Abortions outside medical system increased sharply after Roe fell, study finds

The number of women using abortion pills to end their pregnancies on their own without the direct involvement of a U.S.-based medical provider rose sharply in the months after the Supreme Court eliminated a constitutional right to abortion, according to the most comprehensive examination to date of how many people have ended their pregnancies outside of the formal medical system since the ruling.

Nearly 28,000 additional doses of pills intended for “self-managed” abortions were provided in the six months after the fall of Roe v. Wade — more than quadrupling the average number of abortion pills provided that way per month before the decision and suggesting that many women have turned to medication abortion to circumvent state bans.

The research — published in JAMA on Monday, the day before the highly anticipated Supreme Court arguments on a challenge to a key abortion drug — highlights the importance of abortion pills in post-Roe America. Before the ruling legalized abortion nationwide in 1973, women seeking abortions were forced to find someone to perform an illegal surgical procedure, leading to thousands of deaths. Today, the process for accessing abortion is far easier and safer, with a rapidly expanding online and community-based network of pill suppliers sending pills through the mail into states with strict bans.

Other studies have estimated that approximately 32,000 fewer abortions occurred at licensed brick-and-mortar and telehealth clinics in the six months following the fall of Roe. But the jump in self-managed abortions offsets nearly that whole figure.

“The numbers we’re looking at seem to suggest that (self-managed abortion) is more mainstream than perhaps we thought,” said Abigail Aiken, a professor at the University of Texas at Austin and the lead author of the study. “This is something people are doing on a larger scale.”

Women in states with bans are also using the traditional health-care system to access abortion, traveling out of state to pick up pills or to have a procedure at a clinic in a state where abortion remains legal. A different study published last week by the Guttmacher Institute, which supports abortion rights, revealed that the overall number of abortions facilitated within the formal health-care system increased last year despite the bans, with medication abortions accounting for 63% of the more than 1 million abortions performed in 2023.

Taken together, the flurry of new data points to a perhaps surprising result of the fall of Roe: While the ruling has made abortion more difficult to access for people in antiabortion states, a large portion of those women have been able to navigate around the laws and end their pregnancies.

Self-managed abortions with pills are facilitated in a legal gray area. Women obtaining abortions by mail are not breaking the law themselves; abortion bans are designed to penalize only doctors and others involved in facilitating an abortion. Those involved with distributing the pills could potentially be charged. In many states, abortion bans carry penalties of at least several years in prison.

The landscape of self-managed abortion is sprawling and difficult to quantify, Aiken said. According to Plan C, an abortion rights organization that tests pills and publishes a list of verified sources online, at least 25 websites now mail abortion medication into states that ban the procedure, along with several telehealth clinics and community-based networks.

Aiken identified 15 distinct sources for abortion pills that were operating outside of the formal health-care setting in the first six months after Roe fell, most of which shared with the researchers month-by-month data on the number of pills they distributed to U.S. patients during that period. Some sources relayed the numbers without providing internal documentation, Aiken said, because they do not keep formal records.

Rebecca Gomperts, the founder of Aid Access, the largest telehealth clinic mailing pills into states with abortion bans, and Elisa Wells, a founder of Plan C, are co-authors of the study.

The various sources that mail pills for self-managed abortions operate with very different models, offering a range of medical and emotional support through the process of passing a pregnancy at home, according to the new study.

In the first six months after the Supreme Court decision, the JAMA study shows that most women who chose to self-manage their abortions obtained pills through networks of volunteers that quickly mobilized and expanded after the ruling. These networks — one of the largest of which is based in Mexico — buy pills from international pharmacies, then mail them to people for free without a prescription, offering peer support but typically no direct access to a doctor. The pills often arrive unsealed, according to Plan C.

Along with community-based networks, people are also obtaining pills through internationally based telehealth clinics, which provide a prescription from a doctor, or other websites that sell pills typically without offering any kind of built-in support for women taking them.

Abortion pills have become even easier to get since the immediate aftermath of Dobbs v. Jackson Women’s Health Organization, with new suppliers appearing regularly and existing suppliers expanding to absorb more demand.

In the year since the research in the study was compiled, Aiken said, telehealth clinics in particular have significantly expanded their reach in antiabortion states, leading to far more abortions provided than are reflected in her study. While Europe-based Aid Access, the largest of these groups, initially relied on pharmacies in India to mail pills to patients in states with bans, the organization has now started allowing U.S.-based doctors to prescribe and mail the pills themselves, making use of “shield laws” recently passed in several Democratic-led states to protect the providers from prosecution. That change has reduced Aid Access’s shipping time from several weeks to a few days.

The organization now mails approximately 6,000 doses of medication abortion into states with abortion bans each month, according to Gomperts. She expects that number will continue to grow.

“What we know from other countries is the more this (becomes) mainstreamed, the more people will feel comfortable doing it by themselves,” she said.

Struggling to come up with a way to crack down on self-managed abortions, antiabortion advocates have taken aim at abortion pills more broadly. At Tuesday’s Supreme Court arguments, antiabortion advocates will argue that the U.S. Food and Drug Administration rushed its 2000 approval of mifepristone, the first drug in the two-step medication abortion regimen, as well as subsequent decisions to lift restrictions on the pill. Perhaps most significantly, antiabortion advocates are seeking to reinstate the requirement for people taking medication abortion to see a medical provider in person — a change that could halt the mailing of abortion pills.

“When the FDA is recklessly saying that this is safe and women don’t need or deserve ongoing care — that’s dangerous,” Christina Francis, chief executive of the American Association of Pro-Life Obstetricians and Gynecologists, said in an interview last month.

Leading studies show that medication abortions conducted via telehealth are safe. Major adverse events, such as infections or a hemorrhage, occur in less than 1% of cases, a figure that remains the same whether or not a patient has an ultrasound and an in-person consultation.

The upcoming Supreme Court case could have significant implications for people taking abortion pills in states with bans, potentially preventing U.S. providers from utilizing shield laws.

Abortion rights leaders say they will continue to mail pills into antiabortion states, regardless of whether it’s legal.

“The reality is that medication abortion and telemedicine will continue — but whether it continues from licensed providers, aboveboard, without stigma … is something we have to really be aware of and fighting for,” said Julie Kay, the executive director of the Abortion Coalition for Telemedicine, an abortion rights group.