. “Being pregnant during COVID and having a baby by myself—with everything going on, I couldn’t deal with that,” Carol said. She needed an abortion.
Carol had heard about Aid Access, an Austria-based online telemedicine nonprofit providing medication for self-managed abortion to people in the United States.
After filling out an online consultation and receiving approval from Aid Access doctors, Carol was sent misoprostol. Typically, Aid Access prescribes mifepristone and misoprostol, a two-step regimen that involves a progesterone blocker (mifepristone) and a medication that causes the uterus to contract and expel the contents (misoprostol). But because of shipping disruptions due to the pandemic, mifepristone was difficult to acquire at the time, and Aid Access was relying on the effectiveness of misoprostol alone.
Carol had previously worked as a doula and was familiar with using misoprostol for miscarriage management. She received the medication and opened an email from Aid Access with step-by-step instructions for self-managed abortion. The instructions included information on how to take the medication, what to expect, and signs of a potential complication. While rare, Aid Access advises people to be aware of severe and persistent abdominal pain, heavy bleeding of more than two maxi pads an hour for more than two hours, a fever of 102 degrees Fahrenheit or more, and discharge with a bad odor, which could be a sign of an infection. If a complication arises, Aid Access doctors advise people to seek follow-up care at a hospital.
Later that day, Carol’s friend came over to watch her children and offer support. Carol read through the directions one more time and, at ten weeks’ gestation, successfully self-managed her abortion at home using misoprostol.
When I asked about her experience, she was calm. “I’m just happy to pass along whatever information that can possibly help somebody else,” she said.
Since the Supreme Court released its ruling in Dobbs v. Jackson Women’s Health Organization and overturned Roe v. Wade, the legal landscape surrounding abortion has evolved daily. “Trigger” laws have gone into effect in some states, while temporary state-level actions in others have kept clinics open.
Meanwhile, the public has started to learn more about the medication abortion pills mifepristone and misoprostol, while activists and academics alike are sharing information on how to protect your digital footprint when searching for abortion care.
Safe use of misoprostol for self-managed abortion can be revolutionary.
Misoprostol was originally created to treat stomach ulcers; Brazilian feminists in the 1980s discovered the medication could also induce abortion. Since then, misoprostol has transformed access internationally by providing people with a safe, effective, and cheap method for abortion.
Echoed by some is the notion that we are going back to the “pre-Roe times” of “back-alley abortions.” But because of advances in pregnancy detection, the accuracy of individual assessment of gestation, and medication abortion pills, this new era will likely be very different.
Like Carol, many people will turn to self-managed abortion—the process of self-sourcing abortion pills and managing one’s own abortion outside a formal health-care setting. This process has been found to be safe and effective, especially when people source medication from valid online sources and are guided through the process by physicians or feminist accompaniment groups.
Newly released World Health Organization guidelines recommend self-managed abortion as a safe option alongside clinical management, and organizations like Plan C make it easy for people to learn about authentic sources for medication.
Misoprostol in particular, which some refer to as the original medication abortion pill, has long been used throughout the world for early abortion care. In the United States, when people refer to medication abortion, they typically refer to the two-medicine regimen of mifepristone and misoprostol.
However, recent evidence on the safety and effectiveness of misoprostol alone has reinvigorated the conversation. Studies of self-managed abortion using misoprostol alone have found extremely high levels of effectiveness, ranging from 93 percent to 99 percent of participants reporting complete abortions without surgical intervention.
The history of misoprostol is one of ingenuity, liberty, creativity, and an ongoing collaborations across international feminist movements. In Mexico, misoprostol is readily available over-the-counter in pharmacies, and Mexican feminist activists are motivated to assist people in the United States. Due to its wide range of applications, it is stocked in U.S. pharmacies as well, and it is not regulated by the onerous FDA Risk Evaluation and Mitigation (REMS) classification that makes mifepristone only available from certified clinics, providers, and via telehealth models and qualified pharmacies in a handful of states.
However, people in the United States still need a prescription for misoprostol. For those who acquire it for self-managed abortion and live in states where abortion is now illegal, it holds the heightened risks of criminalization and surveillance. Most recently, in the case involving a Texas woman who was arrested for allegedly self-inducing an abortion, state laws have been used to intimidate and confuse people—part of a long history of prosecutors using laws associated with pregnancy and reproduction to police and criminalize.
It doesn’t have to be this way. The Biden administration’s response leaves much to be desired from our elected officials. Federal lawmakers can both challenge laws that have been wrongly used to criminalize people and move to federally decriminalize self-managed abortion. Researchers, legal experts, and professional organizations (including the American Public Health Association and the American College of Obstetricians and Gynecologists) have made calls for this initiative.
This is a public health emergency, and we have a duty to inform people of the robust body of scientific evidence regarding safe methods for self-managed abortion. Although these methods are certainly not a panacea and may not be feasible or preferable to many seeking care, we do have evidence for their safety and efficacy. The moment to share this life-saving public health information is now.