The Supreme Court has, as expected, overturned Roe v. Wade. The 6-3 decision in Dobbs v. Jackson Women’s Health Organization now makes abortion illegal or severely restricted in several states. The below, originally published in May, has been updated to reflect this reality. The reader service in these stories is still intended to help anyone seeking abortion care no matter where they reside.
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A Primer on Where to Find the Abortion Pill
By Rebecca Grant
As conservative states eliminate clinic-based channels for accessing abortion at lightning speed in the wake of the SCOTUS decision to overturn Roe, unofficial sources for ordering abortion pills online and self-managing at home are a critical lifeline. These online sources, which have grown in popularity, convenience, and sophistication over the past few years, now represent the future of abortion care for much of America. While there are no reliable projections on how many people will self-manage their abortions using pills, the numbers are sure to go up: Research from Advancing New Standards in Reproductive Health at the University of California, San Francisco, found that 7 percent of women will self-manage abortions in their lifetime, and this estimate was made with Roe still in place. “The barriers are going to increase tremendously for people living in one of the estimated 26 states likely to overturn abortion,” said Dr. Daniel Grossman, the director of ANSIRH. “We would anticipate that there will be increased demand for those services.”
The medication-abortion regimen consists of two drugs, mifepristone and misoprostol, and it already accounts for over half of all abortions done through legal channels in the U.S. The FDA approves medication abortion for people who are up to ten weeks pregnant (the World Health Organization says it can be used for pregnancies up to 12 weeks), and research shows a self-managed abortion with pills is safe and effective, with outcomes comparable to getting medication abortion in a clinic. Multiple organizations now provide abortions pills via the mail and ship nationwide for arrival in anywhere from a few days to a few weeks. There are even options if you live in a state that bans abortion, though self-managing may carry legal risks. Below, the rundown on the most trusted providers.
The Deal: Run by a doctor; easy-to-use website; ships high-quality generic medications to all 50 states; offers virtual support; payment and cost flexibility.
The Drawbacks: Shipping times can take up to three or four weeks.
For a patient looking to self-manage at home, Aid Access is by far the most established and trusted option. The service grew out of Women on Web, which was founded in 2005 by the Dutch doctor Rebecca Gomperts to ship abortion pills to countries where abortion access is limited. Gomperts launched Aid Access in 2018 to serve the U.S. market, and it has provided over 30,000 people with medication abortion since then. Even before the fall of Roe, Aid Access had learned how to work around the patchwork of U.S. state laws: If someone reaches out from a state where telemedicine abortion is legal, their case is directed to a licensed abortion provider who approves the medications after a consultation; the pills usually arrive within a few days, and the process complies with U.S. laws and regulations. If someone reaches out from a restrictive state such as Texas or Arkansas, then a European doctor handles the consultation and prescription; the pills ship from India and can take up to three or four weeks to arrive, which can be stressful and potentially disqualifying, as medication abortion is generally recommended only up to 12 weeks.
In part to mitigate the burden of lengthy shipping times, Aid Access recently began offering advance provision, meaning that someone can get a prescription for the pills for later use. According to Grossman, mifepristone has a shelf life of about five years, and misoprostol has a shelf life of about two years. Buying medication abortion through Aid Access costs $110 to $150, though the organization offers sliding-scale payments for those who cannot afford them. Buyers of advance-provision pills have to pay the full amount, which is still a fraction of the $560 median cost of clinic-based care in the U.S. Aid Access operates a full-time virtual help desk and provides telemedical support to patients as needed.
Secure Abortion Pills, Abortion Rx, and Other Online Pharmacies
The Deal: Shipping to all 50 states; a range of options; delivery times under two weeks; anecdotal evidence showing medications are reliable; cheaper than in-clinic medication abortion.
The Drawbacks: No payment flexibility; no telemedical support; manufacturers and distributors are not certified or inspected by the FDA.
At least five online pharmacies — including Secure Abortion Pills, Abortion Rx, Generic Abortion Pills, Buy MTP Kits, and Online Abortion Pill Rx — have been evaluated by Plan C, an organization that aims to make abortion pills more accessible in the U.S. The pharmacies sell these kits for anywhere from $200 to $470 and typically accept payment by Western Union, PayPal, or the Wise app. The pills are delivered in four to 14 days and arrive in discreet packaging. For someone in a state without legal abortion or with severe restrictions, ordering pills from an online pharmacy may be faster than using Aid Access because pharmacies offer express shipping within the U.S. However, these businesses do not offer telemedical support or flexible payment options.
The people running these pharmacies are anonymous, and while Plan C has had the medications tested in the past and found that they consistently contain the correct ingredients and dosage, no institutional accountability is in place. To help people navigate what can feel like the Wild West of buying abortion pills online, Plan C publishes a state-by-state guide that outlines available options and features a report card for these online pharmacies to mitigate patients’ concerns about getting scammed. “We can’t guarantee any of these sites, but we do provide information about what happened when we tested the purchase, and we track complaints,” says Elisa Wells, Plan C’s co-founder and co-director.
The Plan C website also provides information on where people who are self-managing can find medical, legal, emotional, and financial support through organizations like the Miscarriage+Abortion Hotline, SASS (Self-Managed Abortion; Safe and Supported), Repro Legal Helpline, Exhale Pro-Voice, and the National Network of Abortion Funds.
The Deal: If you live in a state that bans telemedicine abortion, using a secondary, out-of-state mailing address may allow legal telehealth providers to send you pills. Access to medical consultation and follow-on support; more affordable than in-clinic medication abortion; faster shipping times than Aid Access.
The Drawbacks: Requires planning ahead and a state ID; could involve added costs and shipping times; secondary shipping may increase legal exposure; may involve out-of-state travel.
During the pandemic, an increasing number of telemedicine abortion providers — Choix, Forward Midwifery, Hey Jane, Just the Pill, and Carafem, to name a few — emerged that conduct medical consultations via video conference, phone, email, or messaging and that ship the pills directly to patients. However, for the 19 states that had laws prohibiting the use of telehealth for medication abortion pre-Dobbs — some of which now ban abortion entirely with few or no exceptions — these services will not ship to those places.
That hasn’t stopped people in restrictive states from getting creative. One such hack: mail forwarding. Someone in Texas, for example, can set up a P.O. Box with mail forwarding in a state where telemedicine abortion services are legal, such as New Mexico. When asked for the shipping address, which has to be in a state where telemedicine abortion is legal, the client provides a P.O. Box number. The abortion provider ships the pills to the P.O. Box and then they are forwarded to the recipient.
“You have to pay for a P.O. Box and a forwarding fee, which adds about $40 to the cost,” Plan C’s Wells said. “And it adds delays because the package has to go through two shippings, but no one is breaking any laws and we know people are using it.”
Another option is to have pills shipped to a post office in a state where telemedicine abortion is legal, perhaps near a state border, using your name, “GENERAL DELIVERY,” and the city, state, and Zip Code of the post office as the mailing address. Someone who lives in Missouri, one of the 13 states with a “trigger law” that will ban abortion once Roe is overturned, could have the pills sent to a post office in Illinois and then go pick the package up there.
Not all telemedicine abortion providers support these work-arounds, and some have measures in place to prevent them. Telehealth provider Abortion on Demand, for instance, does not ship to P.O. Boxes and uses software to confirm that patients are physically in the state they selected for their virtual appointment.
The Deal: Quick delivery times; free or low cost; potential to accommodate specific privacy needs; may not require a bank account, transportation, or internet access.
The Drawbacks: Primarily accessible through word of mouth; legally risky for the person providing the pills.
Many of the options for accessing abortion pills online require internet access and a bank account or credit card. That can pose substantial obstacles for people who are unbanked, for minors, for those in abusive relationships, or for others in vulnerable situations who may not have access to private or independent financial resources. Even if someone does have these resources, they may not be comfortable downloading the Wise app or sending a wire transfer to a stranger. “The purchasing mechanisms through online pharmacies are rather difficult,” said an activist named Stephanie* who has been providing abortion pills via word-of-mouth referrals. “It’s really not user friendly and it makes more sense for someone to be doing it in bulk than for individual clients.” During the pandemic, the clinics that remained open in Stephanie’s region were slammed. After hearing stories about people in her area who were unable to access abortion care, Stephanie found a supplier who could sell her misoprostol in bulk. She now buys misoprostol and mifepristone kits herself and stores them in her home. When someone is referred to her, often through grassroots abortion groups, she drops one of the packages in the mail, switching the post office she uses each time. For the cost of one in-clinic medication abortion — $600 in her state — Stephanie can help at least five or six people self-manage at home with no cost to them.
For some, the person-to-person aspect of underground networks like these may feel safer and more trustworthy than a more anonymous online option. However, the clandestine nature of the service means it’s not as findable or accessible as the sources searchable online.
The Deal: Relatively cheap; less tightly regulated than mifepristone, so potentially easier to access.
The Drawbacks: Less effective than the two-drug regimen.
When Stephanie first started out, she mailed packages containing only misoprostol. “Miso,” as it is sometimes known, or Cytotec, a common brand name, is more effective when used with mifepristone but is nearly 80 percent effective when taken on its own up to 13 weeks of pregnancy. (The miso-only regimen involves at least 12 pills, while the dual regimen involves one pill of mifepristone and four to eight pills of miso.) Miso is much more accessible since it’s also used to treat stomach ulcers and in labor and delivery care. Stephanie sourced her supply through a local doula network, buying bottles of 100 pills for $55. In some countries, misoprostol is sold over the counter. (Texas women have been known to travel to Mexico to buy it in pharmacies there.)
Resources like Safe2Choose and AbortionPillInfo have detailed information about the misoprostol-only protocol as well as the mifepristone-and-misoprostol regimen and the risk factors and contraindications for both drugs. The app Euki, from Women Help Women, an international nonprofit that works on abortion access, also provides the World Health Organization protocols on self-managed abortion and referrals for emotional and legal support.
Next, Make a Medication Abortion Game Plan
By Elizabeth Isadora Gold
My gynecologist told me to expect a “bad period.” It was 2009, and at eight weeks gestation, I was about to have a pharmaceutical abortion for an unviable pregnancy.
Unfortunately, it wasn’t anything like that.
It would be easy to assume my extreme reaction to the process was due to my grief around losing a wanted pregnancy. The actual problem was, as with so many experiences in women’s health care, my doctor didn’t adequately prepare me. She told me I’d have the cramping and bleeding of that “bad period” but didn’t describe the range and type of pain I might experience. Instead of offering sufficient pain medication or techniques to moderate pain, she prescribed six Tylenol with codeine, though she didn’t think I’d “need” them. I did, but who knows if it even helped? My pain came in waves; a grinding in my pelvis, like a mortar and pestle in the range of my pubic bone. (Years later, when I was in labor with my child, I realized I’d already experienced early contractions—during my abortion. Medication abortion can be a sort of in-between of the two experiences, a “bad period” and birth.)
And rather than explaining that I would bleed heavily for days — I spent at least 24 hours in a sort of towel cocoon until I felt as if I could bear to wear anything on my bottom half — she simply said I would “see some clots” but shouldn’t worry unless I soaked through two maxi-pads in an hour for two hours. After it was all over, I bled for two weeks with more mysterious contents in the pads: material that looked like coffee grounds (Google told me they were tiny clots), larger clots, dark blood, pink blood. Blood loss and the hormonal switching made me exhausted, weak, and bloated.
After my termination, physically, I felt off — mentally and emotionally, I felt even worse for being so ill-prepared and uninformed. As my husband put it, “We didn’t even get a fucking pamphlet.” (I should say, my doctor wasn’t “bad” — and my experience wasn’t atypical.)
So as medication abortion is now the first line of pregnancy termination, here’s that. A “pamphlet” — it’s not medical advice but it’s what I would’ve wanted to know, with information gathered from experts.
First, a Review of Some Basics
Pharmaceutical abortion, a.k.a. medication abortion, a.k.a. the Abortion Pill*, consists of two medicines. Mifepristone, a progesterone blocker, breaks down the uterine lining, ceasing the pregnancy’s progress (it will likely cause no symptoms). Misoprostol induces contractions (you can insert pills vaginally or take them “buccally,” i.e., letting them dissolve in your cheek). Expect diarrhea or nausea (the latter may be worse with the buccal method), and take your preferred over-the-counter pain med. Within the next four to 24 hours (though often within the first six), you will — in old-school, blue-liquid-in-the-maxi-pad-ad parlance — “pass the products of conception.” Bluntly, you’ll cramp and then bleed. Maybe a little less than you expect, maybe quite a bit more. There will be clots, probably, depending on the timing of your pregnancy and your own body. If ongoing clots are “larger than a golf ball,” call your doctor or health-care practitioner. You will likely have a heavy periodlike flow afterward for a week or two. (Note: Abortion pills won’t work on ectopic pregnancies, according to the American College of Obstetrics and Gynecology. It’s also not recommended if you have an IUD or certain medical conditions.)
The Difference Between a “Clinician-Supported” Abortion and a “Self-Managed” Medication Abortion
They’re the same in terms of actual dosages and medications; they differ in who provides your pills and (depending on the state) where you will take your initial dose, whether in a clinical setting or at home — in short, if a clinician is involved at some point in the process. Either way, experts say, the steps are the same and the process is equally safe and effective, as long as you have accurate instructions. And patients, whether clinician-supported or self-managed, “can always call Planned Parenthood for advice, even if they didn’t prescribe your pills,” says Dr. Paula Bednarek of the Oregon Health & Science University School of Medicine.
When to Seek Medical Help (Safely)
Medication abortion is over 95 percent successful and requires hospitalization for less than 0.4 percent of patients, according to the Guttmacher Institute. Reasons for contacting providers during a medication abortion could include the aforementioned heavier bleeding and larger clots. These symptoms could indicate the pills weren’t fully effective or another complicating health issue. If you are one of those 0.4 percent of patients who does need to go in for further medical assistance, there will be no physical evidence you’ve taken pills as long as they’ve fully dissolved. (As a note, it is easier to make sure that a pill has fully dissolved if they’re taken buccally.) You are now having a miscarriage; everyone at the ER should treat you accordingly, so avoid mentioning abortion, and the pills, entirely.
Get Your Supplies
Once you have the pills in hand, clear your calendar for 24 to 48 hours. If possible, arrange child care and take a sick day or two from work or school. Don’t count on wanting to do much strenuous activity for the next week or so. That’s when you’ll be having what amounts to a “bad period.”
You will want the option of privacy and, especially, a clean bathroom. Set up your space, and stock up on basically everything you would need for a few days of a stomach flu plus a gnarly period: saltines and Gatorade for nausea, extra pads (you can’t use tampons or a cup), dark towels or old T-shirts you won’t mind throwing away when and if you get stains on them, and heavy-duty black trash bags. “You’ll be glad to have face wipes, diaper wipes, and mouthwash on hand,” suggests a moderator of an anonymous online abortion activist group.
Take the Pills, Following Your Doctor’s Instructions
Experts often say to swallow the mifepristone and try to get a good night’s sleep. The next day — FDA protocols recommend waiting 24 to 48 hours, though doctors say waiting only 12 hours is also okay — choose a method to ingest the misoprostol. Dr. Kate Shaw, the medical director of the telehealth abortion provider Hey Jane, advises placing the pills buccally (again, letting them dissolve in your cheek—but remember, more vomit potential), “if you don’t feel comfortable inserting something in your vagina.” If you do choose to let them dissolve in your cheek, it will take about half an hour (don’t eat or drink anything during that time), then you can swallow any remaining bits with water. You’ll likely feel something happening within around two to six hours.
Expect Some Discomfort
You’ll probably feel pain before you see blood. This is because the drugs for medication abortion aren’t like the morning-after pill (which delays ovulation, preventing conception). Instead, they soften and dilate the cervix and hormonally kick-start the uterus, a muscle, to do what muscles do: contract. During menstruation, the uterus contracts to expel that cycle’s egg and lining. So even in early pregnancy, the uterus must contract harder to expel more than a period’s worth of blood and tissue.
How to Deal With the Pain
However you choose to manage it, any “intense pain lasts for several hours and gradually improves,” says Bednarek. Walk around, stretch, or move your body in whichever direction feels effective or satisfying, she advises. Bouncing on a yoga ball can be either distracting or ridiculous. Breathing techniques or vocalizing (the polite medical term for making whatever noise you feel like) can also help. As can pain relievers.
Standard pain relief for pharmaceutical abortion varies. For example, Hey Jane’s “pill pack” includes both prescription-strength ibuprofen (800 mg. per pill, the equivalent of four Advil) and Zofran (a prescription anti-emetic) for nausea. Most practitioners additionally recommend a heating pad. Bednarek does not prescribe narcotics for patients less than nine weeks pregnant, citing studies showing their lack of efficacy for uterine pain. “Cannabis and CBD have very much helped a few women,” says one underground abortion volunteer — and if I had it to do over again, I think this is where I would land.
About the Bleeding
“Bleeding can be heavy or heavier than a period, sometimes with clots,” Shaw explains. Those contents will vary, depending on the length of gestation and the details of your own body. Bednarek recommends “sitting on a toilet or squatting,” which can be a more comfortable position for the contracting muscles. (Again, a technique used in early labor.) You can also try taking a “warm shower or bath.”
Bednarek says to keep in mind that “it’s a different experience after nine weeks,” when patients may need more pain medication, have more bleeding, and may be more likely to see “fetal parts.” (At that point, she notes, it’s “still very safe and effective,” especially with a two-dose misoprostol regimen.)
Depending on how far along you are, you may be surprised by how much material (including the embryo or fetal tissue) your body has already manufactured — and you’ll be tempted to look. Before eight weeks, doctors say, it’s unlikely you’ll see products of conception; instead, you can likely expect tissue and clots of varying size. After eight weeks, you might be able to see some results of the pregnancy, likely sized between a dime and a nickel. At 12 weeks, you might see larger and clearer products of conception. Some patients may not see anything at all. “Women can feel very moved to look at what’s being expelled from them,” the underground abortion activist says.
Plan Ahead for Aftercare
Doctors say to keep track of bleeding and body temperature for the next 24 to 48 hours: as long as you don’t soak through more than two pads in an hour for two hours, run a fever for more than 24 hours, or feel extreme stomach pain within a day after taking the pills, you should be cleared to return to work or class, take a bath, have sex (if you want to, though nothing should be put into the vagina for 48 hours).
But plan for some extra down time, just in case. You may not need it, but you’ll be happy you planned for it if you do. Consider also: rest and TV and comfort foods. This is less medical advice, more common sense. Just treat yourself well; you’ve been through a change. Don’t be afraid to reach out to friends and therapists. You may be surprised at who knows more than a bit about your feelings.