May 12, 2022 – Emma, a 29-year-old communications manager, recently found out that she is six weeks pregnant. The choices she faces about her health and body are starkly different from eight years ago when, as a college student in Indiana, she decided to have an abortion.
Emma, who asked that her last name not be used to protect her privacy, lives in Texas now, which passed one of the strictest abortion laws in the nation in September. It bans abortions after 6 weeks (once a fetal heartbeat is detected). At that stage, most women don’t even know they’re pregnant.
Texas is among many states that have been tightening their abortion restrictions. And after the bombshell leak of a draft opinion from the U.S. Supreme Court that would overturn Roe v. Wade and return control of abortion laws to the states, the future of abortion access is in even more peril.
“By the time I found out I was pregnant, I already had no choices within the state of Texas,” says Emma says.
But that was in Indiana almost a decade ago. Now, she lives in Texas, and the climate surrounding abortion rights is much different, both in Texas and across the country.
That was true even before the bombshell leak of a draft opinion from the U.S. Supreme Court that would overturn Roe v. Wade and return control of abortion laws to the states.
In September, Texas passed one of the most restrictive laws in the country that bans abortions after 6 weeks (once a fetal heartbeat is detected). At that stage, most women don’t even know they’re pregnant. Other states, including neighboring Oklahoma, are following suit with more restrictive laws of their own.
But there are other options that may even survive the fall of Roe. They’re limited, and some are of questionable legality, but advocates and others are working to make sure women know: They’re not alone.
Elizabeth Nash, a state policy analyst at the Guttmacher Institute, a research group that supports reproductive rights, believes all signs are pointing toward the Supreme Court discarding precedent, upholding the 15-week ban in Mississippi, and gutting Roe, which says no state can ban abortion before a fetus can viably live outside the womb.
Guttmacher estimates that 26 states are certain or likely to ban abortion if Roe is overturned. Twenty-two of those states already have taken steps to adopt early or total abortion bans. That means, Nash says, “that 36 million women of reproductive age would live in a state without abortion care.”
This would especially impact minority women and women living in rural communities, who are already disproportionately affected, Nash says, noting that 75% of abortions are among low-income populations that already lack access to health care in general.
Jessica Arons, JD, senior policy counsel at the American Civil Liberties Union, says the U.S. is likely to be a place where abortion could be outright banned in half the country, where people will be forced to carry a pregnancy to term against their will or find ways to self-manage their abortion.
While the legal risks are not always clear, and will likely be worse if Roe is overturned, in many states, abortion providers want people to know there are still ways to access a medically safe abortion.
In some cases, a doctor might recommend a medication abortion rather than a procedural abortion, also called a surgical abortion. During this process, a patient takes two pills: The first is mifepristone (or RU-486), followed by misoprostol.
A study by Guttmacher found that medication abortions made up 54% of all abortions in 2020. The FDA approved the use of medication to end a pregnancy up to 10 weeks of gestation, but the World Health Organization suggests that the two-pill plan may be safe and effective up to 14 weeks.
Diane Horvath, MD, is an OB/GYN who provides abortions and other gynecological care in Maryland and Alabama. She says abortion medications can be safely used beyond 11 weeks of pregnancy. The biggest risk beyond that period is the threat of criminal prosecution, not a bad medical reaction.
“Illegal doesn’t mean unsafe,” she says. “We have this idea of the coat hanger in the back alley, and that was a reality for a lot of people, but that was before we had these really great medications with very low compilation rates.”
It’s still possible to order abortion pills online, even in restrictive states. Organizations like Aid Access, which advocates for abortion rights, offers online consultations with European doctors for those living in states that heavily regulate access to abortions. According to the group’s website, these doctors connect patients seeking abortion medication to a pharmacy in India that ships the pills by mail.
Horvath emphasized that most of the mifepristone and misoprostol pills bought from international pharmacies are safe to use. Meera Shah, MD, chief medical officer of Planned Parenthood Hudson Peconic in New York, says that people seeking abortions should always be careful about ordering medications online, but that sites like Aid Access and PlanC can typically be trusted, as they have vetted the sources of the medications.
“Because Aid Access is not based in the United States, U.S. enforcement – whether private, state, or federal – cannot reach them,” says Elisabeth Smith, JD, the director of state policy and advocacy for the Center for Reproductive Rights.
But the FDA has still tried to challenge the operations of the organization. In 2019, the agency sent Aid Access a cease-and-desist letter, saying the group was violating U.S. law by selling “misbranded and unapproved new” drugs. The FDA, citing safety and health concerns, argued in its letter that the brand of mifepristone and misoprostol that Aid Access provided to patients wasn’t FDA-approved.
Aid Access didn’t comply with the letter and later filed a complaint against the FDA alleging the agency “may have seized prescriptions and blocked the transfer of some payments from patients to the organization,” Smith says.
A 2017 study found that it’s possible to get legitimate and effective abortion medications online without a prescription, even when the legality of the process is dubious. But the researchers did come across security concerns that could result in legal action.
Charges have indeed been brought against women who have sought out abortion medication. In 2015, a 23-year-old woman in Georgia was arrested for having an abortion through drugs she purchased online. (The charges were later dismissed.) And just last month, a Texas woman was arrested in connection with a self-induced abortion.
“This potential lack of security may be a concern to some buyers given that people in the United States have been prosecuted for using abortion pills they procured online,” the authors of the 2017 study explained. “Nevertheless, to some people seeking abortion, these disconcerting experiences may seem tolerable given the numerous impediments that they may encounter in obtaining care at a clinic.”
In a notable case from 2017, Latice Fisher of Mississippi was charged with second-degree murder for self-managing an abortion; the prosecution’s key evidence was internet search results they found in Fisher’s cellphone data that included the phrase “buy misoprostol abortion pill online.” The charges against her were dropped a couple of years after her arrest.
When Emma needed her most recent abortion, she knew that if she got medication for a self-managed abortion in Texas, she could potentially be charged with a crime. Her only other option was to travel to have a medication abortion at a Planned Parenthood clinic in New Mexico, where it was still legal to do so after 6 weeks. But the idea of having to travel 8 hours in a car or take a flight when she was already having overwhelming nausea seemed unbearable.
Sites like Aid Access and PlanC were able to send her the medication by mail, but the cost was too steep and the time it would take for the medication to arrive was concerning. Emma knew a friend who had gotten over-the-counter misoprostol from Mexico, so she reached out. She was able to get 12 pills of misoprostol to be taken every 3 hours.
After a few hours, Emma had a level of pain that she hadn’t felt in her first medication abortion. And a week later, she was still feeling the same nausea she felt before she had taken the misoprostol. Studies have shown that misoprostol alone doesn’t work as well at ending a pregnancy as mifepristone and misoprostol taken together.
Emma made another appointment with her local Planned Parenthood, scheduling an abortion management appointment rather than an appointment for abortion care. She remained vague during the appointment, only disclosing to the providers that she had a previous positive pregnancy test and has since had bleeding and other symptoms of a miscarriage.
Horvath, the OB/GYN who practices in Maryland and Alabama, says this tactic is a completely legal and safe way to avoid the threat of criminal charges.
“There's no way to tell if your symptoms are from a miscarriage or from an abortion,” Horvath says. “I’m not telling you to lie to your health care providers. I am telling you that if you choose to withhold information for your own safety, that is something that's OK to do. You don't ever have to feel obligated at any point in time to disclose.”
When the clinic practitioners confirmed she was still pregnant, Emma said the focus shifted to the health of her pregnancy and prenatal care. But she knew she didn’t want to carry the pregnancy any further. As she was sitting in the clinic, with her medical gown still on, she began to contact her friend. They were eventually able to track down the combination of mifepristone and misoprostol. Emma said the medication abortion was extremely painful, but it was successful.
Patients who are given the option to have a medication abortion are often told that the process resembles a very painful, intense menstrual cycle. But without medical help and prescription pain medication, the abortion may be even more agonizing.
“People might see this as their only option as abortion access becomes more restricted throughout the country,” Emma says. “So, I would rather an individual prepare for very high levels of pain and anticipate that possibility, rather than walk into this experience thinking it’ll be closer to period cramping.”