At a time when access to abortion is being restricted in many ways in the United States, advocates are working to make abortion pills easier to get and use in privacy.
Several groups are providing the pills using telemedicine and the mail as part of studies. Another group maintains an online list of websites that sell the pills without a prescription. And the American Civil Liberties Union is suing the U.S. Food and Drug Administration to get rid of what advocates see as unnecessary restrictions on the prescribing and dispensing of the pills.
But a new study suggests that sidestepping those tight regulations remains daunting.
Abigail Aiken, a reproductive health researcher at the University of Texas at Austin, anonymously interviewed 30 women and two men from 20 states who tried to get abortion pills online because going to a clinic posed huge financial and logistical problems. None succeeded in getting the pills.
That left some women considering unsafe methods.
"I was really desperate," said a 23-year-old from Illinois. "I heard you could try drinking gin. I found YouTube videos that tell you how to do it with a hanger. I'm not gonna lie — it made me cry."
The small study comes as President Trump's nomination of Brett Kavanaugh to the Supreme Court has raised the possibility that the federal constitutional right to abortion — created by the 1973 Roe v. Wade decision — could be further curtailed or even scrapped. Then, each state would decide how to regulate abortion.
"There is a public health justification to reduce clinic access barriers and to make medication abortion that is sourced online and managed at home as safe and supported as possible," Aiken concluded in the study, published in Perspectives on Sexual and Reproductive Health.
Abortion opponents passionately disagree.
"The abortion industry has been trying to cope with reduced demand and falling revenues by cutting…costs, by going to webcam abortions where an abortionist never physically examines a woman and only monitors her from afar," said Randall K. O'Bannon, a director of the National Right to Life Educational Trust Fund. "It is an irresponsible and dangerous medical abandonment of the woman."
Medication abortion, used up to 10 weeks of pregnancy instead of a surgical procedure, actually involves two drugs. Mifepristone, made in the U.S. by Danco Laboratories and branded Mifeprex, blocks progestin, needed to sustain pregnancy. Later, misoprostol, a drug with a variety of gynecological uses, causes uterine contractions, ensuring expulsion of the grape-size fetus.
The FDA approved Danco's controversial product in 2000 with unusual safety precautions, most still in force. A woman must go to a medical facility and get the pill from a health-care provider who stocks the product and is certified to prescribe it. The FDA's website warns against buying abortion pills over the internet.
More than 3 million American women have had medication abortions, which now make up a third of all pregnancy terminations. Serious complications have been rare, while deaths have been ultra-rare. The FDA's own 2016 review concluded that "medication abortion has been increasingly used as its efficacy and safety have become well-established by both research and experience, and serious complications have proven to be extremely rare."
Given this record, the ACLU lawsuit says mifepristone should be made available the conventional way — by prescription filled by a pharmacy.
"The restrictions have nothing to do with science and everything to do with politics," ACLU lawyer Julia Kaye said.
Still, even advocates disagree about how far to go in allowing women to "self-manage" a pregnancy termination.
Women on Web, based in the Netherlands, is one of several international nonprofit organizations that provide abortion pills by mail after the woman consults online with a doctor, gets a blood test, and, "if possible," an ultrasound to confirm the pregnancy is early. These nonprofits only serve women in countries where abortion is banned — as women in Aiken's study were dismayed to learn. (Aiken's 32 interview subjects were referred to her by Women on Web and another nonprofit, safe2choose.)
Gynuity Health Projects, a reproductive health research organization, uses a telemedicine model for its FDA-approved study in Hawaii, New York, Maine, Oregon, and Washington. Women obtain pre- and post-abortion tests near their home, video consult with a doctor, and receive pills by mail.
"I wouldn't say everybody is in agreement about how to do it," said Gynuity teleabortion coordinator Erica Chong. "There's a diversity of opinion about whether you need an ultrasound, and whether you need follow-up afterward."
The researchers behind a project called Plan C take a pragmatic view, arguing that women are already going it alone. To help them, the researchers ordered abortion pills without prescriptions from 18 online websites — the kind the FDA considers rogues. The results were published as a study that became Plan C's online "report card," which rates the websites based on product quality, price, and shipping time.
Although two orders were never received and some mifepristone doses were skimpy, the researchers concluded "self-sourcing pills from the internet is a rational option."
"We don't advocate that women do this," said public health specialist Elisa Wells, co-director of Plan C. "We know women are already doing this, so we believe they should have access to good information."
Some women in Aiken's study said they considered or even tried ordering from internet sites, but backed off, wary of scams. Ultimately, 27 of the women went to clinics for abortions, three had miscarriages, and two continued their pregnancies.
Aiken's study notes that self-management is "not without legal risks." Seven states have bans on self-induced abortion, 10 states have fetal harm laws, 15 states have vaguer statutes that could be used in prosecutions, and at least 18 women have been arrested for allegedly ending their pregnancies, according to the Self-Induced Abortion Legal Team.
"Right now," Aiken said, "we're very worried about the future of reproductive rights. What we have to understand is that for some women, that reality of losing the right to choose has already dawned."