Now that Roe v. Wade has fallen and abortion bans have begun to spread across the Midwest and the South, we need to strengthen our resistance to the right-wing minority that clings to power in the U.S. and diversify our tactics. Central to that resistance must be a commitment to solidarity with those who face escalating marginalization, criminalization, and threats to bodily autonomy. Feminists and people facing unwanted pregnancies in the U.S. can learn from a decades-old transnational movement for self-managed medication abortion (SMA) that demonstrates daily that a safe abortion does not require a doctor or a clinic.
In the 1980s, women in Brazil began to share information about the use of an ulcer medication, Cytotec (Misoprostol), which causes uterine contractions in pregnant women, and gradually the maternal mortality rate from botched abortions began to fall. The Brazilian government shut down access to Cytotec, but use of medication for abortions both inside and outside the medical system has grown globally.
In the 2000s, an organized movement for SMA began to emerge, spreading rapidly through transnational feminist networks. In 1999, Women on Waves launched a boat from the Netherlands to bring abortion services to international waters near countries where abortion was illegal; a few years later, they launched Women on Web the first abortion telemedicine platform. In 2008, a group of young feminists in Ecuador created the first autonomous abortion hotline, Salud Mujeres, to give women information on how to use medication safely and effectively for an abortion. The Ecuadorian hotline is still running, and hotlines — as well as other activist strategies — quickly spread across Latin America, the Caribbean, Africa, and parts of Asia. Feminists across the Global South have developed solidarity-based direct action strategies to support people with abortions in places where it is highly restricted or outright banned, and have managed the potential legal risks involved. In the process, they have changed global maternal mortality statistics. The U.S. is a latecomer to this movement, but activists here are mobilizing both on and off-line across the country to support women and pregnant people seeking abortions — including in the most conservative states with total abortion bans.
SMA can be done with a combination of two drugs, Mifepristone and Misoprostol, or with Misoprostol alone when Mifepristone is unavailable. Mifepristone is a medication developed and used exclusively for abortion, and pre-Covid it was subject to significant restrictions on prescribing and access in the United States, although recently those restrictions were lifted by the FDA. Misoprostol has multiple uses, from treating ulcers to inducing uterine contractions to preventing postpartum hemorrhage, and is more accessible around the world because it is not just used for abortion. If Misoprostol is taken orally or buccally (under the tongue) then it cannot be detected by the time uterine contractions begin, erasing the difference between abortion and spontaneous miscarriage and making it harder to criminalize people seeking medical care. Research clearly demonstrates that SMA, with both drugs or with Misoprostol alone, can be safe and effective without medical supervision. The most recent World Health Organization guidance (from 2022) says SMA can be carried out during the first trimester, before 12 weeks; accompaniment activists safely support SMA through most of the second trimester, to at least 22 weeks.
Activists have developed three primary strategies for sharing information and support for SMA. A feminist telemedicine organization will train activists in protocols for the use of Mifepristone and Misoprostol and for Misoprostol alone; describe how the protocols for each vary depending on the length of the pregnancy; and detail indicators that someone should not use medication or that they should seek medical attention during an abortion. After receiving training, activists are able to share the information with others through an organized strategy like a hotline or accompaniment collective, as well as with friends, and can consult with more experienced activists when questions come up.
The abortion hotline is the most basic and probably the most widely used way to provide information about SMA: There’s a telephone number that people can call to talk with someone about their situation and get information about SMA. The hotline phone is usually shared among a group of activists so that each person is only responsible for a few days or a week at a time, and the group can support one another and problem-solve together. Hotlines typically also have websites that provide information (partial list here), and in Latin America and sub-Saharan Africa there are websites for regional networks.
Accompaniment, or acompañamiento in Spanish, involves ongoing communication to accompany a pregnant person through the abortion process, from an initial conversation through sharing information about SMA to being with the person as they take pills and have the abortion, usually with some follow up to see how they are doing afterwards. The process often begins with a face-to-face meeting or a workshop with several people in a similar situation, and then the actual accompaniment may be done by text message or phone calls between two workshop participants or between an activist and someone who wants to abort. This form of activism is most common in Latin America, where many countries have active acompañamiento collectives (e.g. Argentina), but ongoing support and communication can be part of hotlines and telemedicine as well. One of the first accompaniment groups, Las Libres in Mexico, has begun to accompany women across the border in the U.S. via cellphone.
Websites provide access to a wide range of information and resources. Hotlines and accompaniment collectives have websites that provide contact information and step by step instructions on the use of medication (in Spanish, in a video, or in an online zine in English), some also provide manuals on SMA and women’s experiences with abortion (in Spanish, in Haitian Creole, and in English).
There are telemedicine websites that will provide an online consultation and send medication by mail, usually with reduced prices for those who need it. Some sites are oriented internationally, like Women Help Women or Women on Web, and others directed primarily at the U.S., such as AidAccess. The emerging movement for SMA in the U.S. is primarily oriented around websites, and Plan C offers a good information clearinghouse with links. I Need an A can help someone find an abortion provider, even in the new post-Roe world. There is also a U.S. legal support website, If/When/How, and information about digital security from the Digital Defense Fund (please keep yourself and others safe!).
For those wondering if this is really legal: Telemedicine is regular medical care, full stop. Activists throughout the world do the work described here — and are highly visible on the internet — based on the right to information. It is also legal to share information about SMA in the U.S., and organizations like ReproAction have done so for years. It is, however, important not to give advice or tell someone what they should do (that could be practicing medicine without a license).
People have been prosecuted in the U.S. and around the world for buying abortion pills, and for engaging in SMA; sharing information about abortion is legal, but obtaining pills without a prescription may violate drug laws, and self-managing your own abortion may be illegal in some places (If/When/How can answer questions about specifics).
We have no idea how many self-managed abortions have happened in the U.S., in part because it is impossible to know if someone has taken these medications unless they tell you.
As we experience profound changes to the landscape of reproductive (in)justice in the U.S., we must throw out the fears of the pre-Roe back alley and replace it with the defiant autonomy of SMA. We can join feminists in Ireland, Argentina, Colombia, Mexico, and other countries who demonstrate every day that solidarity, and pills, are vital elements in the struggle for reproductive justice. The state will not protect our autonomy or our lives, but we can take direct action to care for each other and build a world in which self-determination is not criminalized. In the words of ReproAction, “abortion is unstoppable!”
Naomi Braine is a professor of sociology at Brooklyn College, CUNY. Prior to joining the faculty at Brooklyn, she worked in the nonprofit research sector on issues of drug use and HIV and consulted for community-based organizations and the New York State Department of Health. Her political and intellectual work addresses gender, sexuality, reproductive justice, wars on drugs and terror, and health and collective action, from an intersectional perspective. Her current book, forthcoming from Verso, focuses on self-managed medication abortion as a social movement.
A version of this article appeared in the e-book We Organize to Change Everything: Fighting for Abortion Access and Reproductive Justice, published by Lux and Verso. Download it here for free.