Medical views on self-managed abortion shifting since overturn of Roe
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Three years ago today, the Supreme Court ended the constitutional right to an abortion in the United States. The court has done what it has never done before, expressly take away a constitutional right that is so fundamental.

to so many Americans that had already been recognized. That's then-President Joe Biden a few hours later reacting to the court overturning Roe v. Wade, which for 49 years had guaranteed the right to an abortion nationwide. There had been some warning. A draft of the decision had been leaked more than a month before. But that morning, outside the court, the news was still monumental. When they knew...

The decision was handed down. I just, women are going to die. That's Poppy Luthon from Seattle. She happened to be in D.C. for a conference. She worried about the world her teenage daughter was growing up into. The Supreme Court is meant to give us justice and is being taken away. And I'm overcome. I'm just overcome with grief. But others were celebrating. Very excited, very happy, very grateful, but

Still a lot of work to do. Kelsey Smith from Clemson, South Carolina, was wearing a shirt that read, The Pro-Life Generation Votes. I mean, the pro-life generation and the pro-life movement wants to really...

abortion illegal, unthinkable, and unnecessary. Those two reactions, grief and excitement, played out across the country as the day unfolded. Ann Scheidler, vice president of the Pro-Life Action League, spoke to NPR. It's hard to believe this day is here, even though we had the leak. It's just unbelievable.

We anticipated this day would come someday. We knew the country would come to its senses. Nancy Northup, president of the Center for Reproductive Rights, the Mississippi clinic at the center of the court's decision, spoke with NPR as well. You know, it's absolutely devastating. Even though we had that advanced leaked draft opinion, it is still emotionally stunning to have this opinion now out

and to have had the court just deliver a wrecking ball to the constitutional right to abortion and utterly destroy the protections of Roe versus Wade.

The Supreme Court decision was announced on a Friday. By Monday, 11 states had banned or severely limited abortions. As the legal landscape shifted, the medical landscape of reproductive care was faced with serious questions. Would doctors be criminally prosecuted for performing abortions? How would miscarriages be treated by the law? Would IVF remain legal? And a big unknown,

With fewer legal options available, where would people turn for abortion care? I think that's always a concern, right? When you take away access to care to providers, that people will turn to alternative methods. That's Alexis McGill-Johnson, CEO of Planned Parenthood, talking with All Things Considered at the time. You know, we will support and educate people around methods of self-managed care.

Self-managed care, like abortion pills. Consider this. Three years after the fall of Roe v. Wade, more and more people are managing their abortions without doctors. We'll take a look at the changing opinions about self-managed abortions within the medical community. From NPR, I'm Mary Louise Kelly.

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It's Consider This from NPR. Mifepristone is one of two drugs used in medication abortions. By the time Roe v. Wade was overturned in June of 2022, its use had been approved by the FDA for 22 years. But after the Supreme Court's decision, access to mifepristone became tangled in the legal fight over abortion rights.

U.S. Attorney General Merrick Garland released a statement that same day saying that, quote, states may not ban Mifepristone based on disagreement with the FDA's expert judgment about its safety and efficacy.

Within a few months, a challenge to the safety of Mifepristo went to federal court in Texas. It took two years for that case to make it to the Supreme Court, which ruled last summer that access to the pill should be preserved. So...

Where do we stand now? Abby Windle from NPR's Embedded team has been reporting on self-managed abortions and how the medical community's views on it have changed in recent years. For nearly four years, Maya Bass's commute included a monthly plane ride from Philadelphia to Oklahoma. Do you like flying? Oh no, I get really motion sick.

I'm really good at not vomiting, though, so. Bass made that trip each month to fill a gap. Oklahoma had a shortage of abortion providers, and she's a family medicine doctor who provides abortion. One way was by prescribing abortion pills. Bass was trained to follow a strict protocol around the pills. It included multiple in-person appointments to get an ultrasound and blood work, and to pick up the pills at the clinic.

Bass believed many of these steps kept patients safe. Of course I'm going to confirm exactly how big this pregnancy is. Of course I'm going to confirm that my patient has enough blood to handle this. So Bass was concerned when she first heard about self-managed abortion.

Getting abortion pills without a prescription and taking them without a doctor's oversight. Gosh, what if people are dropping like flies because they're taking meds that are actually rat poison and hurting themselves? A lot of doctors had a similar reaction. People felt it was really unsafe.

This is Jen Carlin, a professor of family and community medicine at the University of California, San Francisco. In the late 2010s, she became interested in the debate about self-managed abortion. I wanted to talk with clinicians about this to find out, are you really worried about the safety of this? And if you are, what aspect of the safety are you worried about?

In 2019, Carlin turned these questions into a study. First, she surveyed 40 abortion providers and asked what they thought about self-managed medication abortions. About half of them were ambivalent. Then, Carlin gave them a fact sheet summarizing nearly two dozen peer-reviewed studies and

that showed self-managing with pills is safe and effective. Like, wait, what? Like, seriously? I never knew about any of this. Bass was one of the doctors in Carlin's study. The research on that fact sheet showed that the protocol Bass used, the multiple appointments, the ultrasound, wasn't always needed. Realizing that I was unnecessarily putting people through hoops, that's hard.

And then I felt also excited slash maybe relieved. Like, this means that I can be less scared for people who are doing this. The next year, 2020, far more doctors changed their minds because of the COVID-19 pandemic and the need for social distancing. Now, all of a sudden, the health care profession is saying, wait, wait, wait, does that person really need to come in to do that ultrasound? And...

Lo and behold, there's all this evidence already out there that no, they don't. During the pandemic, the FDA stopped enforcing regulations on one of the abortion pills, Mifepristone. Patients were no longer federally required to go to a clinic to get abortion pills. Doctors in many states began using telemedicine.

Carlin went back to the doctors she had surveyed in 2019 to see what they thought about medication abortion with less medical oversight. They're seeing it and they're saying, everything I was reading about in those papers is right and I'm seeing it from my own eyes and now I'm even more convinced that it works. Across the country, many doctors who provide abortions embraced a more demedicalized approach. As of 2024, 19% of all abortions happened with telehealth.

But telehealth still requires a doctor to give a patient a prescription. Self-managed abortion goes a step further. People get the pills on their own, often by ordering them online.

More women have done just that since Roe vs. Wade was overturned in 2022. Since then, studies have shown that the rate of self-managed abortion has increased, and so have online abortion pill orders. And organizations that support people through self-managed abortions have seen an explosion in people reaching out. That's true for the miscarriage and abortion hotline, which is run by clinicians. Back

Bass, the family medicine doctor, joined the hotline after reading the research about self-managed abortion. The vast majority of the calls I'm dealing with are people just being like, hey, can you tell me if it worked? Bass knows self-managed abortions can't replace all abortions. Some people need medical intervention or just prefer to go to a clinic. But

But to her, the hotline and the immediate access it gives women to doctors without unnecessary tests feels innovative. It feels like I'm just on the cutting edge of medicine. I'm practicing evidence-based medicine that is the leading edge of what reproductive health care might look like.

The broader mainstream medical community has been moving in this direction too. In 2022, the World Health Organization declared self-managed abortion to be a safe and effective method in the first trimester. And in 2024, the American College of Obstetricians and Gynecologists put out a statement in support of it.

But there's been movement in the opposite direction, too. Last month, Secretary of Health and Human Services Robert F. Kennedy Jr. ordered the FDA to review regulations on mifepristone, which could restore the rules that require patients to get multiple tests and pick up the pills at a clinic. If abortion pills get harder to access through the formal health care system, even more women may look to self-managed abortion.

That's Abby Wendell, reporter for Embedded, NPR's home for long-form documentaries. The podcast just came out with a new series about the history of self-managed abortion called The Network. It was produced alongside Futuro Media. This episode was produced by Noah Caldwell and Lauren Hodges. It was edited by Jeanette Woods. Our executive producer is Sammy Yenigan. ♪

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