When the U.S. Supreme Court overturned Roe v. Wade, they upended a way of organizing medical care—and life—that women of reproductive age in the United States largely took for granted. In June 2022, when the Dobbs decision was officially released, abortion had been legal for 49 years, and while it had been increasingly difficult to access in much of the United States, there is a vast difference between “inaccessible” and “illegal.” In states that have banned abortion, doctors (and hospital lawyers) calculate the odds of criminal prosecution and even incarceration as they make decisions about care for pregnant women with health conditions, often critical ones, that are incompatible with continuing a pregnancy. In states like Texas, where support for a person seeking an abortion has been criminalized, abortion funds have scrambled to figure out whether they can still operate and, in many cases, have had to close their doors and/or relocate to a different state.

In the two months between the leak of Dobbs and its official publication, abortion supporters chanted, “We will not go back!” And they were right, despite the ruling: The reality is that we have not gone back to 1972, a time before both abortion pills and the anti-abortion movement. Instead, we have gone forward into a time in which abortion can be done safely outside the medical system, and increasingly violent far-right movements use gender and sexuality to recruit and mobilize in the United States and globally.

The dominant American experience of abortion as a medical procedure that takes place in a women’s health clinic has become normalized, but historically it’s a very recent invention. Until the mid-19th century, there was no meaningful boundary between irregular menstruation and pregnancy prior to “quickening,” when a fetus begins to move inside the womb, and the practical management of reproduction was the responsibility of women, midwives, and other informal healers within a community.

As a result, abortion was largely not criminalized in the United States, especially in the first four to five months of pregnancy before the fetus begins to move. The creation of “abortion” as a medical event in need of professional intervention was part of the formalization, and masculinization, of the practice of medicine in the United States, England, and Europe. As medicine professionalized, the risks from abortion in the late 1800s were used as one part of a strategy to draw boundaries between “doctors” and “quacks.” This social relocation of abortion from a largely informal and unregulated practice handled by women into a medicalized process handled by male professionals also brought abortion into criminal law: By 1900, all U.S. states had banned abortion except under a narrow range of conditions. Interestingly, during this time, Catholic and Protestant churches were relatively indifferent to the issue; the primary opposition came from the new American Medical Association, who condemned abortion, even by doctors, under virtually all circumstances other than to save the life of the mother. The AMA’s opposition to abortion reflected concerns over health and an emerging understanding of fetal development, as well as the assertion of professional boundaries, but in the process male doctors began to conceptually separate the fetus from the life of a pregnant woman.

Abortion became a visible social issue again in the 1960s, and the clinics and women’s health centers that are now the iconic (and embattled) locations for abortion services in the United States began as a feminist project in the early and mid-1970s. Feminist activists conducted visible and confrontational campaigns to legalize abortion, expand access to contraception for those who wanted it, and transform women’s experiences of health care. There were protests in the streets, at medical conferences, and in courts; sit-ins in hospitals and legislative offices; and relentless campaigns to change laws and expand access to birth control and abortion. In addition, and less visibly, feminist organizations engaged in pragmatic direct action to assist women with abortion, moving information that had previously circulated secretly within private networks into public form. In California, activists not only compiled a list of known abortionists in Mexico near the U.S. border, but also gathered service reviews from women who had gone to those doctors and, when necessary, would pressure a doctor to improve his practices or be removed from the list. An activist collective in Boston created a self-help course to help women learn about their bodies, including ways to end an early-stage pregnancy, and their resource manual eventually became the widely available book, Our Bodies, Ourselves. The Los Angeles Women’s Health Center created programs they called “self-help clinics,” where a group of women would meet for a number of weeks to learn gynecological self-examination and “demystify” their bodies using kits, pamphlets, and other materials that circulated widely in the United States and Canada.

When abortion was legalized, first in states like New York and California and then federally through the 1973 Roe decision, women’s health clinics and abortion clinics emerged to provide the newly legal service. These clinics were founded by women’s health activists and allied doctors to intentionally create an environment that went against the dominant hierarchical structures of medical care. While freestanding clinics enabled the development of woman-centered and explicitly feminist models of care, they also reinforced the separation and isolation of abortion from regular gynecological and primary care. It is worth emphasizing that there is no medical reason for this approach, and abortion could easily be integrated with primary care, as is more common in other parts of the world.

It is important to recognize the role of the far right in the structure of abortion care in the United States, and to understand why abortion care is so embattled and so isolated from other health services. In 1973, when Roe was decided, right-wing organizing focused on defending segregation more than traditional gender roles, and even the Southern Baptist Convention passed resolutions in 1971, ’74, and ’76 supporting legal access to abortion under a range of conditions. In the late 1970s, there was a deliberate shift in the focus of right-wing organizing away from segregation and towards gender/sexuality issues, a shift that has come to shape religious beliefs as well as women’s access to medical care. The previously supportive and empowering care environment of “women’s health” services became embattled and isolated by the systematic political (and physical) assaults of the anti-abortion far right, which made abortion care literally a dangerous profession. Abortion providers and clinics across the United States have been subject to shootings, arson, bombings, and countless threats since the emergence of an anti-abortion movement in the late 1970s. From 1993 to 2016, far-right activists have murdered 11 people at abortion clinics and (unsuccessfully) attempted to kill 26 others. It’s one thing to offer a stigmatized service within a multiservice community care clinic, but quite another to provide one that is the target of politically motivated violence that could place staff and patients at risk.

On the surface, the Dobbs decision appears to replicate the pre-Roe situation by giving states the ability to regulate abortion, but, as noted earlier, the social and political terrain are profoundly different now than in the early 1970s. There is no going back to pre-Roe socially, medically, or politically, and to frame Dobbs as doing so reflects right-wing aspirations to return to a former world in which white men and the heterosexual nuclear family held hegemonic power. The Center for Reproductive Rights and the Guttmacher Institute maintain constantly updated maps of abortion laws at the state level that clearly show how much access to abortion has declined even relative to 2021. Under Roe, the major cities within conservative states often provided some protection for those who lived nearby or could travel; under Dobbs, service provision is determined at the state level, and given the political map of the United States there are now entire regions in which the majority of states have restricted or banned abortion. While spatially this may have some resemblance to the pre-Roe map of state laws, the depth of politicization has changed the level of criminalization, fear, and uncertainty for everyone involved. Another key difference today, of course, is the ability to have a genuinely safe self-managed abortion outside the medical system using a handful of pills and instructions that can easily fit on one page.

Self-managed abortion emerges from new technologies while building on previous feminist strategies to enable women to safely end pregnancies outside the medical system. The most direct predecessor to 21st century SMA was the Jane Collective in Chicago, a direct action group that formed in the late 1960s to provide abortions to any woman who needed one, and who continued their work until the 1973 Roe decision. Jane initially connected women to a man who claimed to be a doctor, but when they found out he wasn’t one, they quickly learned how to do it themselves and began to operate their own abortion service out of a series of Chicago apartments. In a 21st century parallel, a group of feminists in Mexico brought women to a local gynecologist but over time, by listening to the doctor’s instructions, they learned how to safely do a medication abortion. One of the key similarities to contemporary SMA collectives is that Jane provided abortions to anyone, regardless of their politics or ability to pay, and there was no requirement to join an ongoing self-help group or otherwise join the movement. This set Jane apart from other feminist health collectives that were ongoing groups within which women learned about their own bodies and sometimes engaged in practices like menstrual extraction, which enabled safe abortions for early-stage pregnancies, but also required specialized equipment plus some training and experience to be done safely and effectively. Jane worked to make abortions available to anyone who called their phone number seeking help.

In the early 1970s, there was no safe, reliable, easily taught method through which a woman could directly abort her own pregnancy, but towards the end of the 20th century, new medications opened up fundamentally new possibilities. The standard medical protocol for medication abortion involves two drugs, mifepristone and misoprostol, which are taken in sequence: mifepristone is taken first to block a hormone needed to maintain a pregnancy and to help the cervix open, and then misoprostol is used to induce uterine contractions. Mifepristone is an abortion medication, while misoprostol was first created to treat gastric ulcers and has many medical uses, including the prevention of postpartum hemorrhage. The two-drug combination was introduced in France in the late 1980s, and then spread through Europe before finally being authorized in the United States in 2000. Around the time medication abortion began in France, women in Brazil started to use misoprostol, under the brand name Cytotec, to induce abortions outside the medical system under conditions of extremely limited legal access.

While there is no “origin story” of the first woman to take misoprostol alone as an abortifacient, the medication was widely available in pharmacies throughout Latin America as an ulcer treatment and came with a visible warning label on the package stating that pregnant women should not use the drug as it could cause a miscarriage; it does not require much imagination to read the warning label as an invitation. Misoprostol, if allowed to dissolve under the tongue, has the added benefit of being undetectable when uterine contractions begin, making it impossible to prove whether a miscarriage is induced or spontaneous, keeping its user safer in relation to legal persecution.

These two approaches to medication abortion are widely used today, with the two-drug combination available through doctors and online telemedicine services, and misoprostol alone used as a more accessible strategy in many different circumstances.

Excerpt from Abortion Beyond the Law: Building a Global Feminist Movement for Self-Managed Abortion by Naomi Braine. Published by Verso 2023. Copyright © Naomi Braine 2023.