Commentary Abortion

Mail-Order Abortion: The Future Is Now

Elisa Wells & Francine Coeytaux

Women in dozens of countries around the world are already able to mail-order pills for early abortion care. So why not in the United States?

We recently asked a young woman a hypothetical question: If you were pregnant and decided you wanted an abortion, what would be your ideal way to get one? She quickly joked that she’d want to order abortion pills through her Amazon Prime account—free shipping and two-day delivery! Plus, she mused, she wouldn’t have to miss work or encounter protesters, and she could take the pills in the privacy of her own home.

Fat chance of that ever happening, right? Wrong.

What this young woman and most other people in the United States don’t realize is that women in dozens of countries around the world are already able to mail-order pills for early abortion (defined as within 70 days from the first day of last menstrual period). Services such as Women on Web, Women Help Women, and, more recently, safe2choose offer online consultations and express delivery of highly effective and safe early abortion pills directly to women in their homes, all without a physical exam. These sites also offer information and support to women about what to expect; safe2choose even includes a live chat feature.

Unfortunately, despite many requests, none of these services will ship pills to women in the United States. The reason for this has nothing to do with safety—the pills they provide are the very same highly effective and safe pills already available through abortion clinics (mifepristone plus misoprostol). Furthermore, abortion in the United States, unlike many of the countries to which these services ship, is legal. Rather, these services will not ship abortion pills to the United States due to politics and our virulent, powerful anti-choice lobby that could potentially shut them down in response.

It is politics, not medical science, that is behind the severe overregulation and overmedicalization of abortion pills in the United States. In 2000, when the Food and Drug Administration (FDA) approved mifepristone for early abortion, it bowed to political pressure from the U.S. anti-choice lobby and placed special restrictions on its distribution. As a result, in contrast to the vast majority of medications, which clinicians prescribe and patients pick up at a pharmacy, the only approved access is through registered abortion providers, who are becoming fewer and farther between throughout the United States. In addition to the FDA restrictions, some states are trying to further restrict access by passing regulations requiring that women swallow the pills in front of providers (giving the women no control over when the abortion occurs) or requiring women to come for multiple visits, adding to inconvenience and cost.

Given the dismantling of abortion services that has occurred in these states and the harassment women face at the clinics that remain open, it is not at all surprising that some women in this country are doing what women elsewhere have been doing for years: seeking out abortion pills and taking them in the privacy of their own homes.

The good news is that abortion pills are very effective, extremely safe, and easy to take. Even taking misoprostol alone is still highly effective for early abortion (85 percent completion rate when used alone as compared to 97 percent for the combined regimen). But the bad news is that due to all these political restrictions, the pills are difficult to obtain. In contrast to so many other countries, the only channels open to women in the United States seeking to take abortion pills on their own are informal—women obtain pills from friends, from other countries, or on the black market. Even worse news, in some states, women who use or purchase these pills on their own face the threat of arrest; women in Indiana, Pennsylvania, and Georgia have been arrested for doing so and have served or are still serving jail time.

So, can we move abortion access in the United States from its current status of excessive restriction based on politics to one of expanded access based on the demonstrated safety of self-use? Can we take advantage of modern technology—like online ordering and express delivery—and respond to women’s desires for convenience and privacy?

First, let’s fully demedicalize provision of abortion pills based on current evidence that supports the safety and ease of self-use of this technology. For instance, the World Health Organization has endorsed women’s self-use of abortion pills in circumstances where they have a source of accurate information and access to a health-care provider should they need or want it (for instance, if they had questions about bleeding or were concerned the abortion was not complete). Many abortion providers have made strides in simplifying the procedure, allowing women to take the pills at home and eliminating unnecessary tests (such as ultrasounds).

But what is needed is for the medical community to fully relinquish control of the method, thereby empowering women to manage their own care should they choose to do so. We are working to inform women about this option and identify individual providers who will champion women’s self-use of abortion pills and be willing to pilot approaches that put the pills more directly into women’s hands (examples are websites willing to mail pills after an online screening, providers willing to do phone assessment and mail pills, etc.).

International experience has shown this approach to be safe; research on Women on Web’s service found only a small percentage of women needed clinical follow-up for incomplete abortion after obtaining the pills by mail. Research has also demonstrated that women can accurately date their pregnancies, providing assurance that women will use the pills early in pregnancy when they are safest and likely to be most effective.

Second, let’s demand that the FDA change its restrictions regarding the distribution of mifepristone and allow these safe and effective pills to be stocked in pharmacies or even sold over-the-counter, just as they can be in many other countries. Misoprostol is stocked in pharmacies for other indications (like arthritis and peptic ulcers), but women still need prescriptions to obtain it. This change, along with eliminating state laws that restrict telemedicine and online prescription, would go a long way toward improving access, convenience, and privacy.

Finally, we must continue to challenge state laws that criminalize self-use of abortion pills. No woman should be punished for obtaining an abortion, whether secured from a clinician or done on her own in the privacy of her home. A coalition of legal organizations, calling themselves the Self-Induced Abortion Legal Team, has recently formed to ensure that women in the United States who choose to end their pregnancies without help from doctors can do so with dignity and without threat of arrest.

While the idea of mailorder abortion may seem a bit of a pipe dream, we predict it will become a reality in the United States. As women here begin to learn about this safe and effective option and its ready availability elsewhere, they will begin to ask “Why not us too? Why are women in the United States being prosecuted for using this safe technology while women around the world are able to order pills online and have them delivered to their homes?” All women need better access to this safe, effective, and private abortion method. It’s time for the United States to modernize its approach to abortion care, trust women, and make abortion pills more readily available. The future of mail-order abortion in the United States should be now!

CORRECTION: This piece has been updated to clarify the definition of “early abortion.”

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