Abortions After Roe v. Wade Wouldn't Be Just Like the Bad Old Days

(Bloomberg Opinion) -- Experts disagree on the likelihood that the Supreme Court will overturn Roe v. Wade, the legal case that established a right to abortion in the U.S. But they agree that even if that remains federal law, state-by-state regulations could continue to prevent women from receiving an abortion in a clinic or doctor’s office. That won’t end abortions, of course.

Some women will undergo illegal and dangerous procedures outside the legitimate medical system, as was once common in the U.S. But now many women will have an additional option: abortion pills.

Pills have become the predominant form of illegal abortion in Latin America, and they seem likely to become more common in the U.S. as abortion access is restricted further. Already, networks are forming around the world through which women guide other women in the use of the medications, which can be obtained through mail order and are often taken without a doctor’s supervision. But medication abortion will be no substitute for legal access to abortion providers.

Pills are the safest way to end a pregnancy without medical assistance, but the medications sometimes fail, in which case women need to get help from a doctor.

What’s often called an “abortion pill” is really two medications: mifepristone, which blocks the hormone progesterone and allows an embryo to detach, followed a day or two later by a dose of misoprostol, which helps induce bleeding to flush out the embryo. The regimen was invented in France, where it became legal back in 1988. Other European countries approved it soon afterward.

Medication abortions, which some also call medical abortions, weren’t made legal in the U.S. until 2000, and the FDA requires that they be done only under medical supervision. Early on, it looked like the abortion pills would normalize abortion, allowing women to end a pregnancy by going to a primary care physician and taking a combination of pills that would induce a period, said Carole Joffe, a sociology professor at the University of California, San Francisco, and author of the 2011 book “Dispatches From the Abortion Wars.”

It didn’t quite work out that way. Doctors who tried to provide the pills were targeted by anti-abortion activists, she said. The war on abortion simply extended to include the pills. And in some ways, the pills are more complicated than a surgical abortion, requiring the two different drugs, taken at an interval, with a risk of heavy bleeding and nausea.

By contrast, the “surgical” procedure, what she prefers to call an aspiration abortion because it’s not really surgery, is relatively simple, taking about 10 minutes. And some doctors, such as Warren Hern, consider it safer. Hern performs abortions in Colorado, and has written about his experience for the medical website STAT News. “The need for surgical abortions cannot be replaced by any form of medical abortion. Medical abortion may be effective for women in most instances in very early pregnancy, but this always needs to have a surgical backup in case the medical abortion fails or is complicated (this happens a lot),” he told me in an email. If providers like Hern are shut down, who will help these women?

In March, the National Academies of Sciences, Engineering and Medicine came out with a report on the safety of both forms of abortion, and found no evidence for long-term complications either way. The report concluded that at this point, restrictions on abortion are not protecting women’s health, but threatening it, by making access to a safe abortion increasingly difficult. In some states, abortion clinics are few and far between. Some require two visits with a waiting period of up to 72 hours before a woman can get the procedure — a hardship for anyone driving a long distance and unable to afford the time and money to stay nearby in a hotel.

Many people in other countries are already using medication abortions to avoid bans. But as Joffe points out in The Washington Post, if the authorities want to crack down on self-administered medication abortions, they can. That’s been the case in El Salvador, according to a New York Times piece by law professor Michelle Oberman, author of “Her Body, Our Laws: On the Front Lines of the Abortion War, From El Salvador to Oklahoma.”

There, women have been able to obtain part of the abortion pill regimen: the misoprostol, which she wrote works even on its own in most cases if taken in early pregnancy. Though most anti-abortion activists have targeted doctors, they turned on women when laws forced doctors out of the equation. “Government officials there have toured the country’s hospitals to inform doctors of their duty to report women suspected of having induced their miscarriages,” she wrote. Because it’s impossible to distinguish a natural miscarriage from the complications of using misoprostol, authorities in El Salvador tended to single out poor women, assuming they were more likely to try to end a pregnancy.

If medication abortions represent an advance for women’s reproductive freedom, the abortion foes made a more consequential advance around the same time: They invented the concept of right-to-life. The idea of protecting an embryo or fetus was new in the 1980s, said New York University historian Linda Gordon, author of “Woman’s Body, Woman’s Right: Birth Control in America.” Before Roe v. Wade in 1973, abortion had been banned since the mid 19th century, she said, and the premise was simply that abortion interfered with women’s duty to procreate. The same ban also encompassed diaphragms, which were being used for birth control in other countries.

The notion that women have a duty to bear children has grown as antiquated as bustles and hoop skirts — but equating an embryo to a baby can still garner support in the 21st century. In the eyes of the pro-life movement, the abortion pill is in the same category as any surgical abortion, because the outcome is to end the pregnancy.

As divisive as the issue has become, the majority of Americans support the legal right to an abortion — as they have for many decades. Most Americans, then, would surely applaud the fact, noted in the National Academy report, that abortion rates are now about half what they were in the 1980s. The authors of the report attributed this in part to other technological advances — simpler and more reliable contraceptives, and emergency contraception, as well as policies that make contraception cheaper. But the Trump administration has started to roll back those contraception policies, so abortion rates may start to climb again. That’s not a win for supporters of abortion rights or for opponents.

To contact the editor responsible for this story: Philip Gray at philipgray@bloomberg.net

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

Faye Flam is a Bloomberg Opinion columnist. She has written for the Economist, the New York Times, the Washington Post, Psychology Today, Science and other publications. She has a degree in geophysics from the California Institute of Technology.

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