Current activism around self-managed abortion (SMA) in the United States is born out of innovation, resistance, resilience, and necessity. This article examines the historical origins of SMA in the United States from an activist perspective and outlines the opportunities and challenges that SMA presents to people having expanded control over their reproductive lives.
Abortion as a proxy for the right to bodily autonomy is woven into US history, through slavery, the regulation of midwifery, and the medicalization of the practice. Abortion became a politically contentious issue in the United States in the 1970s, when the “Moral Majority” realized that opposition to abortion and gay rights could be used to mobilize voters to support a right-wing agenda. In 1973, when the Roe v. Wade decision legalized abortion, conservatives understood that by shifting to a focus on gender and sexuality, there was an opportunity to move forward an agenda based in racism, religious intolerance, and class inequality (Balmer 2021).
Despite legalization, access to abortion has always been difficult, due to barriers related to geographic distance, economic constraints, and stigma. Abortion care started in feminist and other clinics across the country, isolated from reproductive health services available at hospitals and health centers. Most ob/gyn physicians do not provide abortion care; it has been relegated to a small group of skilled clinicians who practice in dedicated abortion clinics. Access to abortion at clinics was further reduced in 1992, when the Supreme Court's decision in Planned Parenthood v. Casey allowed states to impose restrictions as long as they did not create an “undue burden” for women seeking abortions, further exacerbating existing disparities in access.
Health disparities and distrust in the medical system have also shaped access to reproductive health care for marginalized communities. The historical roots of reproductive injustices, including coerced sterilizations and unethical medical experiments on women of color, have contributed to a lack of access to abortion in traditional clinical settings. Moreover, restrictive state policies targeting reproductive health care, coupled with stigmatization, have perpetuated the notion that seeking abortion services from medical professionals may lead to judgment or mistreatment.
As clinic closures and restrictive legislation proliferated over the last decade, activism around self-managed abortion in the United States has gained momentum. While communities have used a variety of methods to self-induce an abortion, for the purposes of this article, self-managed abortion (SMA) is defined as self-sourcing of abortion medicines (mifepristone and misoprostol, or misoprostol alone) followed by self-use of the medicines including self-management of the abortion process outside of a clinical context (Wainwright et al. 2016).
This article examines the historical origins of SMA in the United States from an activist perspective and outlines the opportunities and challenges that SMA presents to people having expanded control over their reproductive lives.
The International Roots of SMA: Self-help Hotlines and Accompaniment in Latin America
The roots of SMA in the United States can be traced back to the pioneering efforts of feminists in Latin America, a continent which until recently almost universally banned abortion. Starting in the late 1980s, the practice of using misoprostol to self-induce abortions spread throughout the region. Gradually, small activist groups in a number of countries began spreading information about misoprostol and developed hotlines and accompaniment models with the goal of empowering people with information and support to obtain and use misoprostol safely and effectively. The concept of accompaniment, in which trained volunteers support people through their abortion experience while building a sense of community and dismantling stigma, further fortified the SMA movement in Latin America. From 2000 to the present, these hotlines have linked to each other, supported national and transnational activism, and have worked directly or with allies for the legalization or decriminalization of abortion throughout the region. As a result of this activism and the availability of misoprostol, maternal mortality rates from unsafe abortion have historically been lower in Latin America than in other regions where abortion is illegal (WHO 2012).
These hotlines and accompaniment groups saw their work as deeply political and as a response to the state violating their human right to autonomy. They played a crucial role in dismantling stigma and ensuring safe abortion practices, breaking the paradigm that illegal abortions were necessarily unsafe abortions. The hotlines also laid a foundation for challenging the abortion laws and the power structures that sought to limit reproductive rights. The “green wave” of change in abortion laws across Latin America is driven by feminists who call for the destigmatization and decriminalization of abortion and who have supported one another in having safe abortions for decades, with or without the collaboration of health care providers.
The History of SMA in the United States
The SMA movement in the United States draws inspiration from many sources, including Latin American feminism, the self-help movement launched by the publication of Our Bodies, Ourselves in 1970, and the Jane Collective, which operated in Chicago in the 1960s and 1970s and provided over eleven thousand abortions before Roe v. Wade legalized abortion. While misoprostol alone was known and used for abortion (or “bringing down one's period”) in some communities earlier (Rosing and Archibald, 2000), the 2000 FDA approval of mifepristone and misoprostol for ending unwanted pregnancies presented new options for feminist activism.
In 2004, a small group of nonprofit leaders from the Abortion Access Project, the ACLU of Massachusetts, Gynuity Health Projects, Ibis Reproductive Health, and the National Latina Institute for Reproductive Health came together to form the Misoprostol Working Group.1 Their multifaceted strategy included recognizing the need for clinicians to learn more about protocols for abortion that use misoprostol alone, without mifepristone. The group focused on the need to learn more about and support community-based practices, as well as to stop the prosecution of those who were using misoprostol. Members of the group began conducting research to learn more about community-based practices of SMA and presented at several abortion-focused conferences. At the same time, as restrictions on abortion grew in Texas, efforts were launched to educate people in southern Texas about the World Health Organization protocols for misoprostol for safe abortion, recognizing the availability of misoprostol in Mexico and at many informal sites in Texas such as flea markets.
Gradually, the reproductive rights and justice movement began to pay more attention to the issues around SMA in the United States. Increased use of misoprostol plus mifepristone became established at sites that provided abortion care, building familiarity with abortion pills among the medical community and among patients. In 2009 Gynuity Health Projects and the Reproductive Health Technologies Project convened a multiday meeting of experts in a forum, “The Best Defense Is a Good Offense: Misoprostol, Abortion, and the Law,” which generated a range of recommendations for the field. Researchers (Yanow 2009) began publishing papers that documented the practice of SMA (Grossman et al. 2010). At the same time, many states began imposing more and more draconian restrictions on the provision of abortion.
When Donald Trump was elected president, it was clear that the legal right to abortion was in jeopardy. Activists and advocates founded a number of organizations to support those who were self-sourcing abortion pills, out of choice or, more frequently, out of necessity. Organizations that emerged include SASS (Self-managed Abortion; Safe & Supported), which provides information about how to use abortion pills and how to mitigate legal risk (SASS also supports the Euki app); Plan C (provides referrals to reliable sources of abortion pills); If/When/How (provides legal information and support); Aid Access (sends pills from a range of locations); Red State Access (supports those seeking to SMA in states with bans); and the Miscarriage and Abortion (M+A) Hotline (staffed by clinicians and is available to anyone using abortion pills). Additionally, groups like Abortion on Our Own Terms emerged to frame positive messages about SMA and the need to support and decriminalize the practice. Beyond these registered organizations, dozens of community-based accompaniment groups are active in most states with abortion bans and restrictions, quietly supporting those who can find them, often with supplies and support from feminist groups in Mexico like Las Libres and La Marea Verde.
SMA Challenges Prevailing Paradigms about Abortion, Power, and Health Equity
Activists championing SMA view it through various lenses, including health inequity, harm reduction, and social change (Erdman, Jelinska, and Yanow 2018). SMA is seen as a response to the structural inequities that prevent marginalized communities from accessing abortion services, perpetuating disparities in reproductive health care. By offering women an alternative means of abortion, SMA aligns with the harm-reduction approach, seeking to minimize potential risks associated with unsafe abortion practices. For some practitioners, SMA is an anarchist practice, intentionally located outside of laws and controls, calling for new behaviors and norms in abortion care, including highlighting the right to choose how, where, and with whom one aborts and embracing a celebratory approach toward abortion practice, often combined with a calling out of institutionalized obstetric violence in some settings.
At its core, the SMA movement challenges the notion that abortion should be solely within the purview of the medical establishment. Activists argue that all people should have the agency to decide what is best for their bodies and lives, free from punitive legal consequences. This perspective aligns with the global call for decriminalizing abortion to ensure that reproductive rights are protected and respected.
Many advocates for SMA also center the state's responsibility to provide health care for all, including abortion services for those who choose or need clinician care to end their pregnancy. Many SMA advocates in the United States are also part of groups and coalitions that are fighting abortion bans and framing the rights embraced in the 1973 Roe decision as a floor of what is needed, envisioning more comprehensive access to all health care, including abortion in all trimesters, as essential for individuals to lead healthy and autonomous lives.
At the individual level, SMA can be framed as a mitigation strategy in response to harmful policies enacted by the US Supreme Court and misogynistic policymakers. The upsurge in state-level restrictions on abortion services means that SMA is a practical response to safeguarding reproductive rights for those who need to end a pregnancy safely and cannot or wish not to travel hundreds of miles for care.
While SMA is not a “silver bullet” solution to the barriers faced by reproductive health care access, it reduces the harm caused by the courts and legislatures and can become a powerful tool of empowerment for individuals seeking autonomy over their bodies. SMA allows individuals to reclaim agency in making decisions about their reproductive lives, reducing the reliance on medical professionals and the inherent power dynamics that may exist within clinical settings.
The Current Landscape for SMA in the United States
When abortion pills are in the hands of those who need them, bans on abortion can be circumvented. Currently, there are many ways to access pills, as listed on the SASS and Plan C websites. The anti-abortion movement is well aware of this and is doing everything possible to make the medicines less available and to create additional penalties for those who self-manage.
However, it is essential to acknowledge that SMA is not without its challenges. Self-sourcing and self-administering abortion pills require access to accurate information. In the United States, as with so much of health care, there are disparities in access to reliable information. While websites with reliable information have proliferated, so has misinformation planted by anti-abortion activists. Recent studies (Kaller et al. 2023; Kearney et al. 2022) reveal that at least one-third of those identifying as female do not know about abortion pills. If one does not know that abortion pills exist, or that they are a safe option, one will not search for good information. People with less access to the internet, less education, or less fluent in English also may not have the information that they need to use abortion pills in the most effective way or to be prepared for the cramping and bleeding caused by the pills. Before Dobbs, 75 percent of those seeking abortion were considered low income, and 49 percent lived at or below the federal poverty line (Jerman, Jones, and Onda 2016), highlighting the depth of the barriers faced by those seeking abortions in the current environment.
Of particular concern is the lack of knowledge about how to mitigate legal risk and increased risk of criminalization in communities that are already over-surveilled, which are disproportionately low income and of color. A recent study by If/When/How documented sixty-one arrests of people self-managing their abortion between 2000 and 2020 (Huss, Diaz-Tello, and Samari 2023), when abortion was still legal under Roe, and there have been well-documented arrests recently (Levinson 2023). For some communities, the risk of criminalization may outweigh the benefits of accessing abortion pills on one's own.
Conclusion
Current activism around self-managed abortion in the United States is born out of innovation, resistance, resilience, and necessity. Informed by activist strategies from Latin America and rooted in the struggle for reproductive justice, health equity, and autonomy, SMA has broad political implications and being a safe and effective solution for someone with an unwanted pregnancy in the present. While SMA is not a panacea, it stands as a tool of empowerment and a strategic response to mitigate the harm caused by restrictive abortion policies, including but not limited to abortion bans. As the SMA movement evolves, it continues to shape the discourse on reproductive justice, emphasizing the importance of bodily autonomy, comprehensive health care access, and the fight for equitable reproductive rights for all.
Note
The author was a member of the Misoprostol Working Group, and information comes from her personal files.
