Abortion goes back to the shadows
Women seeking abortions in states where the procedure is banned must now rely on mail-order pills and volunteer hotlines, said Caroline Kitchener in The Washington Post. The experience is often traumatic.
ANGEL TUCKED TWO white pills into each side of her mouth, bracing herself as they began to dissolve. Her deepest fears and anxieties took over. Angel had wanted to talk to a doctor before she took the pills to end her pregnancy, worried about how they might interact with medication she took for her heart condition. But in her home state of Oklahoma, where almost all abortions are banned, that wasn’t an option.
The pain kicked in after about an hour, around midnight on a Sunday in January, eventually becoming sharp enough that the 23-year-old said she struggled to stand. While Angel would be fine by the next morning, she worried that something might be very wrong as she lay on the cold bathroom tile, her body racked by some of the worst pain she could remember.
When Angel’s fiancé came in to check on her, she was having diarrhea while vomiting into their popcorn bowl. “F---,” she remembered yelling, over and over. “I feel like I need to push.”
Overwhelming evidence shows that abortion pills are safe and effective, and that many patients who take them go through the process without much difficulty, experiencing little more than the sharp cramping and bleeding of an unusually heavy period. That is true even when the pills, approved by the U.S. Food and Drug and Administration with a prescription for use through 10 weeks of pregnancy, are taken somewhat independently—administered by a doctor over text, email, or a call and mailed to the patient at home.
But the experience can feel very different in states where abortion is illegal. As more women in states with abortion bans choose to end their pregnancies on their own, without directly interacting with a medical professional, they are thrust into a largely ad hoc, unregulated system of online and grass-roots abortion pill distributors—an experience that, while deemed generally safe by medical experts, can be confusing, scary and, at times, deeply traumatic.
“This is not the way health care should be,” said Linda Prine, a New York–based doctor who prescribes pills through Aid Access, a Europe-based online clinic that now sends the pills to at least 6,000 women every month in states with bans. Prine co-founded a hotline for people taking them. “All the options have been taken away from people by these bans and this is all that’s left,” she added, referring to the networks providing pills for women self-managing their abortions. “It really is all we can do.”
Adding to the difficulty is a polarized political debate with dueling narratives about what it’s actually like to take abortion pills. Anti-abortion activists say the pills are highly dangerous, or even deadly, for pregnant women—false assertions based largely on studies that have now been retracted by the journal that published them. Meanwhile, many abortion rights advocates describe the experience as straightforward and easy to handle on your own, a characterization that some women say glosses over what can be a more complicated reality of ending a pregnancy alone in your bathroom.
“I wish I would have known that it wasn’t just blood clots…. I was really confused and shocked,” said Briana, a 34-year-old in Alabama who took pills she ordered online when she was at least five weeks beyond the FDA’s 10-week limit. Like other women interviewed for this article, Briana spoke on the condition that her last name not be used so she could discuss sensitive medical information in a state that outlaws abortion—describing her experience in graphic detail because she said she wanted other women to know what to expect.
AIN OKLAHOMA, ANGEL ordered her pills from Aid Access and took them five to six weeks into her pregnancy. She’d told doctors at the online clinic about her heart medication when she filled out its online form, she said, but no one ever reached out about it—a silence easily explained, Prine said, because Angel’s medication is not one that would raise concerns.
Angel had no way of knowing that. Sitting on the toilet, she could hear her heart pounding in her ears. She placed two fingers on the side of her neck to take her pulse and started a timer, she recalled—counting about 190 beats per minute.
With her heart condition, she said, she was supposed to seek medical attention if her heart rate got that high. Angel had no idea who to call. She vaguely remembered a hotline number in the Aid Access instructions, but figured the line would be closed that time of night. The hospital didn’t feel like an option, either: She worried about the questions she might get from suspicious doctors if she showed up at the emergency room.
She closed her eyes and tried to steady her breath, determined to keep her heart rate down. Then she spoke to herself as she imagined a doctor might. “You will be OK,” said Angel, who would wake up the next morning no longer pregnant, the worst moments of her abortion behind her. “This pain can’t last forever.”
SEMIRETIRED FAMILY medicine physician, Prine co-founded the Miscarriage and Abortion Hotline in 2019 as a resource for people selfmanaging miscarriages or abortions at home. Calls to the hotline surged after Texas enacted an early law banning most abortions in the fall of 2021, Prine said, and again after new abortion bans took effect across the South and Midwest when Roe fell. Now the line is staffed by over 50 U.S.-based medical providers who volunteer their time, a mix of doctors, midwives, nurse practitioners, and physician assistants with experience in abortion care.
By design, the hotline volunteers don’t ask
for the names, locations, or full medical histories of the people who call. The hotline typically receives roughly 30 calls and 50 texts from people every day. Many say they are in states that ban abortion. For those who choose to self-manage their abortions, Prine said, she is there to offer reassurance that their experiences are nothing out of the ordinary, and that they almost certainly don’t need to go to the emergency room. A medication abortion is just like a miscarriage, she’ll tell them, with hundreds of women going through the same process every day.
Of the approximately 5.9 million patients in the United States who took mifepristone— the first drug in a two-step medication abortion regimen—between its 2000 approval and December 2022, just 32 died, according to the FDA. Those cases, the agency says, “cannot with certainty be causally attributed to mifepristone.” Major adverse events—in which a blood transfusion, major surgery, or overnight hospital stay is required—occur in fewer than 0.5 percent of cases, a figure that remains the same whether or not a patient has met with a doctor in person. On the hotline, Prine said she’s felt the need to send someone to the emergency room only once in nearly five years.
AT HER HOME in Alabama, Briana waited to take the pills until she’d put all of her children to sleep.
The cramps in her lower back came first, followed by full-body chills and, eventually, contractions more painful than those she remembered from childbirth. After lying in bed for two hours, Briana felt something “pop” under the comforter, followed by a gush of warm liquid seeping down her legs. She ran to the bathroom, she recalled in interviews and a journal entry, where she felt a mass larger than her palm drop into the toilet.
“This can’t be happening,” she thought to herself. Then she looked down to see a bloody umbilical cord dangling between her legs.
When the pills first arrived in the mail a few days earlier, in April 2023, Briana had expected her experience would be more difficult than most. The doctors who administered the medication through Aid Access cautioned Briana that they “do not like to recommend medical abortions” as far into pregnancy as she would be when the pills reached her.
Briana felt she had no choice. By the time she found out she was pregnant, she was already 11 or 12 weeks along. The abortion clinic she’d called in a different state, more than a six-hour drive from her home in Alabama, where abortion is banned, was booked for surgical procedures for over a month, busy treating patients from other anti-abortion states across the South. She spent nearly two weeks researching her other options, then the pills she ordered took two weeks to arrive.
The 34-year-old was struggling to support the kids she already had. “I didn’t want to take any more away from them...time, attention, money,” said Briana, who estimates that she was 15 or 16 weeks along when she took the pills.
According to data compiled by Aid Access, 1 in 20 patients who responded to the organization’s survey in January took the pills beyond 11 weeks of pregnancy. One in 100 took the pills beyond 13 weeks. (About 20 percent of people who took the pills responded to the survey.) Still, Prine said, she has fielded far more of these calls from women later in pregnancy than she would like—averaging one a day on the hotline in the months after the Supreme Court decision. Some of the callers had no idea how far along they were until they passed the pregnancy, she said. Others knew, but chose to go ahead anyway.
Beyond 12 or 13 weeks, women will see a much more developed fetus, with identifiable features. “We hear the trauma when we talk to people,” Prine said. “It’s an image you can’t get out of your head.”
Alone in her bathroom, Briana had no idea what to do. The Aid Access doctors had told her to expect nausea, vomiting, chills, blood clots, and a fetus at least the size of an orange, emails show. They said nothing about an umbilical cord. “Do I pull the cord out?” Briana wondered, frantically trying to remember what the doctors had done when she gave birth. “Do I just wait to try to push it out?”
Her boyfriend was sleeping in the next room. Even if she woke him up, she wondered, what could he do? If she went to the emergency room, she said, she felt sure she’d be prosecuted. Finally, Briana decided to call the number for the Miscarriage and Abortion Hotline she’d seen in an email from Aid Access. “That’s the placenta you need to push out,” Briana recalled the woman on the hotline saying. “When you feel the next contraction, I want you to push like you’re giving birth.”
Briana said she sat there with her umbilical cord hanging loose for at least 15 minutes before the placenta finally dropped into the toilet.
As difficult as the situation was, Briana says she is extremely grateful that Aid Access was willing to send her the pills—and that someone on the hotline was available to talk her through taking them. “Without the hotline I would have been completely lost and literally completely alone,” she said. “The lady...stayed talking to me for hours,” Briana added. “I wish I knew her name.”
Briana stayed in the bathroom that night for more than an hour. She knew she shouldn’t look at the fetus, she said, but she couldn’t help it. In the toilet bowl, she could make out a head. She remembered thinking that the legs looked long.
“I felt like a monster,” she said, reflecting back on that moment. A year later, Briana said, she is certain she made the right decision for herself and her family. But she wishes someone had told her more about what to expect. If she had known the full extent of what could happen during a medication abortion at 15 or 16 weeks, she said, she probably would have searched harder for an out-of-state clinic with available appointments—and figured out a way to drive six hours or more to Florida, Illinois, or North Carolina.
Before Roe v. Wade was overturned, Briana could have gone to a clinic less than 30 minutes from her house.
A version of this story was first published in The Washington Post. Used with permission.