Medication Abortion Is Not Enough to Solve the Abortion Access Crisis

One of the most important differences between our pre-Roe past and our post-Roe present is the existence of medication abortion. Abortion pills now allow patients to receive care entirely via telemedicine. They also safely allow people to end their own pregnancies without medical assistance, a process known as self-managed abortion.

Thanks to abortion pills, abortions now classified as “illegal” can be medically safe. The significance of this cannot be overstated: Despite its stubborn ubiquity as a protest symbol, gone are the days of the coat hanger. That is, as long as people who are capable of becoming pregnant know about the safety and efficacy of abortion pills, and how to properly use them.

Many activists and organizations have been working to spread the word about abortion pills for years, and in the months since the Supreme Court overturned Roe v. Wade, social media platforms have been awash with posts about the pills that can allow you to have a safe abortion anytime, anywhere. Some abortion providers have expanded their telemedicine offerings, and telemedicine services, such as Aid Access and Choix, have begun offering advance provision of abortion pills, meaning you can order them to have on hand just in case.

Sharing this information is undoubtedly critical — in a 2019 survey, the Kaiser Family Foundation found that only 1 in 5 American adults had even heard of medication abortion. It stands to reason that this number may since have increased, as abortion has dominated the news cycle and medication abortion has continued to grow in popularity, now accounting for over half of all abortions in the U.S. Still, there’s an information gap, and overcoming it could help many more people have safe abortions, regardless of where they live. However, not everyone can have, or wants to have, a medication abortion. And some advocates worry that the intense focus on medication abortion by large organizations and small grassroots groups alike is leaving those people behind.

One group being left out: people who’ve had, or will need, abortions later in pregnancy. Though medication abortion is safe and effective beyond the first trimester, it is only FDA-approved for use up to 10 weeks of pregnancy and is rarely prescribed beyond 11 or 12 weeks in the U.S. As a result, the vast majority of people who need abortions beyond that point must have a procedure in a clinic or (rarely) in a hospital. While research indicates that self-managed abortion can also be safe and effective in the second trimester, there is a higher likelihood that people who self-manage abortions at this point may need follow-up medical care — a reality that could open abortion seekers, and the people who help them, to legal risk.

“It really is like threading a needle,” Jenn Chalifoux-Gene told Truthout. Chalifoux-Gene had an abortion in 2010, after discovering they were pregnant while receiving treatment for an eating disorder. That — plus the fact that they were on the birth control pill — meant that neither Chalifoux-Gene nor the medical professionals caring for them suspected they might be pregnant until well into the second trimester. “I want desperately to acknowledge how important medication abortion is and how helpful it can be for people to be able to self-manage their own abortions. That’s empowering,” Chalifoux-Gene said. “But then sometimes, I see abortion funds that I think are really cool sharing things that seem to imply that if we could just expand access to medication abortion, we would be good. And as a later abortion patient, I personally feel hurt by what I see as a kind of denial of the fact that later abortion patients exist and need different procedures. It’s later abortion stigma or erasure, even within the movement.”

Later discovery of pregnancy is a common reason that people need later abortions. In the Turnaway Study, a long-range project conducted by researchers at Advancing New Standards in Reproductive Health that compared people who were denied wanted abortions with people who had abortions, more than 1 in 5 second-trimester abortion patients discovered they were pregnant after 20 weeks. Those who had abortions at or after 20 weeks discovered they were pregnant at 12 weeks on average, compared to an average of five weeks among first-trimester patients. The study also found that people who had abortions at or after 20 weeks were more likely to have experienced barriers to abortion care, such as cost or difficulty getting to a clinic. With these barriers growing ever greater now that all or most abortions are banned in at least 15 states, the number of later abortions is expected to increase.

“We know that restrictions push abortions later. So now that the choices made by our courts and our government will be pushing many abortions later, it feels a little irresponsible to me to act like if we could just expand access to the pills, and if we could just like decriminalize them, then we solve the problem,” said Chalifoux-Gene.

Now, it is possible for later abortion patients to have medication abortions. But medication abortion is a longer and generally more painful process that Chalifoux-Gene says no one should be forced into. “I’m honestly really grateful that I wound up having an in-hospital abortion procedure instead of doing medication abortion, because with medication it takes a lot longer,” they said. “And when I think about how I was able to go to a hospital, go to sleep, and wake up not pregnant anymore, I’m so grateful. I think having a medication abortion would have been traumatic for me.”

In fact, even in the first trimester, medication abortion involves several hours of heavy cramping and bleeding, with lighter bleeding that can continue for several weeks. In-clinic abortion procedures, by comparison, are much faster, lasting only about five minutes in the first trimester. Using a home pregnancy test to confirm that a medication abortion was successful also requires waiting many weeks, a harrowing prospect for someone in a state where abortion is banned. “Four weeks after the medication abortion, 20 percent of people will still have a false-positive urine pregnancy test, and 10 percent at five weeks. That’s a lot,” Ariella Messing, a Ph.D. candidate in bioethics and health policy at Johns Hopkins University and the founder and operations director of Online Abortion Resource Squad (OARS), told Truthout.

OARS uses an accompaniment model, a community-based approach to helping abortion seekers by providing them with information and peer support. Their trained volunteers ensure that Reddit posts about abortion get accurate answers with quality information and resources. Reddit is also an important place for abortion seekers to share personal experiences and support one another, said Messing. “Rarely can I think of an example of somebody who posts on Reddit saying, ‘I chose a procedure and I wish I had chosen medication.’ But I have seen the reverse a million times, like, ‘I came here thinking I was going to do medication, but then I read all these stories and I got convinced to do a procedure, and I’m so glad I did,’” she said.

None of this is to demonize medication abortion — many people have a strong preference for being able to complete their abortion in the privacy of their own homes. The issue is the lack of choice between medication and an abortion procedure. “People are losing the choice, and not just because of the legal status of abortion, but also just because of pricing. Because some of these telemedicine providers can do medication abortion for $150, whereas going to a clinic costs three or four times as much,” said Messing.

Medication abortion is often touted as being the more private option. Certainly, in some cases this is true — but not always. “The privacy issue I think is really overlooked. Some people prefer medication abortion through telemedicine or something, because they can’t go to a clinic. They cannot get there without somebody finding out that they’re pregnant, so the safest option is for them to fake a miscarriage,” said Messing. “But some people really need to go to a clinic for the same reason. They need the privacy of the clinic. They need to walk in pregnant and walk out not pregnant. Or I’ve counseled people who are trying to do a medication abortion while homeless. Those people deserve to have other options.”

There are various other medical reasons why someone may not be able to have a medication abortion, and it’s not an ideal option for a person who’s gotten pregnant while using an IUD (it’s recommended to have the IUD removed first). Messing also pointed out that many clinics offer patients the opportunity to have an IUD placed at the same time as an abortion procedure, an especially helpful option for patients who may be experiencing reproductive coercion.

Abortion providers and advocacy groups should expand their messaging to capture the full range of medication abortion experiences, said Messing. “I think in general people make it seem like medication abortion is no big deal, that it’s just like a period for most people. And that’s not true. It’s often a lot more painful, and it’s a really prolonged process,” she said. “Even clinics that provide medication abortion, I don’t think many of them prepare people for the wide range of experiences that they could have. So we get questions on Reddit all the time, like, ‘I’m not bleeding enough, I’m not in pain, is something wrong?’ And then we get the opposite, where people are worried they’re bleeding too heavily when what they’re experiencing is normal. We need to broaden those expectations and explain the range of what is okay and what is not.”

Most of all, Chalifoux-Gene implores people who want to improve abortion access to keep fighting for access to abortion at all stages of pregnancy. “I think a lot of the disappointment and hurt that I feel when I see well-meaning overreliance on medication abortion in the movement is coming from wanting to make sure that the way that we respond to this crisis is as expansive as possible and that we’re using this moment not to make compromises or grab whatever straws we can get, but to really demand everything,” they said. “Because the moves that we make and the way that we respond to this moment can change what our movement looks like in the future.”