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Almost 40 percent of abortions in the United States each year are done with pills—but those are just the ones provided in clinics and other medical facilities. An unknown number of people end their pregnancies on their own with pills they bought online or from a pharmacy in another country. This is known as self-managed abortion, or sourcing and using the drugs mifepristone and misoprostol, or misoprostol alone, to end an early pregnancy outside of a medical setting.

Some people prefer going it alone, while others buy their own pills because getting care in a clinic is too difficult, expensive, or risky. Interestingly, some patients who get pills from an abortion provider and take them at home also call that process self-managed abortion, since they are in fact, ending their pregnancy themselves. This confusion highlights the hypocrisy of restrictions on abortion pills, said Dr. Jamila Perritt, an abortion provider and president and CEO of Physicians for Reproductive Health.

“The reality is that whether you’re sourcing the pills from me as a health provider in my office or in the clinic, or sourcing them outside the traditional medical system, the abortion happens in the same way,” Dr. Perritt said. “It all happens at home. The difference, of course, is how you initiate the process and then what risks you incur as a patient based on that decision.”

As states make it more difficult to get abortion pills from providers, they may just be increasing the demand for self-managed options.

How it works

In a clinic, a medication abortion is done with two pills, mifepristone and misoprostol. The first blocks the hormone progesterone, which stops the pregnancy from progressing, and the second causes uterine contractions that expel the pregnancy, essentially inducing a miscarriage. The combo is approved by the Food and Drug Administration for use up to ten weeks into pregnancy. But using misoprostol alone can also be an effective abortion method.

FDA restrictions on mifepristone require it to be dispensed in a clinic or hospital, meaning even if people had a telehealth consult with an abortion provider, they can’t get the pills by mail or at their local pharmacy; they have to pick them up in person. Given the difficulties people already face in accessing clinic-based care—distance to the nearest facility, lack of paid time off work, lack of child care, and the cost of care itself—these restrictions create significant barriers to medication abortion.

Some people buy both pills, or just misoprostol, online. The website Plan C lists both medically supervised and fully self-managed options, like online pharmacies, in every state. In some states, though, the only clinician-supported option is Aid Access, a site run by a doctor in the Netherlands and thereby legally murky due to FDA rules on importing drugs. (The FDA sent the doctor, Rebecca Gomperts, a warning letter to halt deliveries, but Gomperts filed a federal lawsuit to keep operating.)

That’s because 20 states ban telemedicine abortion either by targeting the prescription of pills directly or by requiring an ultrasound before all abortions. (Ohio Gov. Mike DeWine signed a telemedicine ban into law on January 9.)

There are many reasons people choose to manage their abortions at home, and those reasons generally fit into three categories: Care is either unavailable, inaccessible, or unacceptable, Dr. Perritt said. Unavailable means a clinic can’t see someone before the medication abortion cutoff—abortion in general is time-sensitive and this method even more so. Inaccessible comprises the typical barriers to abortion care like cost, transportation, child care, and time off work.

The final category, unacceptable, refers to people feeling that clinic-based care isn’t as safe for them. They might not want to deal with protesters, they may be undocumented and fearful of the medical system, they may be transgender or nonbinary and dislike the typically woman-focused nature of most abortion providers, or they might live in a small town and fear being recognized. Fear of contracting COVID-19 would also fall into this category.

A December study in JAMA Network Open estimated that 7 percent of U.S. women, or one in 14, will try to self-manage an abortion in their lifetimes, says Lauren Ralph, an epidemiologist at Advancing New Standards in Reproductive Health and co-author of the paper. This estimate is based on survey data from 2017, well before COVID and also before the launch of Aid Access in 2018. Only 20 percent of respondents who’d tried to abortion on their own used misoprostol; the most commonly reported methods used were herbs (38.4 percent), followed by other medications (29.2 percent), and, alarmingly, physical methods like being hit in the abdomen (19.8 percent).

The reasons respondents gave for self-managing an abortion included cost and accessibility issues, but also a preference among young people who thought they needed their parents’ permission for an in-clinic abortion, Ralph said. The most common reasons cited, though, were that self-managed abortion seemed easier or faster than going to a clinic.

The shifting legal landscape

For about six months during the COVID-19 pandemic, the United States had a partial experiment of easier access to pills thanks to an injunction in a federal lawsuit that required the FDA halt enforcement of its in-person rules. It meant that providers could mail the pills to their patients in order to reduce people’s exposure to the virus (the ruling did not apply in states with telemedicine bans). But the Supreme Court reinstated the restrictions on January 12 in its first abortion-related case with Amy Coney Barrett on the bench. The Biden-Harris administration could direct the FDA to allow mailing for the duration of the pandemic, and seek a review of the underlying restrictions, but even that wouldn’t improve access in the 20 states that ban telemedicine abortion.

“The intentional exceptionalism with which abortion is treated is disappointing at best and, in reality, profoundly harmful for the people that we care for, especially in the setting of a public health emergency like this pandemic,” Dr. Perritt said.

Ohio law requires two in-person visits to have an abortion, so patients have to pick up their pill in person. This meant that providers couldn’t mail pills during the injunction, said Vanessa Arenas, the deputy director of Preterm, an independent abortion clinic in Cleveland. Before the pandemic, medication abortion patients in the state had to come back to the clinic a third time for a follow-up to confirm that the pills worked. Now, patients are sent home from their second appointment with a pregnancy test, and they have a check-in phone call.

In January, Ohio lawmakers went a step further by requiring that the prescriber be physically present during the appointment and the patient must swallow the mifepristone in front of them. This law bans what’s known as the site-to-site model of telemedicine abortion, where a clinic might have a doctor at one location videoconference with a patient at a different location. Arenas said this is just another barrier in a state where clinics are mostly in bigger cities.

“For people who live in rural areas or regions of the state, that’s just another hurdle, now they can’t even go to some satellite clinics and potentially get [mifepristone] a little bit closer to home,” she said.

“It’s just stark, the level of barriers that have been added and truly just how preemptive the laws have been to really minimize access,” Arenas said. “To think that there’s a law in place that preempts the [FDA] lawsuit from applying is interesting.”

Arenas said she isn’t aware of patients buying their own abortion pills, but Ohio’s laws, like its (blocked) six-week abortion ban, cause confusion about whether abortion is legal in the state. She said Preterm hears from clinics in Pennsylvania and sometimes Michigan about Ohio residents seeking care there instead. She does believe that if abortion medications were easier to get, more of Preterm’s abortion patients would use them—she said only about 20 percent do.

The JAMA study suggests self-managed abortion will only become more common amid this web of restrictions and that the public health imperative is to ensure better access to abortion pills, Ralph said. She says allowing telehealth visits with drive-in pickup and mailing would help improve access to these drugs.

“As abortion clinics close due to increased abortion restrictions, and there’s a reduced demand for facility-based abortion and a growing demand for convenience, privacy, and comfort of self-managed care, it’s likely that self-managed abortion will become more prevalent in the U.S.,” Ralph said. “I think it’s important to get some of the methods that we know are safe and effective, like the medication abortion regimen, into the hands of people, particularly those who face barriers to care.”

Dr. Perritt noted that self-managed abortion isn’t equally safe for everyone from a legal perspective; states have arrested and prosecuted people suspected of inducing their own abortions.

“Folks who are self-managing their abortion who come from historically marginalized communities—like Black women, young people, undocumented folks, immigrants more broadly—those folks are more likely to experience criminalization because of those reproductive choices,” she said, adding “the vast majority of folks have been placed in the criminal legal system at the hands of [a] health-care provider.”

For people who think they may face legal risks, Dr. Perritt suggests contacting If/When/How’s Repro Legal Helpline.