For many people, the phrase “illegal abortion” calls to mind images of back alley clinics, medical providers with questionable credentials, and, of course, the dreaded coat hanger — an object so evocative it’s often been used as a protest symbol. But those images are outdated, belonging to a pre-Roe era. These days, the real action in abortion is now online, as a group of reproductive rights activists use the internet to spread the word about how to use abortion pills. They hope to give pregnant people living in places where abortion is nearly inaccessible, or outright illegal, access to safe and effective ways to take charge of their own fertility.
Thanks to the introduction of abortion pills mifepristone and misoprostol — which, in combination, effectively induce abortion 95 percent to 98 percent of the time — it’s become possible to terminate an unwanted pregnancy without an invasive medical procedure. More to the point, it’s possible for women to take these pills to induce an abortion on their own, without the assistance of a doctor. Those pills can be bought online — so for many people, it’s possible to avoid the clinic entirely.
People in search of information on self-managed abortion have a number of places to turn to, including Plan C, ReproAction, and safe2choose. In many cases, these services are just lists of the facts about self-managed abortion. But some, like SASS (an acronym for Self-Managed Abortion, Safe & Supported), offer access to counselors who can guide visitors through the process of self-managed abortion, answering any questions they may have about their own specific situation.
Launched in April 2017, SASS is an online counseling service provided by the international abortion activist group Women Help Women. Outside of the US, Women Help Women is one of a handful of full-service self-managed abortion support operations, delivering not just support and information, but actual abortion pills to people who make use of the service (Women on Web offers a similar service, safe2choose recently made the decision to step away from direct shipping). But because many US regulations legally prohibit this sort of setup, SASS functions a little differently.
When someone comes to SASS, they get a comprehensive guide to how to have a self-managed abortion. There’s an extensive list of questions and answers, covering all the facts about self-managed abortion: places where abortion pills can be obtained, how to safely induce abortion using both mifespristone and misoprostol or just misoprostol alone, what to expect during the abortion process, what kind of complications require a visit to the hospital, and, perhaps most importantly of all, what you should tell a doctor if you land in the emergency room — especially if you’re in a state where self-managed abortion is illegal. The site also lists resources for people who would prefer a clinic abortion but just don’t know how to make it happen, including information on abortion funds that are set up to facilitate the procedure for low-income people.
For people with more specific questions, there’s an additional option: a web-based help line that allows users to connect with SASS counselors based outside the US. Users submit their questions through a secure portal and are provided with a randomized link where their answer will be posted within a few hours. After seven days, the page goes blank, leaving no evidence of the original question.
If that system seems a little cloak and dagger, it’s for a good reason. “We wanted to be sure that that contacting SASS would be safe,” says Susan Yanow, one of the members of Women Help Women’s US-based team. In many states — including supposed havens for reproductive rights, like New York — self-managed abortion is a crime.
Because a self-managed abortion is medically indistinguishable from a miscarriage, prosecutors rely on other clues to ascertain whether someone attempted an abortion. A stray text message or email referencing self-managed abortion can land someone in jail, as demonstrated by the experiences of people like Purvi Patel, an Indiana woman who was sentenced to twenty years in jail after prosecutors argued that her miscarriage had been induced by abortion pills (Patel’s conviction was later overturned by an appeals court).
While people seeking abortion in the pre-Roe v. Wade era risked infection, infertility, and even death, these days pursuing a self-managed abortion with mifepristone and misoprostol brings with it a different set of challenges.
The most significant obstacle is getting access to the pills in the first place. SASS lists a number of options. Misoprostol (which is frequently prescribed to prevent ulcers and on its own is 85 percent effective when used to terminate a pregnancy) can sometimes be acquired from a doctor, veterinarian, or over the counter in a country like Mexico. Several online pharmacies sell abortion pill kits, but these can be expensive, slow to arrive, and of dubious quality. That’s why Plan C offers a report card that rates different services.
But there’s no guarantee that the information is still up to date. The online pharmacy system is “like whack-a-mole — what’s good information today is not necessarily good information next week or next month or next year, because [the pharmacies] come and go,” says Abigail Aiken, an assistant professor at University of Texas-Austin who studies the motivations and experiences of people who pursue self-managed abortion.
Complications can and do occur: Katherine Olivera, a program associate at the International Women’s Health Coalition who previously worked at the Falls Church Healthcare Center — one of the only abortion providers in northern Virginia — worries about issues like “a missed ectopic pregnancy diagnosis or failed abortion.”
But the greatest risk to people looking to self-manage their abortions may be legal: even when self-managed abortion isn’t explicitly illegal, the practice can be prosecuted under fetal harm laws (which are on the books in ten states, including Massachusetts, Michigan, and Washington) or through misapplication of archaic anti-abortion statutes (which exist in fifteen states, including Alabama, Minnesota, and Nevada). The threat of being arrested after heading to the emergency room to seek care for complications are what advocates see as the most vicious threat — one that projects like SASS hope to combat by educating people about how to avoid incriminating themselves.
It’s difficult to say how frequent self-managed abortion might become in America if Roe v. Wade gets overturned. Even though advocates suspect that state level assaults on abortion access have increased interest in self-managed abortion, there’s not much data on its frequency, in part because of the emphasis advocates place on protecting the anonymity of people who utilize their services. “We think it’s increasing, but we don’t know,” says Yanow. Yamani Hernandez, the executive director for the National Network of Abortion Funds, notes that while the organization does receive requests for information about self-managed abortion, the frequency of requests “is not something we track.”
But projects like SASS are working to ensure that, whatever happens in the reproductive rights fight, we won’t be going back to the era of the coat hanger. By providing information, legal advice, and emotional support, self-managed abortion activists are paving a way for a new future of reproductive rights, one where information is the most powerful tool for ensuring bodily autonomy.