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2021 marked the worst year for abortion rights in nearly half a century, as state legislatures set a record of enacting 108 restrictions on ending a pregnancy. This year, on June 24, the Supreme Court struck down the landmark Roe v. Wade decision and upheld Mississippi’s ban on abortions after 15 weeks of pregnancy.

Without Roe v. Wade, 26 states are certain or likely to enact laws that ban abortion. For people who live in these states, medication abortion—also known as the abortion pill—will become the most accessible way to end a pregnancy, as it can be self-managed and conducted from home. 

Approved by the FDA in 2000, the abortion pill has grown in use over the last two decades and now accounts for the majority of all U.S. abortions, according to the Guttmacher Institute. As restrictions on abortion increase, the pill is expected to become an even more critical option for people who need privacy and abortion access.

How the abortion pill works

Medication abortion consists of two medications: mifepristone and misoprostol. These two pills work together to end an early pregnancy. First, mifepristone blocks the body’s progesterone—the hormone required for a pregnancy to grow. Then, misoprostol triggers cramping and bleeding to empty the uterus.

Research has consistently shown that the abortion pill is safe and effective. The FDA approved the two-drug method for pregnancies up to 10 weeks. The World Health Organization says medication abortions can be safely performed at home up to 12 weeks. Depending on how far along someone is in their pregnancy, the abortion pill works about 87 to 99 percent of the time. The risk of major complications, such as hemorrhage or infection, is less than 1 percent.

“Taking abortion pills is extremely safe,” said Hayley McMahon, a public health researcher and doctoral student at Emory University specializing in abortion. “As long as folks are able to access information about how to use the medication, it doesn’t matter where you swallow the pills. Taking it at home is just as safe as taking it in the clinic.”

How to access abortion pills

Abortion pills can be accessed in-person through physicians, including those at Planned Parenthood health centers. Patients can also receive the pills by mail, as the FDA recently dropped the requirement for people to obtain pills in-person from specially certified health providers. This means that people should now be able to book a telehealth appointment, consult with a medical provider by phone or computer, and have the pills mailed to their home.

But many states have enacted laws that restrict access to medication abortion. Thirty-two states require clinicians who administer medication abortion to be licensed physicians, while 19 states prohibit the use of telehealth to prescribe the abortion pill. Texas and Indiana have laws that ban the provision of medication abortion after seven and 10 weeks of pregnancy, respectively. But even with existing and potential future restrictions, access to abortion pills is still possible—it will just involve a few extra steps.

Plan C is an organization that provides a state-by-state guide on how to access abortion pills safely online. It tracks whether a state restricts access to telehealth abortion and offers resources accordingly. For people who live in states that restrict access to telehealth abortion, there are three main options:

  1. Aid Access ($105). This doctor-supported nonprofit provides abortion pills by mail and offers telehealth services for self-managed abortions. It works around a state’s legal restrictions by prescribing the medication through a licensed doctor in Amsterdam and shipping it from a reputable pharmacy in India. However, it takes about two to three weeks for the medication to arrive.
  1. Online pharmacies ($250 to $400). These are commercial services that can be good options if Aid Access’s two-to-three-week delivery period is too long. Most online pharmacies can deliver in less than a week. However, they do not offer clinician support and typically require a non-credit-card form of payment, such as PayPal or Western Union. Elisa Wells, co-founder and co-director of Plan C, notes that it “does appear to be a little bit shady,” but Plan C conducts regular testing of the sites it recommends (though it cannot guarantee that they will be reliable in the future).
  1. Mail forwarding (additional $40). People can conveniently access abortion pills by setting up a virtual mailbox in a state that allows telemedicine. Through this process, patients can access telehealth services in a state where it is legal, have the medication sent to the virtual mailbox they set up in that state, and then request for it to be forwarded to their home address. This can also work with a friend’s address in a state where telehealth services are legal.

Wells adds that buying abortion pills in advance is another option, especially for people who are worried about the outcome of Roe v. Wade and how it will affect access in their state. Aid Access and Forward Midwifery both offer advanced provision. For more details on any of the options above, use Plan C’s guide to abortion pills.

How to minimize legal risks

Research suggests that about one in 14 women will self-manage an abortion in their lifetime in the U.S. As restrictions increase, this method of ending a pregnancy will likely become even more widespread. The online resources that provide abortion pills by mail are crucial to maintaining privacy and convenience in a stricter environment, but it’s important to note that there are still legal risks involved.

“The biggest risk is a legal risk because we know medication abortion is safe and effective,” said Elizabeth Nash, state policy expert at the Guttmacher Institute. “Someone could put themselves in legal jeopardy if they’re in a state where abortion is banned. The issue is what does the law say around abortion and what other criminal statutes could be used.”

Abortion laws generally target the abortion provider rather than the pregnant person. But many states have other laws in place that could be used to criminalize pregnant people who self-manage their abortions. This includes statutes like practicing medicine without a license, the fetal homicide law, and the child neglect law, which have already been used to arrest and convict people even with Roe v. Wade still in effect, Nash said. 

McMahon also notes that legal risk may be of particular concern for people of color, who have a “long, deep history of being targeted and surveilled by the police and being targeted for criminalization and imprisonment.” 

But just as there is a patchwork of options for abortion access, there are also free and confidential resources for legal guidance and support: 

  • If/When/How’s Repro Legal Helpline offers legal advice about self-managed abortion. The nonprofit also has a Repro Legal Defense Fund that covers bail and provides legal representation for those who get in trouble for self-managed abortion.
  • Miscarriage and Abortion Hotline has clinicians on staff most hours of the day to offer expert advice on self-managing miscarriages or abortions through text or phone call. This is a great resource for people who want to access medical support during their self-managed abortion but are nervous about the legal risk of going to a medical facility to seek help.
  • Digital Defense Fund offers tips on how to avoid leaving a digital footprint when it comes to accessing abortion. Digital footprints can be used as evidence to prove that someone conducted a self-managed abortion.