Self-induced abortion is explicitly banned in seven states, and more have laws on the books that could be used to prosecute women for self-induction, according to a recent report.
The 25,000-member medical society passed a resolution saying it would advocate against “any legislative efforts or laws in Massachusetts or federally to criminalize self-induced abortion.”
It also encouraged its delegates to the national American Medical Association to propose a similar measure there.
“Criminalizing this will actually drive women away from care,” says Dr. Rebekah Rollston of the Cambridge Health Alliance, who helped spearhead the resolution. “Where women really need to access medical care, they may fear that they’ll be reported to legal authorities.”
The resolution did not come in reaction to a pending bill or petition. Rather, Rollston says, it emulates a recent policy passed by the American College of Obstetricians and Gynecologists.
And it responds to a political and legal climate in which efforts to limit or ban abortion are multiplying. As access diminishes, self-induced abortions are making a comeback, she says.
In Tennessee, where she lived until recently, “Access to care really is a significant issue,” Rollston says. “There are a lot of women who, for various reasons — including stigma, or just financial or geographic lack of access to care — are really attempting their own abortion.”
There are no solid numbers on how many women attempt self-induced abortions in the United States, but 20 women in the U.S. have been prosecuted for them, says the recent report by the SIA Legal Team, which backs decriminalization.
In Massachusetts, an 18-year-old woman was prosecuted in 2007 on a charge of procuring a miscarriage, and a judge ordered her to get mental health treatment.
“There are a lot of women who, for various reasons — including stigma, or just financial or geographic lack of access to care — are really attempting their own abortion.”Dr. Rebekah Rollston, Cambridge Health Alliance
If coat hangers were the symbol of desperate do-it-yourself abortions before Roe v. Wade, these days the main method is pills — often the same pills that clinics prescribe for "medical abortions."
They typically use a combination of the drugs misoprostol and mifepristone, and account for about 45 percent of all clinic- and hospital-based abortions within the first nine weeks of pregnancy.
In many countries, the pills are available at pharmacies and even over the counter. Websites like Women Help Women offer support and send abortion pills by mail to women around the world who wish to end an early pregnancy.
But not in the U.S., where mifepristone is highly regulated despite its proven safety. It may be dispensed only in a clinical context by a prescriber who has obtained a special certification from the drug distributor. It is not available from retail pharmacies.
That hasn’t stopped people from buying the drugs from online pharmacies or while traveling to other countries, where they are more accessible.
Women Help Women has created an informational website specifically focused on helping women in the United States understand how to use the pills. A similar site, Plan C, provides a report card on the quality and price of pills bought online and explains how women have navigated the legal risks.
Advocates say many women -- even those with good access to abortion clinics -- choose self-induced abortion over clinic-based care for its lower cost, increased privacy or the convenience of taking the pills at home.
'A Harm Reduction Strategy'
The Mass. Medical Society is not alone in trying to grapple with the rising likelihood that American women will attempt to self-abort using pills. A recent paper in a major medical journal proposed a “harm reduction” strategy for abortion — a public health term more often used about injected drug use.
“In the recent era of safe, legal abortion in the United States, a harm reduction approach has not had a clear role,” write Julia Tasset, a fourth-year medical student, and Dr. Lisa Harris, both at the University of Michigan Medical School. “However, the legal climate for abortion is shifting.”
They suggest that medical staffers who care for women with unwanted pregnancies could give them information about the safe use of abortion medications, which the women could then obtain on their own.
The paper poses difficult questions for doctors about balancing their duty to care for patients against their own legal liability -- questions that haven’t felt so urgent for 45 years, says Dr. Daniel Grossman, professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco.
“There’s good reason to think about this now,” he says. “It’s not about coat hangers, generally. It can be about the use of safe and effective medications.”
Grossman, who was lead author of the American College of Obstetricians and Gynecologists position statement, says he is not optimistic that restrictions on mifepristone will be lifted under the Trump administration, but he and others are working to provide the data needed for reconsideration of those rules in the future.
In four states -- Hawaii, Maine, Oregon and Washington -- Gynuity Health Projects is studying the feasibility of sending pills by mail to patients who have an ultrasound and consult with a doctor via telemedicine. (Nineteen states effectively prohibit abortion by telemedicine.)
Grossman is studying the safety of dispensing the abortion pills at a pharmacy and will soon publish results of a survey that measures doctors’ interest in prescribing mifepristone if the requirement for a special certification from the drug distributor were removed.
Tasset and Harris propose creating a screening tool to assess whether a woman is at risk of self-inducing in an unsafe manner. Doctors could talk with patients about abortion pills, but they likely would have to stop short of telling women how to buy them without a prescription, they said.
So what should a doctor say when a patient asks where to get the pills?
“We don’t have an answer to that question yet,” Tasset says.
Doctors would step into “legally problematic” territory if they directed women to online pharmacies, said Farah Diaz-Tello, senior counsel of the SIA Legal Team. But in most cases, she says, providing information about safe use of abortion pills -- a method that is well-studied and promulgated by the World Health Organization -- is within the law.
From there, she says, “I have faith that people are resourceful and know where to go.”
Doctors can also play an important role in supporting, rather than reporting, women who have had a self-induced abortion, Diaz-Tello says. (Women who need follow-up care after using the pills don’t have to tell health care providers that they had a self-induced abortion, advocates say. Any complications or required care would be identical to those following a spontaneous miscarriage.)
When a woman who needs care after a self-induced abortion needs medical help, doctors "need to provide excellent care to that individual," says Dr. James Broadhurst, who worked with Rollston on the Mass. Medical Society resolution. "They should not be in the position of having to report her or in any other way compromise that care because of a state law."
And more broadly, Rollston says, women need to know that they can safely seek treatment. Otherwise, she says, they may be "driven away from seeking care, which in the short and long term really harms women."