science of us

Why Some Women Choose Mail-Order Abortions

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Though the vast majority of Americans, including most Republicans, don’t want to see Roe v. Wade — the landmark Supreme Court case which banned many (though not all) state and federal restrictions on abortion — overturned, the opening left on the Supreme Court by Justice Anthony Kennedy’s retiring leaves many worried about the fate of abortion rights in America. New York gubernatorial candidate Cynthia Nixon recently held a wire hanger at a rally as she told the crowd about her mother’s own illegal abortion — a reminder that the alternatives to legal abortion are grim, and dangerous.

Due, in part, to the stigma against abortion — and depending on an individual’s clinic access, and the length of their pregnancy — some women may elect to order abortion pills online, as opposed to undergoing the more common suction abortion procedure. These pills — mifepristone and misoprostol — induce a medical abortion, and women who take them generally pass their pregnancy within four or five hours. Abortion pills are recommended as an option only up until ten weeks into the pregnancy; beyond that point, it becomes less effective, and may cause complications. (In some states, too, using the pill beyond ten weeks may be considered illegal.)

In a recent study, Abigail Aiken, an assistant professor of public affairs at the University of Texas in Austin, surveyed a group of 30 women and two men to learn more about their motivations for seeking online abortion services. While abortion may be technically legal (for now), it remains all but impossible for much of the country, and Aiken’s survey (while small) suggests that for many women, ordering pills online may be the most practical option. We spoke to Aiken to learn more about what a world without legal, in-person abortion services might look like, and what women seeking abortions are looking for.

What does your research say as to why certain people might prefer to seek out mail-order abortion pills rather than visit a clinic in person?
The options for many people in states like Texas and other restricted states are really not that different from the options people have in Ireland [where abortion is illegal, though recently in the process of reform]. It’s two totally different contexts legally, but your options — if you haven’t got money and time and resources — are either to travel a long way to the clinic, or find a way to self manage your own abortion somehow.

I think we found two major sides of the same coin in looking at the reasons why people looked online, and one of those is barriers to clinic access. We’re talking a lot right now about the idea of a post-Roe world, where Roe v. Wade would be overturned, or gutted, so that abortion rights are very, very limited across the country. But for many people, I think that post-Roe world is already here. Abortion is legal, but they really have no way of making that happen. People we surveyed told us about about looking online for abortion pills because they couldn’t afford an abortion in the clinic, or they couldn’t go to a clinic, because the nearest one is nearly 60 to 100 miles from their house, and then they’d have to make two or three trips because state policy says they have to go, and then have a 24- to 72-hour waiting period, and then return to the clinic. These logistical and financial barriers really mounted up for people, and a lot of people were looking online for that reason.

On the other side of the coin, though, we have people for whom self managing an abortion with online pills was almost a preference. For them, the idea of privacy and comfort and being in their home environment, not having to go through protesters or talk to anybody — they like that idea. I think especially for some women who are younger and used to the internet as their go-to source for information and goods and services — it’s the idea that abortion pills are safe, so why can’t I just buy them like any other medication? Why do I have to go through all these hoops?

It seems like it’s relatively easy to find these medications online, but not always easy to find them in proper doses or with proper instructions.
Absolutely. Regardless of their motivations, pretty much everybody that we talked to had the same experience. They would find online telemedicine sites that operate in other countries, but they would be really disappointed when they found out the site couldn’t offer them medications in the U.S. What some of those sites do really well is they have good information about medication abortion, they have the instructions that you need, they tell you what to expect to see and feel, and they give you advice on what to look for in the unlikely event of a complication. So that was really appealing to a lot of folks. And when they found out those sites don’t offer the medications in the U.S., they were pretty frustrated, and they would go on to look at these online pharmacies, which are very different from telemedicine sites, because they’re basically just selling pills. You could buy mifepristone, or misoprostol, but they don’t come with instructions or any kind of advice. And for a lot of people, that was too much. They found that too sketchy. They don’t trust that they’re going to get a product, or maybe they’ll get a fake product, or even if they do get the pills in the mail, how will they know it’s safe to use?

Is your takeaway that if this were available online in a more rigorously vetted process, with more information, more women would choose to have medical abortions? If they knew early enough that they were pregnant?
I think it’s what some women would choose to do. I think there will always be folks who would rather have a clinic, they’d rather have a medical setting, they’d rather have a doctor or nurse present. Or maybe they want an abortion that’s not medical, they just want the procedure so they can be done faster. I think there will never be one type of [process] that works for everyone. I think on the basis of the study, we can say that there are some folks who would prefer that kind of online service, and there are also people for whom, right now, [mail-order abortion pills] would be necessary, because they want to get to the clinic and they just can’t.

What role do you think stigma and the associated protestor presence at a lot of these clinics plays in influencing women’s preferences?
Even in those states we would think of as more supportive toward abortion, like California or New York — we still had people in the study saying “Look, I’d rather do this at home, because I don’t want to walk through a gamut of protesters harassing me, or I can’t actually find a good clinic appointment because I have work, and I have children at home.” Or “I can’t get someone to cover child care, or I don’t have transport to a clinic.” One woman in California talked about how it was difficult to find good information about which clinics actually provided abortion because of misleading crisis pregnancy centers, and because it’s stigmatizing to have to call up a clinic and go “Hey, do you do abortion?” Even where abortion is really quite available, there’s still a lot of barriers for people.

Why Some Women Choose Mail-Order Abortions