reproductive rights

Abortion After the Clinic

As Republican lawmakers try to legislate it out of existence, the future of reproductive healthcare may be at home.

After passing a fetal- heartbeat bill, members of the Missouri House throw papers in the air to mark the end of the legislative session. Photo: NICK SCHNELLE/The New York Times/Redux
After passing a fetal- heartbeat bill, members of the Missouri House throw papers in the air to mark the end of the legislative session. Photo: NICK SCHNELLE/The New York Times/Redux

When Leana Wen introduced herself to America as the new president of Planned Parenthood last fall, she had a story she liked to tell — one that showed exactly why abortion access mattered. It was a sad tale of “a young woman lying on a stretcher, pulseless and unresponsive, because of a home abortion.” Wen, an emergency physician who had been plucked from Baltimore’s Health Department to take over the century-old institution, said the young woman had arrived at her ER in “a pool of blood” because “she didn’t have access to health care, so she had her cousin attempt an abortion on her at home. We did everything we could to resuscitate her, but she died.”

Wen was talking about a time when abortion was technically legal, yet the story rhymed with the pre-Roe era, when doctors and lawyers spoke of being radicalized by women filling their wards with blood and desperation, the same nightmare the familiar pro-choice rhetoric warns will soon be upon us. Behind the scenes, however, a vanguard of the abortion-rights movement implored Wen, directly and through intermediaries, to stop talking about “home abortion” in such dire terms. Not because they weren’t horrified by what had happened to that woman, not because they didn’t want better for her, but because these activists — doctors, lawyers, even people running abortion clinics — have concluded that “home abortions,” or, in their preferred nomenclature, “self-managed abortions,” need to be normalized in the abortion-rights conversation. And they didn’t think the president of the most visible pro-choice organization in the country should be scaremongering about it.

“People throughout the world, including here in the U.S., have been since the dawn of time ending their own pregnancies,” says Jill Adams, executive director of the legal nonprofit If/When/How. “And since the advent of abortion pills, they’ve been doing it safely and more effectively. It’s no longer the Chicken Little narrative, where if you pass restrictions, clinics will close, people will be forced to take matters into their own hands, and it’s certain death and destruction from there. Instead, abortion will become even less accessible, and some people will self-manage abortion and most of them will be perfectly fine.” These activists know you think this is radical. They believe it’s the future.

This debate is taking place inside a movement that, despite abortion rights’ being broadly popular, is on the precipice of losing everything. Brett Kavanaugh was installed over the literal shouts of women, and the walls are closing in on clinics in red states now that the Supreme Court has agreed to revisit a recent precedent over whether states can regulate them out of existence. In many states, the crisis is not hypothetical; 58 percent of American women of reproductive age — or 40 million — live in states the Guttmacher Institute says have “demonstrated hostility to abortion rights,” a proportion that has risen by nine points since 2000. The South lost 50 abortion clinics between 2011 and 2017, the Midwest 33. Almost 500 state laws enacted in the past nine years restrict abortion, from forced ultrasounds to 72-hour waiting periods to outright bans that, for now, Supreme Court precedent bars from enforcement. The latest case before the high court, from Louisiana, may not outright overturn Roe v. Wade, but the threat looms, especially if Trump gets to appoint one more justice.

In its safest permutation, self-managed abortion means taking the same pills, mifepristone and misoprostol, that a doctor at an abortion clinic would give you if you chose a medication abortion rather than a surgical one. Medication abortions now account for a third of all clinic abortions, an option that has risen in popularity by 25 percent since 2011. If the Court takes an ax to Roe v. Wade, self-managed abortion will be a backstop, but activists don’t want to stop there. They want the post-clinic abortion to be an option even in places where the procedure is legal, as a matter of patient privacy and personal preference. And the notion is starting to gain purchase in mainstream reproductive-rights groups: In the past two years, in Massachusetts, New York, and Nevada, parts or all of the statutes that criminalize self-induced abortion were repealed. “There has been a veritable sea change in just a few years’ time within our movement,” says Adams. “Folks who were concerned, perhaps even mildly suspicious, today are becoming advocates for the decriminalization and normalization of self-managed abortion.”

Wen lasted only eight months as president of Planned Parenthood before an acrimonious parting that was just now formally resolved. The debate over how to talk about abortion outside a clinic wasn’t why she left, but it paralleled broader concerns that she was trying to drag the movement back to an era of respectability that activists believe helped get us to this wretched point. In the months since she left, in July, Wen has taken to Twitter and op-ed pages to say she lost her job because she wanted to depoliticize abortion and emphasize healthcare, appealing to that imagined middle with a return to Bill Clinton’s position that abortion should be “safe, legal, and rare.”

Wen has few allies within the movement on this idea. NARAL president Ilyse Hogue called the “safe legal and rare” rhetoric “antiquated and outdated. It not only stigmatizes the decision and the procedure, it creates an artificial dichotomy.” Both Wen’s predecessor and her successor at Planned Parenthood all but called bullshit. Alexis McGill Johnson, a longtime board member who stepped in to run Planned Parenthood through the election, flatly tells me, “I think her narrative is a false narrative…. Healthcare without access is meaningless.” Longtime Planned Parenthood president Cecile Richards, says, “I simply disagree that that formulation — I think we’ve moved so far past that.”

To members of the movement’s resurgent left, the grim turn of events under Trump has its roots not only in the right’s single-minded four-decade-and-change focus on banning abortion but in their own side’s approach. “We saw the rise of acceptability politics in abortion,” says Pamela Merritt, co-founder of the more confrontational group Reproaction. “If we wear our nice suits and we go in and we don’t yell, then these people won’t be able to frame us as these loud, crazy feminists. And that, of course, didn’t work.”

Merritt’s home state of Missouri shows how bad the situation has gotten. The state is down to its last abortion provider after repeated legislative onslaughts from Republicans. To meet the demand for abortions, Planned Parenthood of the St. Louis Region and Southwest Missouri built a large-capacity clinic 13 miles away, just across the Mississippi River in Illinois. The facility, which opened last month, would be a “regional abortion-access hub” primed for a “post-Roe world,” its president told the New York Times.

Yamani Hernandez, who runs the National Network of Abortion Funds, knows all about helping abortion seekers cross state lines. She says local groups, largely staffed by volunteers, already help patients pay for the procedure as well as travel, lodging, child care, and other expenses, but it’s nowhere near enough. “The average budget of an abortion fund is $175,000,” she says. Last year, the local funds got around 170,000 calls — and could meet just one-fifth of the requests.

In response to this climate, blue states are firming up their local abortion protections. And some liberal parts of the country, like California and NYC, are looking for ways to help out-of-state patients get abortions in their jurisdictions, mainly by helping them pay. “My biggest fear is that Planned Parenthood is going to turn into a bus stop,” shuttling patients from hostile states to better ones, says scrap-metal heir Jerry Sternberg, who wore a cowboy hat and a leather vest when I met him recently at a donor lunch in Asheville, North Carolina (I was in North Carolina to speak about my book at a Planned Parenthood event, for which I was paid). He and another large donor had helped Planned Parenthood build a new clinic a few years ago, “but we’ll charter a ship if we have to.”

That’s assuming the bus or the ship has somewhere to go. There’s no reason the justices who oppose abortion have to stop at just reversing Roe and allowing some states to ban it. Historian Mary Ziegler, author of the forthcoming Abortion and the Law in America: Roe v. Wade to the Present, puts it starkly: “Overturning Roe isn’t the endgame. Banning abortion everywhere is the endgame.”

Which brings us back to those home abortions. Daniel Grossman, a physician and public-health researcher whose work the Court relied on in Whole Woman’s Health v. Hellerstedt, has noticed something different at the medical meetings and conferences he’s been to lately, even among OB/GYNs in red states who aren’t abortion providers. They’re talking about what they can do if abortion is made illegal. “All this has seemed very theoretical to clinicians up until very recently. For the first time, people are bringing this up themselves. They’re asking what they can do in a way I’ve never seen before,” he tells me. The answer is likely getting out of the way, helping give information on and facilitate access to medication to end a pregnancy safely at home.

Until recently, reports of self-managed abortion were largely anecdotal. Whole Woman’s Health CEO Amy Hagstrom Miller, an independent abortion provider, said she first heard about women taking abortion pills at home at her clinic in McAllen, Texas. It’s just across the border from Mexico, where abortion is largely illegal and where misoprostol is sold by pharmacists as an ulcer medication. “There are communities that have always done their own health care,” she says. “They don’t trust medicine for a whole bunch of reasons.” Still, says Grossman, “I wasn’t sure that the searches online … translated into people really contacting these services and trying to get the product.” But when the FDA cracked down on the abortion-pill operation Aid Access earlier this year, founder Rebecca Gomperts offered numbers on American demand: 37,000 patients had contacted the organization in a little over a year; 7,000 packets of abortion pills were shipped.

“There’s an openness among mainstream medical communities now to demedicalize abortion,” Grossman says. “A few years ago, that would have been a crazy idea, and literally people laughed at me. And now I have a grant that is supporting research to build the evidence base to explore whether this is possible.” Some of the questions: Can patients determine how far along they are? Can they read a simple label on how to take the pills properly?

We still have no idea how many people are ordering pills from other websites — like the one Purvi Patel used in Indiana in 2013. We know about women like Patel only when things go wrong. She took pills she had ordered online to end her pregnancy but started hemorrhaging. (At doctors’ offices, the pills are recommended only up until ten weeks’ gestation; it turned out Patel was more than 20 weeks along.) At the ER she went to, an anti-abortion doctor called the police and left the hospital to go dumpster diving for Patel’s fetus. Patel was charged with feticide and child neglect. At trial, prosecutors used her email records to accuse her of having done “what was easiest and most comfortable for her, even if it was not legal,” of taking “care of herself while her baby laid dying.” Patel was sentenced to 30 years in prison; she served two before being freed on appeal.

Patel’s case represents what everyone agrees is the worst-case scenario for home abortion even when the procedure itself is technically legal. “There is common ground,” concedes Wen. “I think we’d agree that women should not be criminalized for seeking these methods.” Grossman points out that in Latin America, physicians have developed a postabortion-care protocol that doesn’t ask whether the miscarriage was induced.

But activists also imagine a best-case scenario even in abortion-friendly states, where, they hope, mifepristone and misoprostol could be far more accessible, perhaps dispensed by pharmacists. Grossman explains that some states have already made it easier to access birth control without a prescription, and he argues that states, not the FDA, would have the authority to allow abortion pills to be administered at a pharmacy. In an ideal world, patients could still choose the quicker clinic-based vacuum aspiration if they wanted to. “Then maybe abortion after the first trimester would happen in a smaller number of facilities that are regionally concentrated,” Grossman says. What a move toward legal self-managed abortion means for independent clinics like Whole Woman’s Health or for the national network of Planned Parenthoods remains to be seen. Hagstrom Miller is ambivalent: “I love the idea of self-managing the abortion, but I don’t want someone to do it where they feel like they’re hiding or feel ashamed or scared.” And, she says, because early abortions make up the majority of procedures, “I wouldn’t be able to stay open only for post-ten-week abortions. Therein lies the challenge.”

For now, Planned Parenthood is largely steering clear of the debate. When I ask acting president McGill Johnson about self-managed abortion, she stresses that the organization abides by the law. A spokesperson follows up with a carefully worded email: “Planned Parenthood is strongly opposed to the criminalization of self-managed abortion. No one should fear arrest or prosecution because of a pregnancy outcome. Under the current rules, medication abortion has to be provided by a medical professional, and Planned Parenthood follows all laws and regulations.”

Promoting abortion without doctors could make abortion-rights activists look like they’re somehow in favor of the back alley — but it could also scramble traditional right-wing attacks. An anti-abortion activist in Missouri recently conceded to the New York Times, “Between the increased use of medication abortion and of self-managed abortion, should focusing on the clinic itself really be our primary goal?” Without a building or a doctor to target, abortion opponents are left to crack down on the network or on the woman herself.

If, as NARAL president Hogue puts it, “the right’s overreach is our superpower,” self-managed abortion might provide the ultimate overreach — the prosecutorial kind. Reproaction has started putting anti-abortion politicians on the spot, asking them about what the punishment should be for women who abort, and some have been unusually honest. “They’re really afraid of it,” says Erin Matson, the group’s co-founder. “You can’t firebomb every single person’s house in America, wondering what’s in their medicine cabinet.”

*This article appears in the November 11, 2019, issue of New York Magazine  Subscribe Now!

Abortion After the Clinic