The New Autonomy of Abortion

When 18-year-old Rachel discovered she was unexpectedly pregnant, she made what she thought was a natural first step: call Planned Parenthood to schedule an abortion. “I wasn’t ready to be a parent or a mom,” she says. “And I didn’t want to go through giving birth just to give the kid away.” Even in an abortion-friendly state like Illinois, the nearest Planned Parenthood was one hour away, and there wasn’t an available appointment for another month. 

When Rachel consulted ob-gyns, they either told her they wouldn’t provide an abortion or declined to provide recommendations. And since her insurance doesn’t cover abortion care, she’d have to pay the expensive fee out of pocket. “I just wanted it to be over with,” she says.

Feeling judged and scared, she and her mom turned to the internet, where they found a virtual abortion clinic. From there, the process was quick and straightforward: Rachel answered some screening questions to ensure she was a good candidate for medication abortion, chatted with a provider, and within days, the pills—mifepristone and misoprostol—were delivered to her door. Now, Rachel says she would choose telehealth again if she were in need of an abortion. “I liked that it was discreet and it was cheaper than other options.” 

To be sure, many people are not as lucky as Rachel, a pseudonym we’re using to protect her identity. Even before Roe v. Wade was overturned in 2022, abortion deserts—defined as cities or towns located more than 100 miles from an abortion facility—covered large swaths of the United States, while many states had already instituted burdensome gestation restrictions and mandated waiting periods. The Hyde Amendment was also being used to keep some of the most financially precarious communities from accessing abortion care.

In the two years since Dobbs v. Jackson Women’s Health Organization, abortion access has become even graver; 16 states have passed near or total abortion bans, rendering entire regions of the country abortion deserts. But, despite the fear and shame that tends to cloud the subject, seeking abortion care should be as easy as securing any other telehealth prescription: a few clicks, messages exchanged, and then picking up the mail. 

In December 2021, the U.S. Food and Drug Administration lifted unnecessary restrictions on in-person dispensing of mifepristone, while professional organizations, including the American College of Obstetricians and Gynecologists, endorsed a telehealth abortion model. These legislative and organizational changes, coupled with telehealth becoming an enduring norm, have revolutionized abortion care in the U.S.

It’s important to note that telehealth is not for everyone and some abortion patients want or need to go to a clinic. So, while avoiding the clinics is empowering for some, we all deserve access to care that works best for us. 

Finding Freedom in Virtual Clinics

While the future of mifepristone access in the U.S. depends on a pending Supreme Court case, easy, convenient, and compassionate in-home abortion care continues to be an option for many. It’s still legal to access virtual clinics in 24 states and Washington, D.C., and now 16% of U.S. abortions are happening through these clinics. The latest science from Advancing New Standards in Reproductive Health at the University of California, San Francisco, a research group I am affiliated with, shows that abortion via telehealth is as safe and effective as in-clinic care. In fact, medication abortion overall is regarded as safer than many common medications including Tylenol, penicillin, and Viagra.

In response to the 2022 Supreme Court ruling, some states began passing proactive abortion protections, making abortion care in those states more accessible. Six states have begun passing shield laws, which allow health care providers to send pills to patients across state lines, while some people are even securing these pills on their own through what’s referred to as a “self-managed abortion.” 

Research I’ve worked on regarding self-managed abortion indicates that many people inaccurately believe it to be unsafe across the board (e.g., they think of “coat hanger” abortions). In actuality, even the World Health Organization recognizes medication abortion without doctors to be safe and effective.

This trend began in the 1980s, when grassroots feminist activists in Brazil discovered that misoprostol, initially developed and prescribed as an ulcer medication, has abortifacient properties. This discovery led to the creation of whisper networks and “abortion accompaniment” groups, which have since spread throughout Latin America. The groups are now equipped with online tools like WhatsApp to deliver abortion pills and provide emotional support. 

After decades of protests led by these feminist movements, several predominantly Catholic Latin American countries—Argentina, Mexico, and Colombia—decriminalized abortion. While many pregnant people in these countries can now enter local abortion clinics for the first time, pregnant people in the U.S., some of whom can no longer access clinics, are now reclaiming abortion freedom from the comfort of their homes.

The most recent data indicates that around 7% of women in the U.S. have attempted a self-managed abortion, which is likely an underestimation. And in a survey of people who self-managed with abortion pills, 96.4% successfully completed their abortion without needing an additional procedure and only 1% experienced a medical emergency.

Dana Johnson, Ph.D., an abortion researcher at Ibis Reproductive Health, is tracking this trend in the U.S. She’s particularly excited about the emergence of “advance provision” in abortion care, where people can order “just in case” abortion pills online before they’re even pregnant.

While there are various websites offering abortion pills, AidAccess, run by Dutch physician Rebecca Gomperts, is one of the most recognizable names in the game. AidAccess ships advance-provision abortion pills across the U.S., even to states with active abortion bans, which Johnson says helps reduce the anxiety for those fearful of a hypothetical pregnancy: “They won’t have to wait for shipping times,” she says. “They don’t have to worry about someone intercepting the mail. They can tailor it to their lives.” 

Johnson and her research team at the University of Texas, Austin, which has surveyed people across the U.S., have found that a lot of the people who order pills in advance are folks with health issues for whom a pregnancy could be dangerous and even deadly. They’re right to be worried, as story after story has emerged about pregnant people being unable to receive abortions even in the face of life-threatening complications.  

Some people, Johnson notes, are even ordering these pills so that they might be able to help someone else with an unwanted pregnancy. “They were really proud to share medications with the people in their networks. They definitely viewed themselves as activists,” Johnson says. “And a lot of these people who we spoke to weren’t necessarily activists before.” 

Politicians can close down abortion clinics and pass increasingly draconian bills, but at the end of the day, abortion is extremely popular (85% of Americans believe abortion should be legal in at least some circumstances). If anything, research such as Johnson’s shows that people are more engaged and knowledgeable on abortion than ever before. 

Abortion in the Medicine Cabinet

In a country with abysmally high maternal mortality rates, particularly for Black people, and where abortion is 14 times safer than childbirth, having abortion pills in the medicine cabinet is a prudent safety precaution. Johnson recalls one interviewee telling her, “‘You wouldn’t live in a house that didn’t have a fire extinguisher,’ and that’s why she bought the pills.” Another respondent compared it to traveling with an EpiPen. Perspectives like these offer a new way of thinking about abortion: Rather than treating it as a scary, shameful experience, abortion pills can simply be a part of one’s health care arsenal, tucked on the shelf between Tums and Advil.

Other parts of the health industry that were historically considered radical or fringe have also become part and parcel of health care with widely expanded access. Consider mental health, for instance—an area of health care long stigmatized, with a history of criminalizing patients or relegating them to mental asylums. Now, thanks to the Affordable Care Act, insurance companies must cover mental health care, and it’s possible to use telehealth to see a therapist and/or a psychiatrist. 

Getting antidepressants or antipsychotics today can be as simple as seeing a doctor on video and picking up the medicine. You can even keep anti-anxiety pills on hand in case of a panic attack. Why should abortion pills be any different? 

While sexual and reproductive health care are often deemed the most sensitive or controversial aspects of health care, other medicines within this realm have been mostly destigmatized in order to increase access. For starters, people who are concerned about HIV can now take PrEP (pre-exposure prophylaxis), a precautionary pill that lessens the chances of contracting the illness, or PEP (post-exposure prophylaxis) after a potential encounter. 

There are also virtual clinics for HIV/AIDS prevention, including Nurx, which also provides contraception, mental health care, and herpes treatment. Even Plan B, which is closer to the cultural land mine of abortion than other medications, is now available over the counter. Doctors can prescribe the medication to patients who want to have it on hand just in case, rather than needing to jump through hoops for access in a moment of crisis. 

Bringing Back Your Period 

Period pills, which refer to a regimen of mifepristone and misoprostol used in a different way, might be the final frontier in the transformation of our understanding of abortion. Imagine this: Your period is a few days late and you’re worried you might accidentally be pregnant. Some, like Rachel, would take a pregnancy test and schedule an abortion. However, for those who don’t want to have an abortion or don’t have access to the procedure, these pills can simply “bring your period back.” You’ll never have to know whether you were pregnant or whether your period was simply late for other reasons. 

Wendy Sheldon, Ph.D., the lead scientist on the largest study conducted on period pills in the U.S., found that interest in period pills in the U.S. “could be substantial.” During her study, which included nearly 700 people across nine clinics, she and her team found that 70% of patients who didn’t want to be pregnant said they were interested in taking period pills without a pregnancy test. “It was enormous,” Sheldon says. Indeed, she and her team were surprised to find no difference in the levels of interest between blue and red states, indicating that even people living in states where abortion access is protected would be interested in period pills. 

Then why have most people never heard of them? While period pills are technically legal across the country, they are caught in the ideological crosshairs of the abortion debates. On one end, groups who seek to ban or highly restrict abortion view period pills as indistinguishable from abortion—these days, anti-abortion groups argue that more and more parts of reproductive health care, like birth control or in vitro fertilization, should be considered abortion. On the other end of the ideological spectrum, abortion-rights groups view period pills as reinforcing abortion stigma, and that empowering people to circumvent a pregnancy test and an abortion contradicts the talking point that abortion is a normal part of health care. 

Additionally, while period pills have been embraced in countries with poor abortion access around the world (from India and Nigeria to Peru), physicians in the U.S. are skeptical. Some, Sheldon notes, are unwilling to prescribe abortion pills in what’s currently considered “off label,” meaning, these pills are only officially approved to be used after a positive pregnancy test. “I think everyone knows that it’s safe,” Sheldon says, before adding the caveat, “We don’t have enough data yet to publicly convince clinicians.” But in order to get this data, researchers and clinics need funding. Sheldon, for one, was working on a newer study testing the efficacy of period pills but ran out of funding and had to shutter the research. 

Ushma Upadhyay, Ph.D., is a researcher currently leading the first clinical trial on misoprostol-only period pills, but recruiting clinics and participants for the study has been difficult. “The main obstacle to recruiting people into the study is that people just don’t know it’s a thing,” she says. “It’s not mainstream yet. It hasn’t been accepted.” Despite the difficulties, the research must go on. Upadhyay envisions a future in which people—providers and patients alike—“embrace the unknown” as well as the complexity of pregnancy and abortion. 

If we, as a society, can embrace this complexity, we can forge into this new phase of abortion freedom, where it is so normalized that patients can chat with a primary care provider or even urgent care and pick up misoprostol at a nearby pharmacy without worrying about being shamed, let alone arrested. 

Across these various cases, one thing remains clear: While abortion is more restricted than ever before, freedom also abounds. Amid horror story after horror story—especially for those whose pregnancy requires in-clinic care—there are also people taking back their bodily autonomy. Abortion pills keep us safe in the face of bans, whether we order them on an app, keep them on hand, or use them in novel ways. While politicians seek to squash this idea, abortion should remain easy, convenient, and stress-free—and we, regardless of what happens at the Supreme Court this summer, have the power to help our communities ourselves.