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Two hours before the U.S. Supreme Court convened for the case that could make abortion illegal across much of the country, four women gathered on the court’s steps to propose another path forward. With a mifepristone pill in one hand and a loudspeaker in the other, Amelia Bonow started to chant.

“Abortion pills are in our hands and we won’t stop,” yelled the co-founder of the abortion rights organization Shout Your Abortion.

Bonow and three others, none of whom were pregnant, then simultaneously swallowed mifepristone, a pill that can be used to end a pregnancy up to 10 weeks gestation and is widely regarded as safe. The demonstration on Dec. 1, as the court prepared to hear arguments in Dobbs v. Jackson Women’s Health Organization, was an “urgent health PSA,” Bonow said in an interview.

“We reject the idea that this court ever could have told us not to end our own pregnancies,” she said. “We are going to help each other have safe abortions forever, whether abortion is legal or not.”

With the high court poised to dismantle Roe v. Wade, and Texas’s six-week abortion ban still in effect, Bonow and other abortion rights advocates have turned their attention to self-managed abortion, focusing on online organizations that allow people to access abortion pills through the mail, whatever the laws in their states. But while some have cast these services as the future of U.S. abortion care, many people seeking abortions either don’t know they exist, or aren’t sure how to access them. Abortion rights advocates have struggled to get the word out: Especially in conservative states, people in the abortion industry — at clinics and abortion funds — can’t talk openly about abortion methods that exist outside of the formal health-care system.

“How do you do a public access campaign when you could be arrested or fined or punished or criminalized for it?” said Mini Timmaraju, president of NARAL Pro-Choice America, an abortion rights organization.

Antiabortion legislators have signaled a commitment to crack down on both legal and illegal forms of medication abortion, which one Republican Montana representative recently called the “Wild West of the abortion industry.”

“I don’t want women to be self-managing abortions in their bathrooms,” said Catherine Glenn Foster, president and chief executive of Americans United for Life, a national antiabortion group. While people might prefer the idea of taking an abortion pill at home to an in-clinic procedure, pills can cause complications that necessitate a medical professional, said Foster. (Complications from the abortion pill are rare.)

During the pandemic, the Food and Drug Administration temporarily authorized medical providers to prescribe abortion pills — a two-step regimen that includes mifepristone and misoprostol — via telehealth calls in states that do not explicitly mandate an in-person consultation. That decision became permanent on Thursday. While some might refer to the telehealth abortion process as “self-managed abortion,” that term is generally reserved for abortions that patients handle themselves, without a consultation with a medical professional.

Self-managed abortions are much safer today than they were before Roe, said Amy Hagstrom Miller, chief executive of Whole Woman’s Health, a network of abortion clinics with several locations in Texas and across the country. With advancements in medication abortion, people are much more likely to turn to a pill — or a tea or an herb — than a physical object like a coat hanger, Hagstrom Miller said. (Teas and herbs are not generally recognized as safe methods of abortion. When asked about these methods by Vice, the American College of Obstetrics and Gynecology said, “ACOG does not consider herbal abortion as an appropriate way to end a pregnancy. A doctor would never recommend it.”)

Plan C is an abortion rights organization with an extensive website that directs people to online services where they can buy pills, including Aid Access, the most prominent online service offering abortion pills, which operates out of Austria and the Netherlands and mails mifepristone and misoprostol to people in all 50 states. Patients fill out an online consultation form, before pills are prescribed by various clinicians and mailed to their address. (There is some disagreement over whether Aid Access’s services count as “self-managed abortion,” because while doctors review the consultation forms and are available to answer patient questions, patients usually don’t consult with doctors directly.)

Aid Access fielded 57,506 requests for abortion pills between 2018 and 2020 and has significantly increased its output in Texas since S.B. 8 took effect, according to physician Rebecca Gomperts, who runs the site. The last time Texas banned in-clinic services via an executive order at the start of the pandemic, requests to Aid Access doubled over the approximately four-week period during which clinical services were suspended, according to one study.

Aid Access and similar services operate in a legal gray area, said Jill Adams, executive director of If/When/How, a legal advocacy group that works to advance reproductive justice, in an interview earlier this year. Although people aren’t legally permitted to import prescription drugs, Adams said, state or federal authorities do not usually prosecute those who use internationally shipped prescriptions for personal use.

“We know people all over the country are ordering from foreign pharmacies online and not being prosecuted for it,” Adams said. Still, she said, the process does carry some legal risk for the patient, especially for patients of color and others traditionally targeted by the criminal justice system.

Despite a cease-and-desist letter from the FDA in 2019, Gomperts has continued to send pills to the United States through Aid Access. As a physician based in Europe, she says she is not beholden to U.S. laws — and has no plans to cease operations anytime soon.

“My responsibility as a doctor is that I serve people who need time-sensitive, medically urgent treatment,” Gomperts said. “That is what an abortion is: time sensitive and an emergency. So I will do that.”

People might not hear about self-managed abortions — and all the options available for procuring one — because most take place through less visible avenues, said Hagstrom Miller. A pregnant person might cross the border to find pills in Mexico. A midwife or a doula might pass along some herbs understood to help terminate a pregnancy.

Community-based partners who help with self-managed abortions “aren’t hiding,” Hagstrom Miller said. “They just don’t have foundation funding to blast it out on Google.”

When S.B. 8 took effect in Texas in September, banning most abortions after six weeks, Hagstrom Miller knew her staff in the state would get questions about accessing abortion pills online. To protect them from potential lawsuits, she drafted a handout to distribute at clinics, which included resources that offer information on self-managed abortion. If patients who are further than six weeks along ask about accessing pills online, or any other form of self-managed abortion, staff members direct them to Hagstrom Miller’s handout.

Before S.B. 8, Hagstrom Miller said she thoroughly researched what she could and couldn’t say about self-managed abortion in Texas. She talked to multiple lawyers, she said, to figure out what WWH could share on their website without putting the institution at risk. Hagstrom Miller ended up linking to organizations that offer more information, like If/When/How, but none that actually sell pills or other methods of self-managed abortion.

In conservative states, abortion clinics have to tread extremely carefully, said Kwajelyn Jackson, executive director of the Feminist Women’s Health Center, an abortion clinic in Atlanta.

“The block is hot,” Jackson said. Antiabortion advocacy groups, protesters and legislators are watching clinics closely, she said, waiting for them to take one wrong step: “We want to be risk-takers but we have to be risk-averse to make sure we can stick around.”

Antiabortion advocates are worried about organizations like Aid Access, which many expect to gain more traction if the Supreme Court overturns Roe v. Wade. Online abortion pill services can be hard to track and curtail, said Foster, with Americans United for Life. She expects the U.S. Postal Service to step up, she said, and crack down on illegal abortion pills moving through the mail system in the same way they crack down on cocaine.

“That is something they’re used to doing,” she said. “They’re on top of that.”

Nineteen states have already outlawed abortion by mail, even when pills are prescribed by a licensed U.S. physician, requiring an in-person visit. In addition to S.B. 8, which empowers any private citizen to sue anyone who helps someone access abortion after the legal limit, Texas implemented another law on Dec. 2 that outlaws the abortion pill entirely at seven weeks, three weeks before the previous 10-week cutoff. The law also bans prescribing abortion pills online or mailing them to Texas-based patients. Providers who violate the law could face jail time and fines up to $10,000.

As online abortion pills grow in popularity, Timmaraju, at NARAL, expects antiabortion advocates to go after abortion funds, clinics and other organizations that might talk to patients about securing abortion pills.

“I don’t have the playbook for what they’re going to do around mifepristone, but I think we can learn a lot from the playbook that’s already out there,” she said. Antiabortion activists are known for going undercover at clinics, secretly recording conversations with doctors and staff, Timmaraju added.

Abortion pills and other forms of self-managed abortion are not for everyone, said Jackson, of the Feminist Women’s Health Center. Many people are too far along in their pregnancies to use the pill, she said. Others just prefer to have a clinical procedure. As time goes on, Jackson said she expects certain abortion rights advocates to speak more openly about the options. Abortion doulas, who help people navigate their abortions, might be a particularly good source of information, she said.

Bonow is hopeful that her action outside the Supreme Court helped spread the word. She recently added a new section about “at home abortion” to Shout Your Abortion’s website.

“If someone gets pregnant in a red state that has passed an abortion ban, I want that person to think, ‘I know how to find safe abortion care,’ rather than, ‘Oh no, abortion is illegal in my state,’ ” she said.

If Roe is overturned, Gomperts, of Aid Access, suspects that U.S.-based doctors in states with liberal abortion laws, like New York and California, will start prescribing abortion pills for people in more restrictive states, as she has been doing for years.

“I think there will be a moment where it’s gone too far and the resistance will start,” she said.

She just hopes doctors will be vocal about what they’re doing, she said. Otherwise no one will be able to find them.

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