The Abortion Backup Plan No One Is Talking About

Even in states with the strictest abortion laws, pregnant people have a safe, inexpensive option to terminate their pregnancies. But few know about it.

A mail truck rolls down the street, with pills for wheels.
Atlantic

Updated at 6 p.m. ET on October 15, 2021

So many states have restricted access to abortion so severely that people in large swaths of the country feel they have no options if they want to terminate a pregnancy. But technically, those who want an abortion still have options. It’s just that few have heard of them.

Pregnant people in Texas, or in any other U.S. state, can visit an array of websites that will mail them two pills—mifepristone and misoprostol—that will induce a miscarriage when used in the first trimester of pregnancy and possibly even later. The so-called self-managed abortion is therefore an option at least six weeks further into a pregnancy than the controversial new Texas law’s six-week “heartbeat” cutoff for an abortion at a clinic. Though people in other states have several websites to choose from, Texans can visit Aid Access, a website that provides the pills for $105 or less based on income.

A chart showing peoples' knowledge of abortion websites
The Atlantic / Leger

Only 5 percent of Americans have heard of Aid Access, though, and only 13 percent have heard of Plan C, a website that provides information on different mail-order-abortion services by state, according to a new Atlantic/Leger poll. Some people may vaguely know that medication abortions exist, but don’t know the names of the organizations that mail them. However, most poll respondents said that they weren’t aware of any backup options for abortion if a clinic is not accessible. The poll surveyed a representative sample of 1,001 adults across the country from September 24 to September 26, and its results mirror my experiences interviewing two dozen random young Texans recently: None had heard of Aid Access, and the few who had heard of Plan C were confusing it with Plan B, the morning-after pill.

The results also jibe with the experiences of Plan C’s founders. Though they’ve seen a large increase in web traffic, particularly from Texas, since Texas’s abortion restrictions went into effect, “we know that the biggest challenge is to try to get this word out,” says Francine Coeytaux, one of the site’s co-founders. The doctor behind Aid Access, Rebecca Gomperts, told me that according to her own research, 60 percent of her clients did not know about abortion pills before they found her service.

Nationwide, opponents of abortion rights appear to be winning. Though a federal judge temporarily blocked enforcement of the new Texas “heartbeat” law, Texas appealed, and the law remains in effect—at least for now. Texas Governor Greg Abbott recently signed another bill that narrows the window for medication abortions from 10 weeks to seven weeks and bans the mailing of abortion-inducing medications. The Supreme Court is composed predominantly of abortion-rights opponents, and states have enacted 106 different restrictions on abortion this year, the most in one year since 1973, according to the pro-abortion-rights Guttmacher Institute.

Many people in these states, upon getting pregnant, will simply track down a mail-order-abortion service through the internet. But the picture is more worrisome for those who lack internet access or proficiency. “Being in that state of desperation and feeling like you have no options” exacts a mental toll, says Abigail Aiken, a University of Texas professor who has researched self-managed abortion. Some number of those people might harm themselves in a misguided attempt to end the pregnancy. “It would be remiss of us to underestimate the lengths people will go to sometimes when they can’t access the care they really need,” Aiken says.

Abortion pills work best in the first trimester of pregnancy, but it takes time to find the service and order the pills, and for them to arrive and make their way through customs. This is one reason Aid Access is now allowing people who aren’t pregnant to order the pills to have on hand and use later if they experience an unwanted pregnancy. The pills don’t expire for about two years.

Aiken wants Texas schools to start teaching about abortion as part of health class. However, this is unlikely to happen in a state that still does not mandate any kind of sex education.

Coeytaux, from Plan C, suggests that something darker is at work: that abortion clinics and funds are not sufficiently promoting self-managed abortion, either out of a lack of trust or because they fear it will quell the sense of emergency over the war on reproductive rights. Indeed, when I visited the website of one Texas abortion fund recently, it said, “We do not provide advice on self managed abortion care.” (The fund did not respond to a request for comment.) Whole Woman’s Health, an abortion clinic with sites in Texas, does have a page on self-managed abortion, but in an email, its CEO, Amy Hagstrom Miller, said that because Texas does not allow the dispensing of abortion pills by mail, medical professionals “cannot advise Texans how to obtain self-managed abortion medications in Texas.”

The struggle for abortion rights has been about proving that restrictions are an “undue burden” for women—a burden that mail-order abortions arguably lessen. “The strategy of the lawyers and the providers and everybody who’s fighting for our rights … is ‘Oh my God, look what happened. In Texas, there are no options anymore,’” Coeytaux says. “If you come along and say, ‘Maybe your problems of access have just been solved, because you don’t have to travel, you don’t have to pay that much,’ that undermines the Oh my God, this is really terrible.”

Of course, other factors might be discouraging people from pursuing self-managed abortions. The procedure involves severe cramping and heavy bleeding, and in the states that are most hostile to abortion rights, women who self-induce their own abortions must rely on hotlines and text support from faraway doctors if they get scared or experience complications. Aid Access is based in Austria, beyond the reach of Texas law enforcement and the new abortion-medication measure, but the site still inhabits a legal gray area: Four states have criminalized managing one’s own abortion, and about two dozen people have been prosecuted for self-managing an abortion since 2000. Mainstream medical research generally suggests that self-managed abortions are safe and effective, but anti-abortion-rights groups vehemently disagree and have published their own reports saying they are dangerous. Whatever the reason, far fewer women in the U.S. have medication abortions than in some other countries: Medication abortions accounted for 40 percent of all U.S. abortions in 2017, compared with more than 90 percent in Finland and more than 80 percent in Mexico City, according to the Guttmacher Institute.

Sites like Aid Access are quickly becoming the sworn enemies of abortion opponents. “At a minimum, the FDA should warn women, as it has in the past, that it is not safe to use imported drugs bought off the internet that have not undergone agency scrutiny and evaluation as to purity, safety, and efficacy,” Randy O’Bannon, the director of research at National Right to Life, told me via email. “And those entities illegally importing and selling those unauthorized drugs should be prosecuted for those violations and they should certainly be held criminally and financially responsible for any injuries associated with their products.”

Aiken and others, though, doubt American laws will affect Aid Access, because the organization already operates in countries where abortion is illegal. When I asked Gomperts if she feels like she’s under threat from the Texas laws, she said, “Aid Access is serving women who need access to safe abortions. It doesn’t matter where they live or what the legal situation is in that country.” Unfortunately, few Americans know that she’s available to serve them.


This article previously stated that five states have criminalized managing one’s own abortion. Four states have done so.