Self-Managed Abortion May Be The Future — But It’s Complicated

There’s no good time to find out you’re pregnant if you don’t want to be. But the timing for KT Volkova was particularly troubling. They took a pregnancy test the weekend before Senate Bill 8 went into effect in their home state, Texas, in September 2021. The law made it almost impossible to get an abortion after six weeks, and went into effect nearly 10 months before Roe v. Wade was overturned and the Texas Supreme Court allowed an abortion ban from 1925 to be enforced. At the time, Volkova estimated they were about five or six weeks along. They knew they likely wouldn’t meet the cutoff by the time they found an appointment. “I was in a really shitty predicament,” remembers Volkova, who’s in their early 20s.

So they researched online. Because they were active in organizing for reproductive justice, Volkova already knew a fair amount about medication abortion — typically carried out by taking a combination of the drugs mifepristone and misoprostol, though misoprostol can sometimes be used alone. They decided to have a self-managed abortion (SMA), which is done without involving traditional medical institutions like clinics or doctors. They ordered the medication online and had their abortion at home. “I didn’t have to go to a clinic. I could just chill out in my house and be with my cats,” they say. “I didn’t have to worry about clinic protesters. Or about feeling weird in the waiting room that I didn’t have someone with me as support.”

In the wake of the Roe v. Wade reversal, many more people are expected to self-manage their abortions. SMA provides an alternative to going out of state, which will simply not be an option — financially and logistically — for many people in our post-Roe world, especially when the closest viable clinic may be states away.

“We’ve seen a rising trend in self-managed abortion in recent years, and we expect that to continue to grow significantly,” Jill E. Adams, executive director of the reproductive rights organization If/When/How, told Refinery29 in an interview before Roe’s official overturn. And this isn’t surprising. Even before the Supreme Court decision, self-managed abortion was on the rise. In part, because many people already didn’t have easy access to official channels for getting abortions with Roe intact, due to costs, state-level abortion restrictions, being undocumented, and other logistics such as finding childcare, getting time off work, or being under 18 years old.

The week after S.B. 8 went into effect in Texas, there was an average 1,180% increase in daily requests for medication abortion from one specific nonprofit called Aid Access, according to research published by the Journal of the American Medical Association. Throughout the rest of that month, requests for self-managed abortion remained 245% higher than the pre-SB 8 baseline. 

Low-income folks, people of color, and people who live in states with anti-abortion legislatures will now have the hardest time going through official channels to have abortions, no matter how much abortion funds mobilize to help — which is why SMA will be so necessary, according to Elisa Wells, the co-founder and co-director of Plan C Pills. This same group of often-marginalized people could also potentially be the ones most likely to be unfairly punished for self-managing their abortions (more on that later).

While SMA can be a powerful and convenient option for those who choose it, it's worth doing research before diving in (ideally using private browsers like DuckDuckGo).

To start you on that journey, here are a few things to know about self-managed abortions in a post-Roe world.

Today, the term self-managed abortion (SMA) refers to an abortion someone does on their own. Most often, SMA refers to the use of medication to prompt an abortion, typically the aforementioned mifepristone and misoprostol combo (which is sometimes known by the brand name, Mifeprex and can be taken up to about 10 weeks in most pregnancies). But some people use herbs or other means.

When it comes to the pills, many people order them online, but some get them via doulas, or from someone who’s been prescribed the medication for another medical reason (misoprostol, for example, is used to treat ulcers). Some people even have the pills on hand before they need them or have a friend who does (Aid Access offers “advanced provision,” meaning folks can order abortion pills before they get pregnant). Others still will purchase the medication in other countries such as Mexico, where the pills are available over the counter. 

Speaking of OTC, it’s important to note that SMA is also not the same as the morning-after pill, Plan B, which isn’t abortion and is available to anyone over the counter in the U.S. for now. Another important distinction: SMA is often carried out through medication abortion (again, the pills with the long M-names), but the two are not synonymous. Medication abortion can be a self-managed abortion, or it can be medically supported through telehealth or provided by a healthcare provider in a clinic.

There are big benefits, financially and logistically, to having your abortion at home, either through telehealth or by self-managing. Like Volkova says, it’s nice to be able to cuddle a pet or have your favorite essential oils nearby. And there are other important and personal reasons that make this method optimal. Like Volkova, Oliver Hall wanted an abortion in their home in Kentucky when they were 19. They identify as a trans-masculine nonbinary person, and they were apprehensive about seeking care at the closest clinic, which had the word “women” right in the name.  

“I had already had negative healthcare experiences related to my gender expression and my sexuality,” continues the now-27-year-old reproductive rights activist. “To [go] somewhere, where I would already feel vulnerable due to the nature of the way abortion is framed in the U.S., and considering how young I was, and thinking I would be likely to have another negative experience around my gender expression — [it] wasn’t something I felt willing to do if I could find a way to avoid it.” 

Medical experts and studies from established journals like The Lancet Regional Health explain that self-managed medication abortion is, indeed, safe.

A lot of politicians and members of the media have predicted that the more abortion is legislated and restricted, the more folks will go underground to access it, which will add to the medical risks. This is where the stark visual of a coat-hanger often comes in — an image that most advocates would say is problematic, undermining the fact that SMA can be done safely. It’s true that Roe’s reversal is dangerous on the whole, and SMA will ultimately be less safe if people self-managing abortions feel they can’t access healthcare if they have a rare complication — or if they don’t have the resources or the access to unmonitored broadband internet to learn about how to safely use abortion pills. Or, if think their only option is a coathanger due to the repetition of the imagery. But self-managed abortion with pills is often the same process as a medication abortion done with provider assistance, says Danika Severino Wynn, CNM, VP of Abortion Access at Planned Parenthood Federation of America. 

“Our organization is very much against the rhetoric about so-called ’back-alley’ abortions and that self-managed abortion isn’t safe,” says Rachael Lorenzo, co-founder of Indigenous Women Rising. “Our ancestors have been self-managing abortion within our own communities for centuries before colonization.” 

There are certainly some exceptions to who can use the pills to self-manage — medication abortion isn’t recommended for people with bleeding disorders, who have IUDs, and those who need abortions late in pregnancy. Medication abortion also has to be carried out correctly. The New Yorker spoke to a clinic worker who’d heard of women taking too many pills at once, or inserting a large number of abortion pills vaginally, which can result in a fatal bacterial infection. The pills should be taken orally and buccally, and there's a very detailed explanation of how to do this here. When carried out correctly, SMA with pills is a valid option, and fear-mongering, especially with problematic imagery, isn’t helping anyone. 

The legality of self-managed abortion can be a bit murky, particularly since the Food and Drug Administration has said that abortion medication is safe and effective, which raises questions about whether states can ban it without their laws being preempted, says Mary Ziegler, a visiting professor at Harvard Law School and author of Dollars for Life: The Anti-Abortion Movement and the Fall of the Republican Establishment.

Some advocacy groups say SMA is largely unregulated, not illegal, except in three states with old laws on the books prohibiting it (Oklahoma, Nevada, and South Carolina). SMA is not called out specifically as a crime in the vast majority of states, but people are sometimes criminalized despite that, often “through misuse of laws that were never meant to apply in these situations,” Adams says.

"While trigger laws and other clinic-based abortion bans do not authorize states to criminalize people who self-manage their abortions, they will indirectly increase the likelihood of criminalization,” Adams adds. “These bans fan the flames of abortion stigma, foment suspicion, [increase the likelihood of] surveillance of people who experience pregnancy loss, and embolden law enforcement to misuse other laws [which] never meant to apply to someone who has self-managed an abortion.”

In this line of legal thinking — that SMA is unregulated — in order to make SMA truly "illegal," states would have to introduce new laws specifically punishing people who have abortions themselves. Wells, of Plan C Pills, says this is politically unpopular. It's not totally unheard of, though — Louisiana recently proposed a failed bill that would have classified abortion as a homicide and allowed patients themselves to be charged. But it's more likely that new laws post-Roe will target and criminalize providers over individuals, Wells explains.

Not everyone agrees with this legal analysis, though. “In places where abortion is illegal, obviously self-managed abortion will be illegal too,” Ziegler says. “In the short term, people who live in states with trigger laws are unlikely to be criminalized — at the moment… That said, SMA will still be considered a crime, and others who help pay for or obtain pills could face criminal consequences, and pregnant people might have to worry about escalating digital surveillance from lawmakers looking to identify people having abortions.” 

In the end, even the language around legality is complicated — when I asked if I should use the words “legal” and “illegal” when describing the future of self-managed medication abortions, my experts were somewhat split, some saying that just hearing the word “illegal” could stop folks from pursuing an option that could help them.

No matter which legal analysis you go by, with any criminalization of self-managed abortion in our new post-Roe world, there may be a lot of bias involved. “How likely someone is to be surveilled, to be arrested, to be charged, and to be convicted, depends greatly on their identities, their income level, their location, and other circumstances,” Adams adds. “We’re particularly concerned about Black, Indigenous, and other people of color, young people, trans and gender-nonconforming folks, immigrants, and people who are experiencing poverty being the most criminalized.”

And this criminalization is happening already. If/When/How has been working on a multi-year research project working to better understand criminalization in the world of self-managed abortion. Preliminary findings show over 60 cases between the year 2000 and 2020 of people being arrested in the U.S., charged, or imprisoned for ending their own pregnancies or helping other people do so. They believe that’s an undercount. The examples are chilling: two months ago, a woman in Starr County, Texas, was arrested, jailed, and charged with murder for allegedly self-inducing a medication abortion. The charges were later dropped after reproductive justice organizations such as the Frontera Fund intervened and ​​If/When/How’s Repro Legal Defense Fund paid bond. Still, her name and mug shot will always be out there. Even when charges are dropped, criminalization will have devastating effects on folks.

Although some fringe anti-abortion advocates believe that criminalizing abortion, including SMA, will deter people from having them, “it hasn't and it doesn’t and it won’t,” says Adams. Although up to 26 states have or will outlaw almost all abortions without Roe there to stop them, affecting about half of the U.S.’s population, the number of abortions is expected to fall by much less than half. The decline in “legal” abortions will only be about 13%, according to an analysis by Caitlin Myers, a professor of economics at Middlebury College. And the total decline in abortions will be even less if you count those self-managing off the books. Myers told Refinery29 via email: “This projection assumes the ban states don’t succeed in limiting interstate travel.”

“There will always be those for whom self-managed abortion is their preferred option, and now there will broad swaths of the population for whom self-managed abortion will be their only option,” Adams says. 

Although, again, most anti-abortion folks say they don’t want to punish the pregnant person for pursuing abortion, recent history shows criminalization of SMA was happening, even when Roe was intact. There will likely be more of this and potentially laws making it harder to self-manage or even find information about SMA in the coming years. 

While SMA will likely continue to be a more affordable option than traveling to a clinic out of state, self-managing abortions with pills or going through telehealth isn’t always cheap, either. Costs vary drastically depending on how you get medications, though. Telehealth services are often cheaper than clinic-based care, and some offer discounts, "some down to $0 if that is what the patient says they can afford," Wells says. Aid Access has a "pay what you can" model as well. Outside of these options, one reporter for The New Yorker went to Ciudad Juárez in Mexico and bought a box of abortion pills OTC for less than $30.  

Still, the median charges for medication abortions in the U.S. escalated from $495 to $560 between 2017 and 2020, according to researchers at the University of California, San Francisco. And the insidious truth is, in that same timeframe, more abortion bans and “heartbeat” bills passed, moving the cut-off for abortion to earlier and earlier in pregnancy. Thus, as costs rose, people had less time to come up with the cash. And that problem will only grow worse in our new, post-Roe world.

As with all medical information, it’s a good idea to be thoughtful about what you share with those around you and to protect yourself digitally by using encrypted messaging through platforms like Signal. But it’s equally important not to isolate yourself from resources that are available to you because you’re scared of repercussions like being criminalized based on your state’s laws.

If a rare complication arises, folks should be able to seek medical help without fear of prosecution. This isn't always the reality though, which is why experts emphasize that the treatment for miscarriage and medical abortion is the same, and it’s not necessary to tell healthcare providers that you took abortion pills if you seek medical support, says Laurie Bertram Roberts, who’s directed and co-founded abortion funds in Alabama and Mississippi.

With this in mind, know that how and when you talk about SMA is worth paying attention to, and the boundaries will be different for everyone. In May, after a draft decision leaked signaling to Roe v. Wade's imminent reversal, a social media post went viral that told pregnant people in states where they “could be prosecuted” to: “Tell no one, wear a hoodie and keep your head down. Pay cash. Do not get a test through your doctor…”

Lorenzo, of Indigenous Women Rising, emphasizes that this kind of messaging is problematic, and adds to abortion stigma. “Putting it out there that people should isolate themselves is not helpful and it could further discourage someone from getting help when they should really seek medical help or legal help,” they say. 

Protecting yourself legally is important. But so is getting help if you need it, and having access to emotional support. Ultimately, who you tell is your choice and is important to consider. The best way to make a choice about this is by doing your research and making sure you’re getting help from friends, family, and folks you trust.

Hall could have benefitted from more emotional support during their abortion. They didn’t self-manage through the typical medication abortion regimen, with mifepristone and misoprostol, because they couldn’t figure out how to access them at the time. Instead, they used other known abortifacients. “The experience was a bit stressful for me because I was alone and worried and it took quite a while, but the only pain I experienced was some nausea and cramping. I was scared because I didn’t tell anyone. I felt weird about being able to become pregnant to start, and I felt embarrassed that I didn’t feel able to go to the clinic.” This is just one example of why the criminalization and stigmatization of abortion care — both then and now — can make people feel scared and alone. It shows how harmful the Roe reversal is. 

It is for many. In Volkova's case, they were thankful that they were able to self-manage the abortion they needed, despite S.B. 8’s deterrent effects. It helped that they’d already had some experience volunteering for abortion rights organizations, and knew a bit about what their options were before they were pregnant. But in a post-Roe world, they worry that others won’t be able to get the same crucial healthcare — or if they do get it, they’ll be prosecuted. 

​​“I knew without a doubt that an abortion was what I needed,” they say. “There was a lot of my own personal grieving on my end, and I felt guilty and stupid because I’m always advocating for people to have safe sex… But I realized: mistakes and accidents happen. Stuff like this happens all the time and this is why we have abortions available to us: because shit happens.”

When accessing self-managed abortion, going to a trusted organization is a good idea (be warned: some anti-abortion organizations co-opt the language of legit websites, so be wary if you run into references to religion or sites calling fetuses "babies"). We recommend starting with the below options, and using a secure search engine like DuckDuckGo to check them out.

Plan C — they’ll help you understand your options for getting abortion pills via mail in all 50 states. They also have information and resources about options like SMA and how to use mail-forwarding services to get pills from telehealth providers in states without abortion bans.

Aid Access — This European website connects people in places where abortion is not allowed or has been criminalized to pharmacies in other countries. Because getting the pills can sometimes take weeks, they also offer what’s called “advanced provision.” That means you can order abortoin pills to have on hand ahead of time before you even get pregnant.

If/When/How’s Repro Legal Helpline — they provide callers with secure, confidential, and free legal advice about self-managed abortion. They also offer information on how to stay safe digitally when looking for abortions online through their Internet Safety Guide. Call 844-868-2812 or go to reprolegalhelpline.org. 

The Digital Defense Fund — they have a guide to abortion and pregnancy privacy and a Mobile Abortion Privacy Quick Guide that summarizes their recommendations for abortion-seekers and the folks helping them.

The Miscarriage and Abortion Hotline — They are volunteer clinicians in the U.S. who provide a free, confidential text and phone consultations for people who have questions about miscarriage or abortion. 

Hackblossom’s DIY Guide To Feminist Cybersecurity  — Another good resource for technological security. 

I Need An A – helps you find out the abortion laws in your state and connects you to abortion providers and other resources.

How to Use Abortion Pill — offers info for before, during, and after medication abortion. 

SASS – Self-Managed Abortion; Safe & Supported — offers counseling and resources for self-managing abortion and answers some medical questions.