The coat hanger is a symbol of an era before Roe vs. Wade, when abortion was illegal and people tried managing it with the only means they knew: a straightened coat hanger used to dangerously induce a termination that would often result in hemorrhage, and sometimes death. While outdated, the symbol of the coat hanger is a persistent reminder that when abortion is illegal or out of reach, people will find other means to terminate their pregnancies. Today people have safer means of self-managing abortion.
Roe vs. Wade legalized abortion in all 50 states in the United States in 1973, but it didn’t give everyone an unfettered right to access it, either without burden or significant obstacles. As an abortion provider who has worked in New York and Texas, I’ve been able to witness the stark differences in policy and how they directly impact abortion access. An abortion experience varies by zip code. Because of state-mandated insurance bans, a patient in Texas will have to pay out of pocket for her procedure (and she will have to wait at least 24 hours to have it done). But in New York, a patient with Medicaid coverage will not only get her procedure covered, but she can very likely have the procedure done the same day.
I know that medication abortion and procedural abortion are both two of the safest medical procedures. A termination can involve either a series of pills or a two to three minute in-office procedure. Even though both procedures are safe and simple, legislators across the country have placed over 400 restrictions on abortion since 2011. The legislation around medication abortion is particularly unjustified and even harmful.
Abortion care is cost-prohibitive for most people, estimating about $500 on average. And there is a dearth of providers in the U.S.—Missouri, for example, only has one abortion clinic. Many of my patients have told me they didn’t know that abortion was even legal. It’s not uncommon for me to be asked if I’m worried about people returning to the dark days of hanger-induced abortions. While this could be a possibility, it’s honestly not very likely. In the context of coat hangers, self-managed abortion—or abortion performed outside of a medical setting—is often viewed as desperate last resort, especially in the event that we see even more limitations to abortion access.
But that’s not always true. The conversation around self-managed abortion has shifted, and while in many cases it’s seen as a workaround, it’s often the first choice for many. I have had transmasculine patients who have told me they would not feel comfortable seeking an abortion in a clinic—a waiting room full of female-identified people can be triggering. I have had a patient tell me that taking any more time off of work would risk them getting fired or that finding childcare was almost impossible. I have also had patients tell me that they thought about managing their own abortion because they simply didn’t want a doctor or anyone else involved. I once had a young patient tell me she was using her father’s insurance and she was scared he would receive an explanation of benefits from his insurance company, so she looked up ways to end her own pregnancy on the internet.
A simple Google search reveals several options for self-managed abortion at home. Some involve over-the-counter medications, some involve tinctures and teas. To be clear, however, these are considered to be less safe and less effective methods of self-managed abortion; in some cases, they’re entirely unsafe. Other methods of self-managed abortion involve purchasing pills to induce abortion from an online vendor. The World Health Organization recommends that with the appropriate counseling, and when taken according to evidence-based guidelines, abortion pills can be safe.
Medication abortion is an FDA-approved method to end a pregnancy in the first trimester. After more than 15 years of use in the U.S., its safety has been well-documented and serious complications are rare. Medication abortion involves mifepristone which ends the pregnancy and misoprostol which induces bleeding and cramping and expulsion of the pregnancy (similar to what occurs during a miscarriage). The combination of mifepristone and misoprostol is over 96 percent effective. Or, medication abortion can just involve misoprostol, which is over 80 percent effective in the first trimester. The complications of a medication abortion, although very rare, are similar to those of a miscarriage: infection and bleeding. Again, these complications are very rare. And just to be clear, self-managed abortion with medication is not the same as emergency contraception (commonly referred to as Plan B, Ella or ParaGard IUD). Emergency contraception will prevent a pregnancy from occurring, but will not end a pregnancy that has already occurred.
Planned Parenthood recently launched a telemedicine abortion initiative in order to help expand access for patients in remote and rural communities and for those who seek an abortion experience that occurs mostly at home. While telemedicine abortion is linked to the medical system, it is an attempt to reach those who either have limited access or those who prefer less medical intervention. While telemedicine is legal in many states, unfortunately, telemedicine abortion has specifically been made illegal in several states like Indiana and Louisiana. It’s not because medication abortion is risky—a recent study found that medication abortion had a low rate of complications—but to prevent access to abortion.
With increased restrictions to abortion care, the risk is more legal than it is medical. People who terminate their own pregnancies or those assisting them may be targeted, reported, prosecuted, or even jailed. Low-income people, people of color, and immigrant people disproportionately face this risk. In 2015, an Indian woman in Indiana, Purvi Patel, was sentenced to 20 years in prison for inducing her own abortion. Fortunately, her conviction was eventually overturned. The Self-Induced Abortion Legal Team found at least 21 arrests related to alleged self-managed abortions in the United States. These prosecutions are politically motivated, often using antiquated laws.
Unjust laws, abortion stigma, and deeply rooted health and economic inequalities create barriers for many people to make their own decisions about ending or continuing their own pregnancy. If people are turning to self-managed abortion because of the lack of access to medical care, because they feel unwelcome in a clinical setting, or are unable to navigate confusing laws that obscure reproductive options, then we must do better. We must advocate for better insurance coverage, for no restrictions on abortion access including telemedicine for abortion, and for the decriminalization of self-managed abortion.
We must also ensure that people are able to receive accurate and unbiased information about their options, including self-managed abortion. The FDA needs to remove the unnecessary requirement for medical providers to supply the mifepristone pill in office, allowing instead pharmacists to dispense it directly. As an abortion provider, I commend the work of organizations taking unique approaches to protect the health and safety of people who face barriers in accessing abortion and people who seek an abortion in the privacy of their own home.
Dr. Meera Shah, MD, MPH, MS is the Associate Medical Director of Planned Parenthood Hudson Peconic in New York and a fellow with the Physicians for Reproductive Health.