What Americans Can Expect If Abortion Pills Become Their Only Safe Option
The things Desireé Luckey remembers most about finding out she was pregnant for the first time are how fast the little test strip turned positive — and how irritated it made her feel. It was one more hassle in a summer that already felt overwhelming. Within the span of a few weeks in 2012, Luckey had graduated college, ended an emotionally unsafe relationship and started a new — but frustratingly unpaid — job with former President Barack Obama’s reelection campaign. From her dorm bathroom, she immediately began figuring out what she’d need to do to get an abortion.
Kelsea McLain also knew she wanted an abortion as soon as she found out she was pregnant. Graduating college during the Great Recession, she was surviving on unemployment and about to lose her apartment. Both women wanted private, inexpensive abortions. Because of that, they chose medication abortion — two pills that, when taken together, effectively mimic the biology of an early miscarriage. Medication abortion allowed Luckey and McLain to abort their pregnancies at home. It was logistically simpler than going to a clinic for a procedure. It was cheaper. And it was just as safe.
But it can also be terribly painful. McLain suffered through intense cramping, nausea and weeks of heavy vaginal bleeding. Not everyone’s medication abortion is like that — Luckey’s was straightforward and less uncomfortable than periods she’d had, and she was back walking the full parade route at Capital Pride in Washington, D.C., the next day. No one knows ahead of time whether their experience will be more like Luckey’s or more like McLain’s.
In just a few months, many more Americans may be rolling that dice. The Supreme Court is weighing the constitutionality of a Mississippi law that bans most abortions after 15 weeks of pregnancy, with an opinion expected by June. The court’s conservative majority is expected to make it easier for states to at least restrict abortion access, and it’s possible that it could overturn Roe v. Wade, the 1973 decision that established a constitutional right to abortion, which would allow states to ban abortion outright. If that happens, a lot more people will be obtaining abortion pills illegally.
Medication can be an effective tool for people trying to evade abortion restrictions, and it’s much safer than other illegal abortion methods. But as abortion access is further restricted, increased reliance on pills could also make more people struggle through an intensely painful — even traumatic — experience, with little access to medical support, lots of stigma and more legal risk than ever before.
For almost three decades after abortion became legal, Americans who wanted to end their pregnancies had one option: an in-clinic procedure. That changed in the fall of 2000, when the Food and Drug Administration approved mifepristone, an abortion-inducing drug that allows people to go through the physical process of an abortion at home. To end a pregnancy, people first take mifepristone, which stops the pregnancy from growing. Then the second drug, misoprostol, which is usually taken 24 to 48 hours later, tells the uterus to expel the pregnancy. According to current FDA regulations, the combination can be used until the 10th week of pregnancy.1
The introduction of the pill sequence transformed abortion in the U.S. At first, it wasn’t an especially popular choice, largely because the FDA imposed lots of restrictions on the medication. But that changed in recent years, in part because of the pandemic. By 2020, the Guttmacher Institute estimated that more than half of abortions in the U.S. were medication abortions.
As access to in-person abortion dwindles, medication abortion is more available than it’s ever been. For a long time, the FDA’s regulations said that medication abortion needed to be provided in-person, in a medical setting, but after the rules changed — temporarily at the beginning of the COVID-19 pandemic and then permanently a few months ago — a crop of abortion-focused telehealth companies sprang up with the goal of making the process as seamless as possible. As a result, it’s now possible to get an abortion in more than 20 states without ever setting foot in a clinic. That also means it’s cheaper.
Anti-abortion lawmakers have realized this and are trying to crack down on the mail distribution of abortion pills in several states. A Supreme Court decision to allow states to ban first-trimester abortion would likely increase those attempts to control supply, since it’s a big loophole: Even if abortion is illegal, someone could order abortion pills from a telehealth company in a state where it’s legal and mail them to a person in a state where it’s not, or order pills from an online pharmacy. Access to abortion pills could undermine the coming wave of abortion bans, and everyone knows it.
As medication abortion gets drawn into the political fight over abortion rights, the physical comfort of people seeking those abortions often gets overlooked. The side effects of medication abortion aren’t widely discussed, and it’s easy to understand why. There is lots of misinformation about abortion pills online, and anti-abortion advocates often greatly overemphasize side effects like pain, nausea or bleeding in an effort to make the procedure seem dangerous, which it’s not. In a country where abortion is such an intensely polarized issue, it’s hard to hold two ideas in place at the same time — that medication abortion is very safe, and also sometimes unpleasant to go through.
McLain decided to start her abortion while she was moving out of her apartment. As she carried boxes up and down the stairs, her uterus contracted over and over again, working to expel the pregnancy. She started to bleed — a lot. She threw up. After a while, she began to pass big, heavy blood clots. The pain was unbearable. “There were times that my pain was 10 out of 10,” she said. “I felt like I was going to pass out.” And it didn’t stop after a few hours. It just kept going. “I remember thinking everything was over, and then all of a sudden, bleeding heavily again,” she said. “It was like two weeks where I didn’t trust that my body was actually done.”
She didn’t regret the abortion. In fact, McLain was intensely relieved that the pregnancy was over. But she felt traumatized by the pain, the isolation and the unshakeable feeling that the pain was her punishment for getting pregnant in the first place. The difficulty of the experience felt like something she had to stoically deal with, though in retrospect she thinks her feelings of anxiety and shame actually made the pain worse. “That whole experience, how alone I felt when I didn't need to feel alone, it really just left this lasting impact on me about the injustice of it all,” she said.
But McLain’s experience is not a rare one. Although most clinical trials of medication abortion don’t track it, the few studies that do suggest pain is common. A 2006 systematic review, for example, found that 75 percent of women in five large studies from the U.S. and United Kingdom experienced pain severe enough to be treated with narcotics. In other studies, women consistently reported high levels of pain — with averages ranging from 5.6 on a 10-point pain scale to 8.4 on an 11-point pain scale. “There are people who are still experiencing severe pain, and we need to do additional studies to find ways to help people manage their severe pain at home,” said Dr. Alyssa Colwill, a professor of obstetrics and gynecology at Oregon Health & Science University who studies pain relief for medication abortion.
And although most people who have gotten medication abortions say they are satisfied with them — as high as 98.4 percent who reported their experience in one study — that may not tell us much about how they felt. When one survey compared medication abortion with the alternative — an outpatient, physical procedure sometimes erroneously called a "surgical abortion" — more people seemed satisfied with the in-clinic option. Colwill said that to her, the high satisfaction numbers for medication abortion are just women “telling us they’re happy they’re no longer pregnant.”
This is part of a larger problem that goes far beyond abortion. In general, gynecological pain isn't well studied or well treated. “Pain, generally in medicine but particularly in obstetrics and gynecology, has been minimized and overlooked, and that's related to misogyny,” said Dr. Daniel Grossman, director of the Advancing New Standards in Reproductive Health program at the University of California, San Francisco. “There was kind of an assumption that women could tolerate the pain.” This is a pattern that’s well-documented in medicine — women’s pain tends to be undertreated for all kinds of conditions, from chronic illnesses like fibromyalgia to more acute issues like broken bones. Other forms of reproductive care, like IUD insertions, are also notoriously painful for some, with many women reporting that their experiences were just shrugged off.
Part of the challenge is that it’s hard to predict what any one person will experience. Doctors might not want to offer heavy hitting pain medications right away, since it’s possible that the experience will be like Luckey’s — uncomfortable, but not a big deal. But for people who have a lot of pain, the options for relief are not great. McLain, who had her abortion before the opioid crisis made doctors leery of prescribing narcotics, could take the painkiller hydrocodone if things got bad. In the U.K., where the vast majority of abortions are medication abortions, patients who choose to do their abortion at home receive another painkiller, dihydrocodeine, as part of their take-home package.
In the U.S., however, most abortion patients now get a strong dose of ibuprofen — a choice consistent with World Health Organization guidelines. In the studies those guidelines are based on, ibuprofen was the only treatment to consistently produce evidence of reducing pain during a medical abortion, said John Reynolds-Wright, a clinical research fellow at the University of Edinburgh who is currently working to synthesize the evidence on pain management for medication abortion. But that's not the same thing as ibuprofen working well, he told us. And those studies looked at 800- or even 1,600-milligram doses of ibuprofen, much higher than the 400-milligram dose people are used to taking at home.
Pain, as Colwill pointed out, doesn’t necessarily indicate something is unsafe, even though everyone wants to avoid it. But if abortion is banned, people could be taking abortion pills without much medical guidance, and the consequences could be more dire. Several states, including Oklahoma and South Carolina, already have laws on the books that can be used to prosecute people who self-manage abortion. Mary Ziegler, a professor at Florida State University College of Law who studies abortion law, said that because states will find it hard to enforce abortion bans as long as pills can be mailed in discreet packages, more anti-abortion state lawmakers might consider making it a crime to use abortion pills or help someone obtain them.
If that happens, people could end up being prosecuted if they use abortion medications in a state where it's illegal, particularly if they end up going to the hospital. Physically, there's no way for medical professionals to be able to tell the difference between a pregnancy loss induced by abortion drugs and one that happened as part of a miscarriage, Grossman said. And the only way the difference would matter medically is if the patient had induced their abortion with some other substance like an herb concoction, rather than tested, FDA-approved meds.
But that's not information people will necessarily know. In 2018, one group of researchers ordered abortion pills from 16 different websites and found that none of them came with instructions. Some people may make the mistake of telling medical staff about taking abortion meds — and then find themselves in legal trouble. It’s rare for people to be prosecuted for self-managed abortion, but it has happened. “Unfortunately, a lot of the ways that people have been criminalized is through the providers they turn to for help,” said Farah Diaz-Tello, senior counsel at If/When/How, a legal advocacy group that focuses on reproductive justice issues. That happened in 2012 when a woman in Pennsylvania helped her daughter obtain abortion pills online. The daughter later went to the hospital because the pain was so frightening and unexpected. The mother told hospital personnel about the pills, they reported her to child protective services, and she ended up in jail.
Even if it doesn’t end with prosecution, self-managing an abortion can be a scary and isolating experience. That’s a harm that women will have to absorb, too. And even though it has expanded access significantly, medication abortion won’t preserve abortion access if restrictions continue to mount. For one thing, there are limits to how much telehealth abortion companies can help people in states where abortion is illegal. Leah Coplon, the medical director at Abortion on Demand, a telehealth abortion company, said that although it’s very helpful, remote access to medication abortion can’t replace brick-and-mortar clinics. “I hesitate to have telehealth medication abortion seem like a panacea,” she said.
And perhaps most fundamentally, as abortion becomes more restricted, people are losing the ability to decide for themselves what the experience will be like. Luckey and McLain both went on to have other abortions, and their decisions weren’t what you’d necessarily expect. Despite having a good experience with medication abortion, Luckey opted for an in-clinic abortion later, wanting the procedure to be over and done with quickly.
McLain, meanwhile, had two more medication abortions — both of which were less traumatic than the first. By the time she needed another abortion, she was working in reproductive health and felt much less stressed about the whole process. For her, the feeling of being in control and lack of stress changed everything. “It was no big deal,” she said. “I remember the abortion being so completely pain-free and uneventful, I was worried it didn't work.”