Learning to Self-Manage Abortions Is Key in a Post-“Roe” Society

For many of us, the fall of Roe v. Wade was one of the most devastating events of 2022. When Politico published a leaked draft of the Supreme Court decision in Dobbs v. Jackson Women’s Health Organization, I was deeply rattled. My intellectual awareness that such an outcome was likely, given the Republican’s seizure of the Supreme Court, had not prepared me emotionally for the sight of those hateful, arcane words. Like many people, I was overwhelmed by the impulse to do something useful. So, I trained to become an abortion doula, which means that, in addition to my work as a writer, organizer and podcaster, I also provide various forms of support to people who are seeking to end pregnancies. Through that work, and my coverage of abortion rights on “Movement Memos,” I have built relationships with some great people who are working to help folks around the country access abortions. About six months out from the fall of Roe, we all agree about one thing: We desperately need to normalize knowledge of self-managed abortion.

For many people, getting an abortion through a licensed medical provider has become next to impossible in a post-Roe world. In Louisiana, for example, most patients are paying more than $2,000 and traveling more than 1,900 miles, roundtrip, in order to access abortion care. Even with abortion funds working hard to accommodate those in need, some people are not in a position to travel, and some financial needs will go unmet. Many of us have donated to abortion funds, because we believe that helping people access abortions is deeply important, both morally and politically. But in this untenable situation, where fewer and fewer people are receiving care, we know that more must be done. In the case of the Jane Collective, specialized knowledge and clandestine practices enabled a group of women to provide safe abortions outside the law in Chicago during the late 1960s and early 1970s. In these times, there is certainly some clandestine work to be done, but some of the most important work ahead of us involves the very public deconsolidation of information about self-managed abortion (SMA). In 2023, let’s make the facts about SMA common knowledge.

While news of the draft leak prompted many of us to share information about SMA on our platforms, and great resources like abortionpillinfo.org and the Repro Legal Helpline have circulated on social media, there were 10,000 fewer reported abortions in the two months following the fall of Roe. According to Robin Marty, author of The New Handbook for a Post-Roe America, and operations director of the West Alabama’s Women’s Center, information about SMA is not reaching those who need it most. “It breaks my heart to see how many people are resigned and just accepting it,” Marty told Truthout in a recent interview. “That’s what the right wanted. They wanted people to just say, ‘Okay, it’s too hard and I can’t do anything about it.’”

Marty emphasized that we can simplify matters for pregnant people in crisis. “We need to make this easy,” she said. “There’s an easy way for people to be able to access medication. There’s an easy way for people to be able to perform their own abortions. This is not difficult. And the fact that the government is blocking them from it, that is cruelty. It’s nothing short of cruelty.”

Marty explains that the fall of Roe, and the experience of forced pregnancy and forced birth, likely feels inescapable to many people who might have previously sought abortions at the West Alabama’s Women’s Center, because the status quo of structural harm that they experience likely feels inescapable. “Being forced to stay pregnant and give birth is just another way that the government is fucking them over,” said Marty, “because the government has always fucked them over, has always denied them medication, has denied them insurance, has denied them well-paying jobs, has denied them the right to vote. So, they just see this as yet another sign of how little power they have over their lives.” Such people, Marty explained, often are not Googling abortion funds or practical care organizations or looking up the World Health Organization’s (WHO) guidelines on SMA.

If they did look up those guidelines, they would learn that, according to WHO:

In the first 12 weeks of pregnancy, a medical abortion can also be safely self-managed by the pregnant person outside of a health care facility (e.g., at home), in whole or in part. This requires that the woman, [girl or other pregnant person] has access to accurate information, quality medicines and support from a trained health worker (if they need or want it during the process).

WHO describes self-managing an abortion with mifepristone and misoprostol in combination or misoprostol alone as a “highly acceptable option to pregnant persons.”

A medication abortion is a relatively simple process. As WHO explains, “The combination regimen consists of 200mg mifepristone, administered orally. This is followed 1–2 days later by 800μg misoprostol, administered vaginally, sublingually (under the tongue) or buccally (in the cheek).” Self-Managed Abortion; Safe and Supported (SASS) recommends that the 800μg of misoprostol be consumed buccally, suggesting that the person self-managing place “4 tablets of misoprostol in the cheek between the gum and lower teeth, 2 on each side, and keep them there for at least 30 minutes, or until they are dissolved.” As an abortion doula, I was taught that oral absorption methods, such as the buccal method SASS recommends, can be preferable for people who are concerned about medical surveillance, given that the undissolved remnants of misoprostol that is inserted vaginally can sometimes be discovered during a pelvic exam, if a person seeks medical attention. In the absence of such visible pill remnants, a miscarriage caused by abortion pills is medically indistinguishable from one that is not self-induced.

If the person terminating a pregnancy only has access to misoprostol, SASS suggests, “A person should put 4 pills of 200 mcgs (or 8 pills of 100 mcgs) of misoprostol under the tongue and keep them there for at least 30 minutes, or until the tablets are dissolved. They can swallow their saliva, but NOT the pills. After 30 minutes, they can swallow what remains of the pills.” SASS recommends repeating this process, with the same dosage, three hours after the first dose, and again, three hours later. Their guidelines suggest that a person can eat or drink normally between doses but should avoid alcohol, in order to maintain their awareness.

According to SASS, the success rate of using misoprostol alone to end a pregnancy before the 12th week is approximately 85-95 percent. The success rate of using mifepristone and misoprostol together, prior to the 12th week of pregnancy, is 95-98 percent.

Many resources exist to help guide people through this process. Doctors Without Borders/Médecins Sans Frontières (MSF) and HowToUseAbortionPill.org have created a short video series that explains the process of self-managed abortion in clear, accessible terms. The Miscarriage + Abortion Hotline (1-833-246-2632) is run by a team of pro-abortion clinicians with years of experience in caring for miscarriage and abortion. They can be reached by phone or text and can give expert advice on self-managing a miscarriage or abortion.

Most people self-managing an abortion will not need medical attention, as complications are rare. According to SASS, a person who is self-managing their abortion should seek medical attention if they experience “severe bleeding that soaks through more than 2 maxi pads an hour for more than 2 hours in a row” or “severe abdominal pain that isn’t relieved with painkillers or continues for 2-3 days.” A person who is self-managing an abortion should also seek medical attention if they have a fever that reaches 102 degrees Fahrenheit (102°F), at any time, or if they have a fever of more than 100°F for more than 24 hours. Abnormal vaginal discharge that is “an unusual greenish or yellowish color and/or has a strong unpleasant odor” is also a sign that a person self-managing an abortion should seek medical attention. These complications are unlikely, but if a person who is self-managing an abortion seeks medical attention, they need only inform clinicians that they think they might be having a miscarriage. No further information is required for medical purposes.

The website Plan C provides “up-to-date information on how people in the U.S. are accessing at-home abortion pill options online.” SASS emphasizes the importance of confirming a pregnancy and how far the pregnancy has progressed before making a plan to self-manage an abortion. SASS also suggests that plan include a support person, in case of complications. Side effects from abortion pills can include bleeding, cramping and diarrhea. Knowing what symptoms to expect while self-managing an abortion is important, because being caught off guard can lead a person to seek medical attention unnecessarily, which can result in surveillance and criminalization.

While self-managing an abortion is considered medically safe, the legal system can and has, at times, ensnared people for the practice. Farah Diaz-Tello, senior counsel of If/When/How: Lawyering for Reproductive Justice, told Truthout in a recent interview, “The most important thing I think that people need to know about the law and self-managed abortion is that it can be quite complex, and it varies from state to state, and people who are self-managing are not alone. We have an extremely important resource in the Repro Legal Helpline.” The Repro Legal Helpline is a website and a helpline (844-868-2812) where people can get information and legal advice about their rights as abortion seekers and about the risks they may face with respect to self-managed abortion. People who reach out to the Repro Helpline can also get information about how to get an abortion as a minor, given that, even in states where abortion remains legal, young people often face additional legal hurdles.

“I think the important thing to know is that in most jurisdictions, it is not explicitly against the law for a person to end their own pregnancy,” Diaz-Tello told Truthout. “The only exceptions are, at this point, South Carolina and Nevada.” But Diaz-Tello notes that the absence of specific statutory codes will not necessarily insulate a person from criminalization. “What it all comes down to is that if a prosecutor decides that somebody should be punished, if they want to punish somebody for ending a pregnancy, they’re going to find a way to do so almost in spite of what the law says,” said Diaz-Tello. People accused of self-managing abortions around the country have faced an array of charges, says Diaz-Tello, from “life-changing charges like homicide or feticide, all the way to other offenses like improper disposal of human remains or charges like concealing a birth, which are laws that were mostly passed in the 1800s to punish out-of-wedlock births.”

The threat of criminalization makes informational security a major concern for people self-managing abortions. SASS recommends using DuckDuckGo for private searches without online tracking, and Signal and Proton mail for written messages. SASS also recommends reading the Surveillance Self-Defense guide to online privacy and using the Euki reproductive health app, which does not store user data anywhere outside of your phone, to look up information about abortion.

But while many people are rightly concerned about digital security, Diaz-Tello stresses that “the biggest threat to an individual who self-manages an abortion is other people who betray their trust.” From health care providers who report patients to law enforcement, to an angry or abusive partner, people who are criminalized for pregnancy outcomes are often reported by people they chose to confide in. “We have seen many instances of reporting to law enforcement a self-managed abortion as a tactic of abuse and control,” said Diaz-Tello. This trend underscores the importance of normalizing knowledge that will allow people who are acting outside the law to end pregnancies safely, while involving as few people as possible — including medical professions.

In order to reach the people who might benefit from knowledge of self-managed abortion, either for themselves, or in order to assist peers and loved ones, Marty argues that we have to normalize knowledge in our offline spaces. “The information is out there and getting spread to people who already have access to this information,” says Marty. “Technology is the biggest way of pushing it: websites, emails, Twitter, all of these electronic disseminations.” Marty stresses that these modes of accessing information are ill-suited to people in rural areas, who might lack internet access, and to people who may have a partner or family members who might surveil their phone or internet usage. “We need to figure out how to reach these populations,” said Marty. “We need to figure out how to make information available in manual ways.”

Marty’s book is a powerful tool in such efforts, and she is currently working on a new edition that will take on the problem of spreading awareness offline. “I was talking to a class at Tulane,” said Marty, “and we were talking about how to do guerilla drops where essentially we would just place QR codes all over the campus that led to information” about how to access and use abortion pills. Marty suggested the QR codes could be accompanied by text that read, “You need this info” or “Oh God, have you seen this?”

Another way to spread awareness about SMA is through the use of zines, which are non-commercial, DIY publications, often assembled out of typing paper. Zines have been a popular means of storytelling and knowledge sharing in subversive communities for generations. Red, an organizer with the Support Ho(s)e Collective, who has been making zines since they were 14, and is currently doing their Ph.D. research and writing about zines, recently told Truthout, “I’ve recently seen and felt an uptick in a return to offline crucial info sharing amongst sex working, drug-using, trans health care- and abortion-seeking people.” Red says zines are an essential tool in the current political moment, and not simply because they cross the digital divide. “I’m not the first to say this obviously, but creating our own media and knowledge sharing methods is intrinsic to many of our community members survival and access to affirming and accurate care about all sorts of needs and desires.” Red noted that zines are part of a much larger lineage of resistance for people practicing Liberatory Harm Reduction. “People have been making and updating and swapping and trading zines about all sorts of harm-reduction tactics, care, advice and best practices since… forever. If we don’t make what we need, and get it out there ourselves, it will not happen.” Red also stresses the importance of storytelling, adding that, “I don’t think the importance of telling our own stories and sharing our own strategies can be overstated. Not everyone has access to online spaces. Zines have meant getting creative and resourceful about where your people are, thinking through how to best reach them offline, working through the conversations y’all are having most, and sharing what you’ve seen work in practice.”

As an abortion doula, Ash Williams also believes in the power of storytelling. Williams recently told Truthout that he has learned a great deal from people who have self-managed their abortions, who opted to share their stories publicly or in groups. “I definitely go back to and rely on the stories that I’ve heard shared with me as someone who’s had two procedural abortions,” said Williams. “I rely on the experiences of others and the stories of others.”

Williams works with the Mountain Area Abortion Doula Collective and is currently the Decriminalizing Abortion resident at Project NIA. Since the draft leak, he has helped train around 200 new abortion doulas “in communities across the US” via Zoom. Williams told Truthout, “These folks are social workers. They are parents and caregivers. They are abortion advocates, reproductive justice volunteers, clinic escorts and generally people who are concerned about the lack of access to abortion, as well as the criminalization of abortion.” Williams says that this new wave of abortion doulas are “people who want to show up in their communities with good information, with a listening ear and with a caring heart to provide people with the best abortion care possible.” Abortion doulas provide various forms of assistance to people who are seeking to end pregnancies, and Williams emphasized that sharing information about SMA is an important element of that work. “We have to continue to increase the options for all types of people who want abortions, and that has to include people who want to self-manage their abortions.”

Interest in abortion doula work is high, at present. In the fall, Williams vetted 800 applications for a training series with 40 available slots, which speaks to the importance of abortion doulas, and others deconsolidating knowledge as broadly as we can.

Red described getting creative and resourceful about “where your people are,” and Williams has seen that kind of creativity in action. “I have been seeing a lot of infographics and very simple messaging on things like stickers or postcards, being left in public places,” he said. He stressed the importance of creating resources that highlight local options and resources. Williams says the he has left information about self-managed abortion and how to access abortion pills in public places, in addition to stickers that direct people to his group, the Mountain Area Abortion Doula Collective. “I have also worked with artists in the community to come up with graphics that are relevant to where we are in time and space to help us again further the message that sharing information about abortion is okay, and you should check these places out, these resources out,” he said.

I have spent a lot of time thinking about what it means to get creative and resourceful about where people are, and normalize knowledge about self-managed abortion, such that anyone coping with an unwanted pregnancy would know the basics, or at least know someone who does. I am envisioning a wide array of educational posters and stickers about SMA. I am imagining songs, poetry, fiction and plays that include information about SMA. So many skills can be brought to bear in this effort. As Marty told Truthout, “At some point, we are going to figure out how to saturate, and that’s what we need to do.” Marty envisions zines, flyers, drop cards and even billboards about SMA. “How do we make billboards? Are we going to have to graffiti billboards? Maybe,” she said. “That’s a great way to reach a population that nobody else is able to reach.”

In addition to needing to extend the reach of this information offline, we also have to be mindful that the right to share information about abortion online is not permanently guaranteed, any more than the right to an abortion was. Abortion scholar Hayley McMahon was recently suspended from Twitter for 12 hours for tweeting the WHO protocol for self-managed abortion. McMahon’s tweet was flagged, according to Twitter, for violating “our rules against promoting or encouraging suicide or self-harm.” But the restrictions of a privately owned platform like Twitter are not the only threat to our ability to spread information about SMA online. As Melissa Gira Grant has reported, there is a federal law “quietly sitting on the books” that could be used to criminalize discussions of abortion online. The Telecommunications Act of 1996 is ready and waiting to be exploited by the likes of Florida Gov. Ron DeSantis, should he ascend to the presidency. There could come a day when publications like Truthout are ordered to remove articles like this one, due to its inclusion of information on SMA methods. So, you might want to preserve this article offline, or even fashion it into a zine and share it far and wide.