As the White House moves to block federal funding for family planning clinics unless they stop providing abortions or abortion referrals, supporters and opponents of abortion rights are gearing up for a familiar and likely protracted fight.
The proposal stops short of the full gag order that President Reagan issued in 1988, barring providers at those clinics from mentioning abortion, but opponents say the new plan would have about the same effect.
Yet abortion access is fundamentally different than it was 30 years ago, in at least one significant way: Women today have access to safe, private, do-it-yourself abortion -- if they know where to look. Or rather, which search terms to type into Google.
Abortion pills -- typically a combination of misoprostol and mifepristone, the same drugs used in medication abortions initiated at a clinic -- are widely available for sale from online pharmacies.
That’s reassuring to people who support abortion rights, as President Trump works to make good on a promise to “defund” Planned Parenthood, and as emboldened conservative governors race to pass restrictive state laws, with a legal challenge to Roe v. Wade in mind.
But it also raises the stakes for women, if the call to punish those who self-induce abortion grows louder. And it puts a sharp focus on why the battle over abortion increasingly is a battle over health information, because an informed woman can gain access to abortion drugs via the Internet no matter how far she lives from a clinic.
Websites like Women Help Women and Plan C are at the front lines. They explain in easy-to-understand language how abortion pills are used to end early pregnancies, what the symptoms of complications are, and how women have navigated the legal issues of buying a drug for which they don’t have a prescription, or self-inducing abortion in a state where such an act could lead to legal trouble.
The pills have a track record of being safe and effective. In some countries, they are sold over the counter. In the United States, mifepristone is highly regulated. Still, the pills hold the promise of making the dangerous pre-Roe back-alley abortions truly a thing of the past, said Farah Diaz-Tello, senior counsel for the SIA Legal Team, which advocates for legal protection of women who have a self-induced abortion.
"A rallying cry has been the idea that we won’t go back," she said. "We actually have a realistic possibility that, no matter what happens to access to abortion in clinics … that we would actually not go back. We have the potential for people to have their own health care in their own hands.”
Anti-abortion-rights lawmakers historically have had little appetite to punish women who have an abortion, focusing instead on limiting access to providers. But as the number of clinics dwindles in many states and the role of self-induced abortion grows, Diaz-Tello says she worries that will change.
Seven states now explicitly ban self-induced abortion. Ohio’s proposed abortion ban would criminalize it. And anti-abortion-rights advocates are talking more openly about the prospect of punishing women, she says.
Doctors are beginning to grapple with the issue, too. The Massachusetts Medical Society took a stand last month, saying women should not be punished for inducing their own abortions, echoing a similar statement made by the American College of Obstetricians and Gynecologists in January.
And a pair of papers published last month raised the question of whether -- and how — doctors could provide women with the information they need to seek out a self-induced abortion if access to clinics is restricted further.
It’s a conversation that likely will grow to include many more people: public health officials, primary care doctors, sex educators and parents. By most accounts, interest in self-induced abortion is increasing, though there is no clear data on how many women have one.
The New York Times reported that the number of Google searches for information on self-induced abortion spiked in 2011, when a spate of state restrictions took effect. The website Plan C, launched in 2016, had about 58,000 unique visitors last year and is on track to surpass that number in the first half of this year, co-director Elisa Wells said.
Cultural change is happening quickly, she said, pointing to the #MeToo movement and the Women’s March. When young U.S. women learn that their peers in other countries have easy access to abortion pills but they do not, she said, “they are on fire.”
Several groups of researchers are studying ways to make the drugs more accessible to women in the United States, sometimes using telemedicine to conduct a remote consultation with a doctor, who typically reviews the patient’s ultrasound before mailing her the drugs. Plan C is hoping to join them, with a study that would eliminate the requirement for an ultrasound.
“This is a way to try and say, ’It doesn’t need to be medicalized,’ ” Wells said. “We have the technology and the technology is safe. What’s needed is to trust women.”
And to educate them, said Susan Yanow, co-founder of Women Help Women, which mails abortion pills to women around the world, though not in the U.S. (Her group commonly serves women in Ireland, where voters on Friday will consider whether to repeal a constitutional amendment banning abortion.)
“It’s a challenge that many, many people don’t know that these pills exist,” she said. “I believe people should learn about abortion pills at the same time they learn about contraception.”
Yanow emphasized that promoting self-induced abortion protects access but it also offers choice. Some women simply prefer it over clinic-based care.
Going to a clinic may mean taking one or more days off from work, contending with protesters and spending $500 or more. Online, the pills cost around $200, and a woman can take them privately and get follow-up care as needed. Perhaps, Yanow suggested, she takes the pills on a Saturday in the company of a friend who makes tea and offers support.
That’s a long way from the back alley.