Illegal Abortion Will Mean Abortion By Mail

What to expect when you’re expecting your abortifacient pill delivery

Carlos Barria / Reuters

With the prospect of a more conservative Supreme Court on the horizon, some progressive women have begun to fear what will happen if Roe v. Wade, the case that legalized abortion, is overturned. Some of these prophecies have centered on a popular meme in the pro-choice community: The coat hanger.

During a recent rally, New York gubernatorial candidate Cynthia Nixon held up a wire coat hanger as a warning that we should not return to the previous generation’s means of obtaining illicit abortions. And Representative Lois Frankel, a Democrat from Florida, banged a coat hanger on the table at a briefing while discussing the latest Supreme Court nominee, Brett Kavanaugh.

And this isn’t counting the many happy hours in progressive cities that have become peppered with gallows-humor cracks about coat hangers and back alleys.

But medical technology has progressed significantly since Roe was decided in 1973, and we—realistically, fortunately—won’t see a return to women using coat hangers or other implements to self-abort. Instead, it’s more likely that more and more women will turn to shady online pharmacies to buy abortion pills through the mail—a practice that is already occurring with surprising frequency and effectiveness around the world.

Women who want to have an abortion early in their pregnancies can take a combination of two drugs: misoprostol, whose brand name is Cytotec, and mifepristone, which is also called RU-486. They are both on the World Health Organization’s “List of Essential Medicines,” which means they are considered safe and effective. The combination can be used until about the tenth week of pregnancy, and the medications are already used in roughly a third of all abortions.

Misoprostol, which also treats ulcers, is available in pharmacies, and it’s about 85 percent effective in inducing an abortion on its own. It is much more effective when used with mifepristone, but FDA restrictions dictate that patients can’t receive mifepristone even at a retail pharmacy, and possibly not through the mail, either. Most abortion providers think it’s really only legally safe to dispense mifepristone to patients directly, in person. In some places, like the Hawaiian island of Kauai, there are no abortion providers, and women must take a 300-mile round-trip flight to get an abortion. So instead, many turn to Google.

Abigail Aiken, an assistant professor of public affairs at the University of Texas at Austin, conducted interviews with 32 people from 20 states who sought out abortion pills online for a study she and her colleagues published last week. She found women turned to mail-order abortions because a clinic-based abortion was too expensive, or because state restrictions around abortions—like waiting periods and ultrasound laws—were too onerous. Some just preferred the privacy and convenience of doing their own abortion at home.

These online abortion pill pharmacy websites, though, seem to give the women pause. They seem illegitimate and are riddled with broken English: “In this recession growing economy were we can’t afford more childrens, we need some source which can be easily available online,” one website notes. Some of the websites pop up, then shut down unexpectedly. It would be difficult for these same pharmacies to open up in the U.S., since FDA regulations require pharmacy patients to have prescriptions. In the end, none of the people Aiken interviewed ordered the pills, instead opting for unreliable herbal treatments or a last-minute clinic visit.

For a study published earlier this year, Elizabeth Raymond, a senior medical associate at the research organization Gynuity, Googled phrases like “buy abortion pills online.” The researchers ended up ordering 18 of the pill combinations from 16 different websites, none of which required a prescription. The pills came from India, where there is a large generic-drug industry. Shipments cost between $110 and $360, and the packages took between three days and three weeks to arrive.

Even then, it wasn’t entirely smooth sailing, as Raymond and her co-authors write:

Two buyers received troubling communications from product vendors. One warned about the legality of purchasing online: “Please do not share this info with any other side because investigation team is searching the details for this type of medicine.” In the second case, the vendor complained that he was unable to get payment from the online payment platform and threatened to withhold shipment until the buyer paid another way. After some convincing, he finally sent the product. In addition, one buyer who paid with Western Union received two fraud alert calls—one from Western Union advising against purchasing pharmaceuticals online and another from her credit card company.

Raymond noticed that some of the blister packs of pills were broken. “It’s our speculation that the shippers are afraid that the customs service will be able to feel through the packaging and see that that there are pills in there, so they crush the blister pack,” she says.

Although the mifepristone pills contained the expected amount of the medication, most of the misoprostol pills contained less than the labeled dose. (They might still work, even at a lower dose, Raymond says.) What’s more, none of the pills came with instructions for use.

Still, says Daniel Grossman, a professor of obstetrics and gynecology at the University of California, San Francisco, “it doesn’t appear that women are having serious complications” from these DIY regimens. If the pills are taken late, they could still work, but are less likely to. Mifeprex, the brand name for mifepristone, has been used by more than three million women in the United States and has caused 19 deaths, a rate of adverse events that’s lower than that of Viagra.

Pro-life groups, meanwhile, insist that the pills are not safe. Because of the risk of ectopic pregnancy, among other reasons, “the practice of obtaining abortion pills over the internet is risky, and it ought to be illegal,” says Steve Aden, chief legal officer at the pro-life group Americans United for Life. (Grossman says that while attempting to self-abort could delay the diagnosis of an ectopic pregnancy, the pills don’t affect ectopic pregnancies or make them worse.) The people held accountable, Aden says, should be the companies providing the pills, rather than the women themselves.

If Roe is overturned, Raymond says, the abortion landscape will roughly look like this: “In some states, abortion will still be legal, so people will travel to those states. Some people won’t get abortions. Some people will get abortions, but later. And more people will probably use these alternative methods for getting the service.”

Women on Web, a Canada-based service, ships the abortion pills to patients who live in countries where abortion is illegal. Rebecca Gomperts, the organization’s founder, says the organization gets 10,000 emails each month asking for help and staffs a help desk that speaks 17 languages. The service asks women to fill out an online form about their health status, which doctors in various countries review, then fill prescriptions for the abortion pills. In 12 years, she estimates they’ve helped 70,000 women perform their own abortions.

Women on Web doesn’t ship pills to the United States, however, because as Gomperts told me, in America “there’s such an aggressive anti-abortion movement that will do anything they can to close down services. It could potentially jeopardize all the other work of Women on Web.”

The United States, she said, “should be able to solve its own problems” regarding abortion access. “It’s a very rich country,” she added. “The problem there is caused by the huge inequality in the society. There’s no reason the situation in the U.S. should be the way it is.”

If women do start turning to web-based services in greater numbers, it raises the question of whether they’ll face legal risks. Gomperts says it’s legal, in most countries, to receive medicine through the mail for personal use. But other experts I spoke with were not so sure.

The SIA Legal Team, a group of lawyers who specialize in women who induce their own abortions, knows of 21 people who have been arrested or prosecuted for ending their pregnancies outside a medical setting, or for helping someone else do so. (It might be an undercount, since the organization relies on news reports to track cases.) The charges brought against women who self-abort can range from child abuse, to the abuse of a corpse, to a failure to report a death, says Jill Adams, SIA’s chief strategist.

None of the women were prosecuted for buying abortion pills, specifically. But Adams notes that buying pills online and even Googling “buy abortion pills” can leave a paper trail that can be used as evidence in a trial.

Because of this risk, Plan C, an organization that provides information on self-abortion, says some people seeking abortion pills try installing private networks on their computers in order to hide their search history, use secure texting services like Signal, or pay with Bitcoin and other private methods.

In seven states, self-induced abortion is already illegal. In 2015, a woman in Indiana named Purvi Patel was sentenced to 20 years in prison for feticide after she allegedly used abortion pills she ordered online. Prosecutors claimed her fetus had been born alive, and she allowed it to die. Her conviction was later overturned on appeal.

Sites like Women on Web tell women that if they require medical attention after aborting at home, they should just tell the doctors they had a miscarriage. The doctors shouldn’t be able to perceive the difference, they say. “The police in some countries put a lot of pressure on women to confess,” Gomperts said. “They should never confess that they did [abort].” If women are further along than 10 weeks, the service sometimes advises them to go to the emergency room of a hospital and take the pills there, in case complications occur.

If Roe is overturned, abortion laws would be up to the states, and about 22 states would likely ban abortion, Amy Myrick, staff attorney at the Center for Reproductive Rights, recently told Kaiser Health News. In those states, Grossman speculated, doctors might begin to practice harm reduction by, for example, giving women information about how to use the pills, without providing the actual pills themselves.

However, it’s not likely that, say, a doctor in California could prescribe abortion pills to a woman in Texas over the internet, since Texas has already outlawed the practice of telemedicine abortion, and it would likely continue to do so.

It’s also possible that Roe won’t be overturned outright, but abortion restrictions will tighten further under a more conservative Supreme Court. That’s already the reality for women in many states. Across wide swaths of the country, women must take multiple days off work and drive for hundreds of miles to get an abortion because their home states have imposed waiting periods or created restrictions that have caused clinics to close. In the past seven years, states have enacted nearly 1,200 such restrictions.