With the retirement of Justice Anthony Kennedy from the U.S. Supreme Court, it’s crucial that we consider what would happen in a state that effectively outlawed abortion. We still hear stories about the dangers of unlawful abortion in the U.S. before Roe v. Wade made the procedure legal in all 50 states. The specter of the back-alley abortion and the imagery conjured of the coat hanger have loomed large. Whether used as a rallying cry to protect abortion rights, a warning, or a solemn remembrance of women’s lives lost, these symbols persist in the public imagination and the stories they represent are told and retold by those who lived through the era.
As an abortion provider practicing in a post-Roe United States, I have been privileged to see abortion provided safely and effectively in impeccable clinics and by caring providers. And, as an abortion provider, I have taken care of women who have made the decision to end their pregnancy outside of the “traditional” medical system. Although abortion is legal in the U.S., it is not always accessible. I have counseled and cared for women who have chosen to manage their own abortion for reasons that have ranged from difficulty accessing abortion services in their community to a desire to avoid an in-clinic abortion.
The high cost of clinical care, particularly for those who live in states with restrictive abortion laws in place can prove to be an insurmountable barrier for some women who are already struggling financially. The average cost of a first trimester abortion in the United States is $500. This does not include travel or other secondary costs. Given that 75% of patients who have abortions are low-income, they are often most significantly impacted by restrictions on access to clinic based care impacting likelihood or willingness to self manage their abortions.
As the reasons an individual may decide to self-manage their own abortion have varied, the reality of abortion in the United States has also changed, and that includes what a self-managed abortion might look like. Even as we honor and remember this history, we must acknowledge where medicine, science, policy, and law have changed so that we can understand what abortion looks like today.
Historically, restrictions on legal abortion have resulted in maternal death due to increases in the frequency of unsafe abortion. We saw this in the United States, prior to legalization of abortion and it continues to occur internationally in places where abortion is restricted. In the U.S., historians credit two major events for steep declines in the number of women dying from complications related to abortion: first, the introduction of antibiotics in the 1940s, which allowed for effective treatment of infections, and, second, the Roe v. Wade decision in 1973 that made abortion legal in all 50 states.
Of course, Roe did not make abortion accessible to all. Shortly after the Hyde Amendment was passed in 1976, banning Medicaid insurance from covering abortion, Rosie Jiménez, a Chicana mother and teaching student from South Texas, died from complications from an unsafe abortion.
Advancements in medical science save women’s lives, as do public policies that ensure abortion is legal, accessible, and affordable. But women face many more restrictions to accessing abortion today. Are we headed back to the bad old days?
Thankfully, the reality of abortion in the United States has changed. Today, a woman who has decided to manage her own abortion may choose to buy abortion pills online. The abortion pill is safe, effective, and simple to use. This practice goes all the way back to Brazilian women in the 1980s who first discovered that a widely available ulcer medication (misoprostol) could be used to end a pregnancy – a discovery which saved many women’s lives in a country where clinical abortion was essentially unavailable.
It may be surprising for some of us to consider that someone might decide to end their own pregnancy, but for some, self-managing an abortion at home fits with the reality of their lives. As U.S. politicians pass new restrictions that push abortion out of reach — financially, geographically, or otherwise — some women may seek to self-manage an abortion because they don’t have another option. For others, self-managed abortion is the preference. When someone has decided to end a pregnancy, they should be able to do so safely, effectively, and with dignity, when they go to a provider and when they manage their own abortion.
I think one of the reasons the coat hanger imagery has resurfaced is that many people are concerned about the future of abortion rights in this country. With a president who vowed to punish women for abortion and a vice president who wants to consign Roe v. Wade to the “ash heap of history,” these concerns are not hyperbolic. And if abortion is outlawed outright or in all but name only, we could return to a time of widespread self-managed abortion. But thanks to the abortion pill, women would have a safe and effective option.
Jamila Perritt, MD, is a board certified, fellowship-trained obstetrician and gynecologist with a comprehensive background in family planning and reproductive health.