by Catherine Trautwein

When Tami, a mother of three in her early 30s, found out she was pregnant, she began researching her options for an abortion. She discovered that there were only three remaining clinics in Louisiana, and the closest was hours from her home. And under state laws, Tami would need to make multiple trips: she would have to first receive an ultrasound and undergo counseling, then wait 24 hours before the actual procedure.

“I know what I want,” she said. “But the laws in the state make it so hard.” Instead, she turned to the internet.

Tami, not her real name, was one of 32 anonymous participants in a 2018 study on U.S. residents who tried to order abortion pills online. The idea of self-induced abortion may evoke coat hangers and knitting needles — symbols of a pre-Roe v. Wade world. But the development of medical abortion has vastly changed the landscape.

“For a lot of people, there’s a perception that self-management is usually done outside the formal health care setting, and therefore it is going to be unsafe,” said Abigail Aiken, an assistant professor at the University of Texas and author of the 2018 study. “With the availability of abortion pills, we’ve seen that this is actually not the case.”

In The Abortion Divide, FRONTLINE explores how the abortion debate has evolved in a Pennsylvania community over more than three decades. One of the major developments was the introduction of medical abortions, also called medication abortions, which have opened up access to the procedure in both Pennsylvania and across the country.

In the U.S., nearly one-third of women who terminate their pregnancies at non-hospital facilities use pills. A medical abortion, available for roughly the first ten weeks of a pregnancy, is usually administered through a combination of two medications called mifepristone and misoprostol. Mifepristone was approved by the FDA in 2000, after a decade of political push-pull. When it was introduced in the U.S., mifepristone seemed poised to radically change abortion access. Health care providers that didn’t offer surgical abortions signaled a willingness to prescribe the pill. In advance of its arrival in the states, one Seattle doctor told The New York Times that it was the “best means we’ve had yet for defusing the abortion conflict.”

As of December 2018, about 3.7 million U.S. women have used mifepristone, according to the FDA. The pill’s regimen has a 95-99 percent success rate, with “serious complications requiring hospitalization for infection treatment or transfusion” happening to less than 0.4 percent of patients, according to the Guttmacher Institute, which studies reproductive health.

“In the build up to medication abortion’s approval in the U.S. there was a lot of speculation that this could really revolutionize abortion access,” University of Ottawa professor Angel Foster told FRONTLINE. “Here we have this medication that was safe, effective, simple to administer, very few [risk factors]— and is something that could literally and figuratively be placed in women’s hands.”

But it isn’t quite that simple. Under FDA regulations, mifepristone can’t be accessed through pharmacies, and most states required abortion, even medical, to be administered by a licensed physician. In response, some states have implemented a telemedical model for administering the pills. However, 17 states mandate that a health care provider be physically present for the abortion.

Laws requiring ultrasounds and waiting periods, restrictions on insurance coverage and other logistical challenges can make it difficult for people — like Tami, the Louisiana mother of three — to obtain a medical abortion. That has left some women in the U.S. looking for a simpler way to access it.

Participants surveyed for the University of Texas study sought pills on two websites — Women on Web and Safe2Choose — that mail doctor-prescribed medical abortion pills to people in countries where access to the procedure is limited. Neither of the two groups offer their service in the U.S., so people in Aiken’s study — who attempted to order the pills in 2017 — were unable to receive them.

However, Aid Access, founded by the same doctor behind Women on Web, began shipping abortion pills to hundreds of American women last year. The FDA ordered Aid Access to cease deliveries in March, citing risks of the “introduction of a misbranded and unapproved new drug” into the country. Aid Access had been shipping unapproved versions of the pill bought from a pharmacy in India.

When Aid Access launched in the U.S., Students for Life of America president Kristan Hawkins called the organization’s model “a disaster waiting to happen.” Americans United for Life president and CEO Catherine Glenn Foster said her group was investigating ways for Congress to halt the abortion provider’s operations.

According to the study, people were driven to seek abortion pills online by a variety of factors: high costs, transportation barriers, and the prospect of harassment. And there is a question of access: as of January, eight states had just one abortion clinic, according to Refinery29. But in addition to these hurdles, some women just wanted privacy.

“There were also folks who were also making the point that, ‘I keep seeing everywhere that these medications are safe and effective; why is it that I can’t have them in my own home?’ I don’t want the stigma of going to an abortion clinic, or I don’t want to deal with protesters, or I just want to be at home where I can look after my kids and not have to try to go through all the hoops to get to an abortion clinic,” Aiken said.

Abortion provider Dr. Jennifer Conti wrote in recent article for Self that self-managed abortion carried the same potential risks as medical abortions administered in a clinic: heavy bleeding, nausea, abdominal cramping, and infection or fever. “But on top of that, you have to consider that you’d be navigating these risks without any guidance and support of a medical provider,” she said.

But Aiken sees a different problem. “Probably the biggest risks are not medical, they are legal,” she said.

Several states in the U.S. have laws, including ones on fetal harm, that could land people self-inducing abortion into legal trouble, according to Jill E. Adams, executive director of reproductive justice-focused organization If/When/How. Six states have specifically barred self-managed abortions, a move Adams says could be unconstitutional.

“Due in large part to information that is accessible through the internet, and abortion pills, self-managed abortion is physically safer in 2019 than it’s ever been in the past,” Adams said. “But as the threats from the dangerous methods of the days of yore have waned, now legal threats from punitive state responses have emerged.”

Research from Adams’ organization has shown that at least 21 people have been arrested in the U.S. for allegedly ending their own pregnancy or assisting someone else in doing so. She believes that number is just “the tip of the iceberg,” and may not account for dropped charges or plea bargains.

Women don’t only use abortion pills to try to induce abortion. They might also take Vitamin C, herbs, or contraceptives — or engage in potentially dangerous behavior, such as being punched in the gut, according to research among Texas women.

“People who become pregnant have self-managed their abortions for eons, but historically that’s happened through either things that are not especially effective but not especially harmful — so, various kinds of tinctures and herbal preparations and things like that — or things that are effective at terminating a pregnancy but also carry significant risks, particularly to the pregnant person,” said Foster.

“Medication abortion gives us the tools to be able to have self-managed abortion in safe and effective ways that have historically not been as possible,” she added.

Aiken suggests it may be difficult to contain the trend towards availability of abortion pills on the internet.

“We’re not living in a society where we block websites, or where we are able to really control what people do online,” Aiken said. “To me, just the mass availability of those things and the conversations that are going to be provoked by the fact that that’s out there are potentially game changing.”