Safe Abortions Everywhere, Regardless of the Law

From 2017 to 2020, I spent three years talking with feminist activists in Latin America, Europe, sub-Saharan Africa and the United States about their work supporting and enabling people with undesired pregnancies to self-manage a medication abortion. Late last year, the results of that research were published in my book Abortion Beyond the Law: Building a Global Feminist Movement for Self-Managed Abortion. After Texas passed a six-week abortion ban in 2021, and the Supreme Court overturned federal abortion protections the following year, I conducted more interviews with Mexican and U.S. activists about how they were responding. 

That research and these ongoing conversations reveal a world in which women have long experience with safe medication abortion in their own homes and communities, without medical supervision, despite restrictive laws and hostile governments. And it’s a world that U.S. feminists concerned about abortion rights have been learning from during the last two years.

In the Global North, most women trace the history of medication abortion to the invention in the 1980s of the French abortion pill RU-486, now known as mifepristone. In the Global South, medication abortion also began in the 1980s, but in a much different context — well outside of pharmaceutical labs and the drug approval process. In Brazil, where abortion was so heavily restricted that it was functionally unavailable, women began using the prescription ulcer medication Cytotec (misoprostol), which came with a Black Box warning that the medication could cause a miscarriage. Even in a pre-internet age, news of this strategy to end unwanted pregnancies spread so effectively that maternal mortality from botched abortions decreased significantly in Brazil. A Chilean activist similarly told me that septic units in Chilean hospitals began to close as the use of medication for self-managed abortion spread through the country. 

Today, medication abortions typically involve a combination of both drugs, but can still be safe and effective with misoprostol alone if mifepristone is unavailable. (Misoprostol has many medical uses, from treatment for ulcers to the prevention of post-partum hemorrhage, and is therefore widely available. Mifepristone, however, is primarily used in relation to abortion and miscarriage, which means it is more tightly controlled.)

In the early 21^st century, the contemporary universe of SMA began to take shape. In the early 2000s, the Dutch feminist group Women on Waves began to sail a boat into international waters outside countries with restrictive abortion laws — including Ireland, Poland and Portugal — and distribute abortion pills from the boat. In 2005, the group added a digital arm, Women on Web, which became the first online abortion telemedicine service worldwide, prescribing and mailing abortion pills to women in much of the world.

Around the same time, in the conservative Mexican state of Guanajuato, where abortion was highly restricted, the women’s rights NGO Las Libres began teaching women how to use misoprostol to self-manage abortions and accompanying them through the process.

These two streams of activism came together to form the contemporary movement. The work of Women on Waves and Women on Web laid the groundwork for transnational telehealth abortion, and trained frontline activists in local organizations around the world in the use of abortion pills. Web staff worked closely with the activists who launched Ecuador’s hotline, and supported the other hotlines that quickly followed. The accompaniment model created in Guanajuato spread globally and has since become one of the primary strategies for enabling a completely de-medicalized worldwide. This movement has changed global public health as well: The World Health Organization now publishes protocols for SMA in the community, without medical supervision, and no longer classifies it as ​“risky,” based on epidemiological research done collaboratively with feminist hotlines, accompaniment collectives and telehealth services across the world.

Today, safe abortion phone lines exist in some 34 countries globally, including the United States. Some are hotlines in the traditional sense of a phone number people can call for information and personal support, while others offer an initial point of connection with accompaniment collectives. As the model of accompaniment first developed by Las Libres in Mexico began to spread across Latin America, it was adapted to other formats, including in-person group meetings between activists and people seeking abortions. A central element of accompaniment is assigning an acompañante, similar to a doula, who stays in contact with the person as they go through the abortion process — by email, text, phone, or sometimes in person.

In 2023, more than half of all U.S. abortions were conducted with medication. Some of these abortions begin with an appointment with a provider, others by filling out a form for an online telemedicine service. But an unknown number start with an encrypted text message, or perhaps phone call, to obtain pills and instructions on how to use them outside the medical system for an entirely self-managed abortion.

Abortion outside the medical system still carries an aura of danger and illegality for many people in the United States, where we are relative newcomers to the world of de-medicalized abortion. Self-managed abortion emerged more recently in the United States than in many other parts of the world, in large part because abortion was broadly legal, despite accessibility problems, until 2022. During an interview in 2019, a U.S. activist described a moment when she realized it was probably easier to obtain abortion pills in the highlands of Ethiopia than in the state where she lived.

This began to change after Texas introduced its six-week abortion ban bill (SB8) in 2021; Mexican activists publicly offered to accompany women in the United States and U.S. feminists began to learn from their more experienced compañeras in Latin America. In early March 2022, I participated in an online meeting that brought together Mexican and U.S. feminists, with simultaneous translation, to talk about SMA, community support and cross-border collaboration.

There is now an active and growing SMA movement in the United States. Some doulas and midwives have long quietly supported people with abortion as well as childbirth; since Dobbs, this has become somewhat more common, if still very quiet outside states with protective legislation. Experienced activists, many of whom also work internationally, have been holding ​“train-the-trainer” events to create a pool of people who can share information about SMA and teach others to do so. Community-based networks that share information and support are active throughout the country in places where abortion is restricted, and these networks provided more than half of the medication used for SMA in the six months following Dobbs. These are networks of community activists, not medical providers in shield law states, that create U.S. analogs of the accompaniment and support collectives that exist across the Global South. Notably, while Dobbs has restricted and complicated legal access to abortion in many states across the country — including proliferating restrictions on abortion medications — the grassroots feminist response appears to have actually increased access to abortion pills overall.

That matters, not least because the combination of state-level restrictions and the heightened politicization of abortion has created profound anxiety and uncertainty among pregnant people, doctors and activists. Emergency room personnel and OBGYNs fear providing basic care for people whose pregnancies have encountered problems, thanks to both the increased political attention on the issue and the legal confusions generated by rapid changes in laws post-Dobbs. Medical providers, and hospital lawyers, are not used to navigating laws that prohibit treatments recommended in professional standards of care —nor should they be — but sadly this is not uncommon throughout the world (for trans youth as well as pregnant people).

U.S. medical providers may need to learn strategies for harm reduction and working around the laws, practices that are more familiar to both providers and pregnant people in parts of the world where abortion has long been restricted or banned. For example, when I was in Chile in 2017 — a time when all abortions, for any reason, were still banned by the state — a gynecologist introduced me to the person to whom she referred patients who needed to buy abortion pills outside the medical system. The gynecologist had confidence in the quality of the medication sold by her contact, and she could provide post-abortion care herself if needed. In a more publicly visible example from Argentina, before abortion was legalized in 2020, some of the clinics that are the first point of contact for pregnant women seeking medical care used to carry cards with contact information for the Socorristas, the country’s primary feminist network providing support for SMA.

Few U.S. doctors or patients are experienced with working around abortion bans in these kinds of ways, and those who are may be highly vulnerable immigrants. But the considerable experience medical providers in other countries have in finding ways to both assist their patients and manage the associated anxieties is a resource U.S. doctors might find valuable.

Despite the elevated fear, confusion and uncertainty that surrounds all abortion, including self-managed abortions, as of this writing, there have been few prosecutions of doctors, activists or people having abortions post-Dobbs. In particular, no one in the United States has been criminally charged over sharing information about how to safely self-manage and abortion, although many people are doing so and sometimes in very public ways. There has been no change in the number of abortions that take place within the medical system, even perhaps a slight increase, although almost 20% of patients now have to travel to another state in order to obtain an abortion.

Abortions happen, and while legislation can make the process easier or harder, the global data clearly indicates that people with unwanted pregnancies will terminate them, or at least try to. The work being done by feminists in the United States and around the world enables those abortions to be safer, less isolated and under the control of the pregnant person themselves — regardless of the law.

In the words of an Argentinian acompañante, ​“A big part of this movement is … joining together to solve everyday problems among ourselves… For some who rule this world, we are committing an offense. And so, on this sometimes slippery ledge we’re moving along, I think we’re developing a particular kind of feminism … a feminism of direct action.”