Following a positive pregnancy test, an 18-year-old from Washington state, USA, took ibuprofen and caffeine pills, antibiotics, and alcohol and then bled for three weeks. One woman, also 18, drank vodka for over three hours. Another took regular ibuprofen and antibiotics over a week, before having a clinical abortion. A 15-year-old girl took three contraceptive pills at once. A few hours later she vomited a few times and passed the pregnancy.

All of these accounts are from a 2021 paper in which researchers carried out in-depth interviews with 14 women who had attempted to self-manage an abortion at some point in their lives. “It was dumb, it was an ill-informed decision. I wish that I had been better informed. I wish that I’d asked for help from other sources as well,” the 15-year-old told them.

These interviews were carried out before the overturning of Roe v Wade, the landmark US Supreme Court decision that had legalised abortion nationwide, in June 2022. Since then, 14 US states have enacted near-total abortion bans. At the end of July, Iowa became the fourth state to ban the procedure past six weeks of pregnancy, before many people even know they are pregnant; 22 states now restrict abortion to a greater extent than the situation under Roe v Wade.

Now, new research demonstrates just how important it is to continue to fight for reproductive rights everywhere. In the wake of the fall of Roe v Wade, more people are attempting to carry out abortions themselves. Researchers surveyed 7016 people in 2021-2022 and 7148 in 2023, and found that roughly 7% of reproductive-aged women in the US have attempted to induce their own abortion, up from 5% before the fall of Roe.

Self-managed abortions are safe and effective under the right conditions. But the research found that  a majority of people surveyed tried to end their pregnancies using potentially unsafe methods. In 2023, about 25% of those who attempted to self-manage their abortions used herbs; 22% hit themselves in the stomach; 19% used alcohol or other drugs. Of these, 15% – one in seven – experienced a complication requiring medical treatment. Only 11% said they had taken mifepristone, one of the drugs typically used in a World Health Organization-approved two-pill protocol, and 16% said they had used misoprostol, the other pill, on its own.

Around the world, where abortion access and rights vary widely, 61% of unwanted pregnancies – and 29% of all pregnancies – end in abortion. That’s about 73 million abortions a year. Global estimates indicate that 45% of these are unsafe.

Here’s The Evidence

I spoke to two experts – Dr. Bela Ganatra, head of the WHO’s Prevention of Unsafe Abortion Unit; and Dr. Andrés Constantin, a legal advisor at the Center for Reproductive Rights in the US, to find out more.

“These findings are far from surprising,” Constantin says. “By now we all know and agree that abortion bans do not get rid of the need for abortion.”

Ganatra agrees: “The number of abortions doesn’t depend on how restrictive the legal framework is. What changes as you put restrictions in place is the ability of women to have safe abortions.”

Nor are they surprised by the study’s finding that people from marginalised groups were more likely to report having attempted to end their own pregnancies. “Abortion is already a stigmatised area,” Ganatra says. “When you add the stigma and issues related to race and ethnicity, gender orientation, being young or being poor on top of that, it multiplies the effect.”

Both experts emphasised that in the first trimester of pregnancy, people can safely manage their own abortions using the abortion drugs mifepristone or misoprostol and do not need to resort to the unsafe methods cited in the study. The World Health Organization offers advice on how to do so, even in places where abortion is banned or restricted. Services such as Women on Web provide abortion medication by mail around the world, allowing people to manage their abortions safely at home.

“It’s really important that we support people towards safe self-managed abortion,” Constantin says.

Yet even in countries that have liberal abortion policies, there are often multiple barriers in place that impede people from having a safe abortion, self-managed or otherwise. So what kind of abortion policy would we see in an ideal world? And is this a world that we’re heading towards, or are contexts like the US and Poland indications that recent progress in reproductive rights is under severe threat?

‘There is no utopia’

“The reversal of Roe v Wade certainly strengthened anti-abortion movements globally,” Constantin says. “But there are lots of reasons for optimism. There is a very clear trend towards abortion liberalisation globally.”

Since the 1990s, 60 countries have liberalised abortion laws, and only four have restricted them: the USA, El Salavador, Nicaragua and Poland. In the past five years, the marea verde, or Green Wave, feminist movement in Latin America has seen abortion access increase in Argentina, Colombia and Mexico.

The trend is encouraging but, Constantin says, “we do need to be vigilant, and remain alert to new forms of oppression.” In Argentina, for example, there have been significant attempts to repeal the 2020 legalisation under the far-right government of Javier Milei.

“There is no utopia out there,” Ganatra says. “There is absolutely no country that has laws and policies in perfect alignment with WHO recommendations. Every country has some areas in which it can make access more easy.”

The gold standard, in Constantin’s view, is to prioritise the decriminalisation of abortion. I was shocked to learn that only one country in the world has fully done so – Canada, in 1988. Several high profile cases around the world – such as in the UK, where a woman who terminated a pregnancy after the legal time limit during lockdown was jailed, and then released on appeal after public outcry – have recently highlighted the horrors of keeping criminal penalties for some forms of abortion while liberalising the law in other cases. “If a law exists, it can be used,” says Ganatra. There are worries, for example, that if Donald Trump wins the 2024 US election, he might enforce the Comstock Act: a 151-year-old law that could theoretically be used to ban the shipping of abortion pills.

There are so many ways that countries can work to improve access and prevent unsafe abortion. Some, including Argentina, Pakistan and Japan, have made changes to the approved medication list to make WHO-approved drugs more accessible. Other countries have made progress by recognising that abortion provision does not need to be restricted to facility-based doctors. In France, as well as enshrining reproductive rights in the constitution, midwives have recently been given the power to perform surgical abortions.

“Midwives, nurses, GPs are all capable of providing abortions,” Ganatra says. ”Expanding services to such practitioners is extremely important in expanding access but most importantly, doing so equitably.”

Trust women

In contexts where making legal or policy changes is difficult for political or other reasons, powerful changes can still be made. Ganatra raises the example of Bangladesh, where “menstrual regulation services” allow healthcare practitioners to provide medical and aspiration abortions under the guise of « regulating the menstrual cycle“.

Since COVID, telemedicine has emerged as a vital tool by removing some of the barriers people face in accessing abortion. Some of these barriers are practical – going to an abortion clinic requires time and money. Others are less tangible. In the recent US study, most people said they had attempted to self-manage an abortion because they wanted privacy. Fear about facing stigma, judgement, or anti-abortion protestors at an abortion clinic were often mentioned.

All of this emphasises the need for policies that support and enable self-managed abortion. Safe self-management of abortion requires knowing that it is possible, knowing who or where to go for support or for medication, and knowing one’s rights. Often, lack of access to such knowledge is the first and most important stumbling block.

“I wish sex ed in high school and resources in the community had been better advertised … better quality,” the 15-year-old interviewed for the 2021 paper said.

Communicating the evidence doesn’t only help people who need it – it can also help to direct polarised debates in a positive direction. “There’s a whole spectrum of people out there who either don’t have the complete information, who maybe have some preconceptions, but who are willing to engage, are willing to learn more, and are willing to potentially change their opinions,” Ganatra says.

“The most important thing,” she finishes, “is to trust women. To support their choices, rather than sit in judgement.”

Research Round-up

Here’s what else is making the news:

1. 🩺 A previous edition of The Evidence covered reasons why women doctors may see better results than men. Now, a new study highlights how doctors routinely minimise women’s pain.
2. 📱Watching under ten minutes of “pro-anorexia” TikTok content can negatively impact a woman’s body image, a US study has found.
3. 🌎 Meanwhile, a comparative study indicates that white, Western women tend to be less confident about their bodies and face greater media pressure to look thin, compared to black Nigerian and Chinese women.

About The Evidence

The Evidence is a supplement to the Impact newsletter designed to help you understand gender inequality – and show how we might fix it. Impact is a weekly newsletter of feminist journalism, dedicated to the rights of women and gender-diverse people worldwide.

This is the English version of our newsletter; you can read the French one here.