After Marie decided to take medication to end her pregnancy, it took several days for the pills to work.

When the uterine contractions started, Marie recalled, she experienced “a lot of bleeding, a lot of pain, a lot of cramps. Just like a bad cycle.” (Marie asked that her last name not be used because of legal concerns.)

She used a sock filled with rice, heated in the microwave, as a heating pad to relieve the cramps, and put on soothing music to help her calm down. One thing she didn’t do was call her doctor.

Though there’s no comprehensive data on the phenomenon, experts say a growing number of pregnant people are, like Marie, choosing to self-manage their abortions, getting pills or herbs over the internet, through friends or non-clinical providers, and taking them on their own. Advocates say the number is likely to grow even more in the years to come.

With states passing ever-stricter abortion laws, dozens of clinics closing in recent years, and a potential challenge to Roe v. Wade on the horizon, it’s becoming increasingly difficult for many Americans to get an abortion from a medical provider. If near-total bans like the ones recently passed in Louisiana, Mississippi, Georgia, and Ohio are allowed to take effect, more pregnant people could find self-managed abortion their only option.

But some are choosing self-managed abortion even when they can legally have the procedure at a clinic. Marie, for instance, chose to end her pregnancy with pills she got through a friend after a bad experience seeking an in-clinic abortion in the past. “I didn’t want to go back to the stigma I already faced,” she said. “I didn’t want to go back to being judged for something that I know I had a right to.”

As self-managed abortion becomes increasingly common, advocates argue that it’s time for America to get past the “coat-hanger narrative” of unsafe home abortions and embrace the new reality.

“Self-managed abortion is going to play a bigger role, no matter what happens with Roe,” said Farah Diaz-Tello, senior counsel for If/When/How, a legal and policy advocacy group centered around reproductive health.

An evolving procedure

In the years before Roe v. Wade established the right to an abortion in America, people who wanted to end their own pregnancies sometimes turned to household implements like pencils, Coke bottles, or the coat hangers that have since become a symbol of the long struggle for abortion rights. The results could be lethal: No one knows exactly how many people died as a result of abortions before Roe, but in 1930, abortion was listed as the cause of death for almost 2,700 women.

But medicine has changed since Roe was decided in 1973. In 2000, the Food and Drug Administration approved a medication called mifepristone, which became widely known as RU-486. The drug blocks the hormone progesterone, stopping a pregnancy from progressing. Taken with misoprostol, a drug used to treat ulcers that also causes uterine contractions, mifepristone can be used to cause an abortion at up to 10 weeks’ gestation.

The introduction of RU-486 inspired intense media scrutiny and pushback from anti-abortion groups, and its use was heavily regulated; it could only be dispensed in clinics or other medical facilities, not at pharmacies, and patients had to visit a provider three times to get the full regimen of medication. (The required number of visits has since been reduced to one or two, and medication abortions, as they are known, are now available by telemedicine in some states).

Because they induce miscarriage, mifepristone and misoprostol typically cause the kind of cramping and bleeding that Marie experienced. But “both of those pills are very safe,” said Jamila Perritt, a Washington, DC-area OB-GYN and fellow with Physicians for Reproductive Health.

Medication abortions have become an increasingly common choice for people seeking to end their pregnancies in the first trimester. As of 2018, the method made up almost 33 percent of abortions in the first eight weeks of pregnancy, according to the Kaiser Family Foundation.

Those are just the official numbers. Some people obtain mifepristone and misoprostol — or just misoprostol, since it can work on its own to end a pregnancy — as Marie did, going outside the medical system, to websites based abroad that supply them, or to friends or unofficial providers such as a network of women that assists with at-home abortions.

Over time, the term “self-managed abortion” arose to describe the abortions that occur outside a clinical setting, explained Yamani Hernandez, executive director of the National Network of Abortion Funds, a group that helps patients pay for abortions. It’s a term advocates today prefer to the older “self-induced abortion.”

The term “self-managed” reflects a patient’s ability to “manage the entire process of an abortion,” Hernandez said. “‘Inducing,’” she added, “sounds like it’s just starting something, but not necessarily taking care of themselves throughout.” While some people self-manage abortions with herbs or other compounds, mifepristone and misoprostol have the most conventional research behind them.

People who self-manage their abortions typically fall into one of two categories, said Jill Adams, If/When/How’s executive director. There are “people who would prefer to have clinic-based abortion care, but there’s some impediment that keeps them from reaching that,” Adams explained.

That barrier could be distance: As of 2014, 90 percent of counties in the United States had no abortion clinic. It could be cost: Because of the Hyde Amendment, which bars the use of federal funds for abortion care in most cases, Medicaid does not cover most abortions, and many state and private insurance plans also exclude the procedure. Or the hurdle could be that a patient is concerned about going to a clinic because of their immigration status, or for another reason, Adams said.

The other type of person who might opt for self-managed abortion is someone who prefers it to visiting a clinic, she said. They may have been judged or treated poorly by doctors in the past because of their gender presentation, HIV status, or body size. They may want to integrate a religious practice or cultural tradition into their abortion, or come from a country where self-managed health care is the norm. “There are people who have already had pregnancies and miscarriages and abortions, and they know their bodies and they trust themselves to know how to do this and whether they need to seek care,” Adams added.

“I hesitate to say one thing is safer”

However a person gets misoprostol or mifepristone, the next steps are the same: Patients take mifepristone, if they have it. Then, up to 48 hours later, they take misoprostol, which causes contractions, making the uterus expel the pregnancy. Even if they get it from a medical provider, patients can take the misoprostol at home.

Because they essentially cause a miscarriage, Perritt said, they carry the same risk of complications someone might face from having a miscarriage at home, including excessive bleeding or infection. However, she said, “that’s rare for miscarriages and rare for abortions, too.”

Complications from medication abortion occur in less than 1 percent of cases, according to the National Academies of Sciences, Engineering, and Medicine. The pills work to end a pregnancy about 95 percent of the time if taken before 10 weeks’ gestation, according to the Guttmacher Institute, a reproductive health research organization. When they don’t work, a pregnant person may need a surgical abortion or another dose of the medication.

When patients get the pills outside the medical system, those pills may not have been through the FDA’s system for regulating the potency and content of medication, Perritt said. That can lead to safety concerns. However, one recent study by the reproductive research organization Gynuity of abortion pills ordered online found that most contained enough of the appropriate medication to be effective. And Perritt noted that going to a health care center can have its own safety risks, including trauma after encountering protesters outside, for example. “I hesitate to say one thing is safer or less safe than the other,” she said.

Facing jail time

Today, the biggest danger for some people who self-manage abortions might be prosecution. Five states — Delaware, South Carolina, Arizona, Idaho, and Oklahoma — have laws on the books that specifically ban self-managed abortion. A sixth, New York, recently passed legislation to eliminate its ban and remove abortion from the criminal code, fully decriminalizing the procedure.

However, “even laws that were not intended to address self-managed abortion can be twisted to punish people for ending their own pregnancies,” said Diaz-Tello, senior counsel for If/When/How.

An example is the case of Purvi Patel, an Indiana woman who in 2015 was sentenced to 20 years in prison for violating a decades-old feticide law, as Christophe Haubursin reported for Vox. Such laws are usually used to prosecute people for violence against pregnant women, but authorities in Indiana charged Patel after she went to the hospital, bleeding from what she said was a miscarriage.

Patel’s conviction was eventually overturned, but advocates remain concerned that the legal landscape across the country could leave people who self-manage abortions — and people who have miscarriages — vulnerable to investigation and eventual prosecution. In some states, feticide laws have an exception that they can’t be used against people who end their own pregnancies. But nine states lack such exceptions, and others have laws that can be used to criminalize people who self-manage abortions, even if they don’t ban the procedure outright, Diaz-Tello said.

Most mainstream anti-abortion groups oppose prosecution of people who get abortions, preferring criminal penalties for providers. But abortion opponents have been relatively quiet on the issue of self-managed abortion, where the patient and provider are one and the same.

“We do think that there are dangers involved with a woman completing an abortion or an abortion being performed while she’s at home,” said Christina Fadden, chair of the group New York State Right to Life. However, she said, “we don’t have a specific position on that, other than that we are concerned.”

The group did oppose New York’s removal of criminal penalties for abortion, arguing that they had been used not to prosecute people who self-manage abortions, but to punish people who abuse pregnant women and cause them to miscarry. The penalties were “an active tool that prosecutors used when a woman is a target of violence by somebody else,” like an abusive partner, Fadden said.

Self-managed abortion could become more common, regardless of what happens with state laws

The risks for people who self-manage abortion could be growing as more states pass strict bans on abortion in general. In Georgia, for instance, the near-total abortion ban passed last month gives a fetus legal personhood status. Some have argued that this could lead to patients who self-manage abortions being prosecuted for murder.

Many reproductive rights advocates say it’s not clear whether the law would be used in this way, but some agree it could give prosecutors ammunition. “I wouldn’t put anything past a prosecutor who’s decided they want to punish somebody for ending a pregnancy,” Diaz-Tello said, adding that prosecutors have tried to use fetal personhood language to prosecute people for terminating pregnancies.

Neither the Georgia ban nor any of the other near-total bans passed in recent months have taken effect. But they may lead to an increase in interest in self-managed abortions, as coverage of the bans leads some to believe that abortion is already illegal in their state. People are already calling the If/When/How legal help line confused about whether abortion is still legal, Diaz-Tello said, and doctors have reported similar confusion.

Meanwhile, activists on both sides of the abortion issue are preparing for a possible end to Roe v. Wade, and a future in which states would be allowed to institute total bans on abortion. Self-managed procedures, done in the privacy of home, could provide another option.

To protect patients now and in the future, If/When/How and other groups are working to repeal the remaining bans on self-managed abortion, as well as offering legal support to people prosecuted under feticide laws. In addition to backing New York’s decriminalization effort, they’ve had recent success in Nevada, which repealed its self-managed abortion ban.

And Diaz-Tello is hopeful that because of widespread public backlash against the near-total bans passed in Georgia and elsewhere, more legislators in blue or even purple states might consider loosening abortion restrictions.

At someone who has felt shamed for having an abortion, Marie takes a dim view of the bans sweeping the country.

“A lot of people just don’t have the information they need for safe sex, and sometimes you could be the safest person and end up in the situation that I was in,” she said. The new abortion bans are “just stupid,” she added, “because you don’t know people’s life. You don’t know people’s stories.”