This is the future of abortion in a post-Roe America 

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Activists hold signs, some reading “I am the pro-life generation,” and one reading “Keep aborton legal,” outside the US Supreme Court.

Anti-abortion and abortion rights activists during the March for Life on January 19, 2018, in Washington, DC. | Alex Wong/Getty Images

The fall of Roe v. Wade won’t end abortion. Here’s what it will do.

If Roe v. Wade falls, what happens to abortion in America?

That’s the question on a lot of Americans’ minds after the death of Justice Ruth Bader Ginsburg, with the Supreme Court on the brink of a 6-3 conservative majority. If the Senate confirms President Trump’s nominee, Amy Coney Barrett, the Court will likely have the votes to overturn the landmark 1973 decision that established Americans’ right to terminate a pregnancy.

Some have predicted a Handmaid’s Tale-esque future in which women are forced to bear children. Meanwhile, anti-abortion groups have begun quietly preparing for a baby boom once all Americans are forced to carry their pregnancies to term.

But the reality is that overturning Roe won’t end abortion in America. What it will end, across much of America, is legal abortion.

That will have devastating consequences for many people, especially low-income Americans and people of color in red states where the fall of Roe would likely shut down the few remaining clinics. “This is already an abortion desert,” Laurie Bertram Roberts, the executive director of the Mississippi Reproductive Freedom Fund, told Vox. If Roe falls, “you’re just talking about an abortion wasteland.”

But that doesn’t mean people who want to end a pregnancy would be completely without options. Abortion funds around the country would continue their work, in some cases helping patients travel to blue states to get the procedure. Community-based providers, who perform abortions outside the official medical system, would likely continue to operate. And self-managed abortion, in which people perform their own abortions with pills, would take a bigger role.

Preparing for that reality will require a lot from advocates and providers, from raising money to campaigning against laws that can send people to jail for self-managing an abortion. But people have been ending their pregnancies in America since long before Roe v. Wade or even abortion clinics existed, and a court decision isn’t going to stop them. It’s just going to change what their options — and the risks involved — look like.

Abortion law in America has a complicated history

To understand the future of abortion in America, it helps to understand the past. For generations, most reproductive health care in this country, from labor and delivery to abortion, was provided by midwives. As Michele Bratcher Goodwin, a law professor at UC Irvine and the author of the book Policing The Womb: Invisible Women and the Criminalization of Motherhood, put it,the origin story in the United States is that women controlled reproductive health care.”

Midwives were a racially diverse group — before the abolition of slavery, half were Black, Goodwin said, a quarter were Indigenous, and another quarter were white. They generally cared for people in their homes, and there were no laws prohibiting them from performing abortions before “quickening,” or the time when a pregnant person can feel the fetus move (usually around 16 to 18 weeks). That began to change in the mid-19th century, when male doctors began an effort to supplant midwives and monopolize reproductive care.

Through the American Medical Association, founded in 1847, these doctors began to lobby for restrictions on abortion in part as a way of stopping midwives from doing the procedure. It worked. By the beginning of the 20th century, the percentage of reproductive care provided by midwives had plummeted, Goodwin said. And abortion bans proliferated around the country, with most states banning the procedure by 1880.

In the decades that followed, people who wanted an abortion had to find a doctor who would do the procedure illegally — an easier task for those who had money — or try to end the pregnancy themselves, using herbs, turpentine, or, yes, coat hangers. Such procedures could be dangerous, although the exact death toll is uncertain since deaths from illegal abortions often were not recorded as such. And abortion, though it remained illegal, became much safer in the mid-20th century with the widespread use of antibiotics. Underground provider networks like the Jane collective, founded in Chicago in 1969, also sprang up to help people get abortions, working with local doctors and even performing the procedure themselves.

Meanwhile, in the 1960s, states like California were beginning to liberalize their abortion laws. The Supreme Court was also laying the groundwork for constitutionally guaranteed reproductive rights in cases like Griswold v. Connecticut, a 1965 decision that struck down state restrictions on married couples’ use of birth control. And in 1973, the Court invalidated the remaining state abortion bans in one fell swoop, finding in Roe v. Wade that states could not impose an undue burden on Americans’ right to an abortion.

Ever since then, Roe has limited what states can do to restrict abortion. But they’ve still been able to do a lot within those limits. Especially after 2010, when Republicans took control of many state legislatures, states in the South and Midwest passed a flurry of laws restricting the operations of abortion clinics, such as by requiring providers to have admitting privileges at a local hospital. As a result, dozens of clinics in those regions shut down, leaving many states with just a handful of places — or only one — where patients can legally get an abortion. And laws requiring ultrasounds and waiting periods before a patient could get an abortion drove up the cost of the procedure and made it more time-consuming for patients. The Hyde Amendment, passed in 1978, also bars Medicaid from covering most abortions, meaning low-income Americans must often pay out of pocket even though they have the least ability to do so.

Today, many Americans have to travel hundreds of miles and pay hundreds or even thousands of dollars to get an abortion — if they can access one at all. And people in poverty, people of color, LGBTQ Americans, and undocumented immigrants all face disproportionately high barriers to ending a pregnancy. As Amanda Beatriz Williams, executive director of the Lilith Fund, an abortion fund in Texas, put it, “Roe is and has never been enough to protect our communities.”

Years of restrictions have forced advocates to adapt

Because of the ongoing march of restrictions in many states, abortion rights advocates have practice helping people access the procedure under difficult conditions. In Mississippi, for example, where only one abortion clinic remains, the Mississippi Reproductive Freedom Fund helps about a dozen people a week with money for an abortion procedure or travel to a clinic. For many others, the fund provides logistical support, helping patients find the nearest clinic or figure out how many pay periods they have left to save up for an abortion before they’re too far along. “We’re like abortion concierges, and also in a way like travel agents,” Roberts said.

Roberts isn’t sure exactly how many people the fund has helped over the years, but others have assisted hundreds — the New Orleans Abortion Fund, for example, has helped more than 1,500 patients get abortions since it was started in 2012.

Meanwhile, an increasing number of patients are choosing to manage their own abortions outside of the official medical system, often by taking the drug misoprostol. The drug, along with another medication, mifepristone, can also be prescribed by a doctor, and the regimen is approved by the Food and Drug Administration for use in abortions up to 10 weeks’ gestation. However, because of the difficulty of getting to a clinic to get the medications — whether because they have experienced discrimination in medical settings, or simply want privacy in ending their pregnancies — some people obtain the medication online or through a friend or other source, and take it on their own.

It’s difficult to estimate how many people go this route, since self-managed abortions happen outside official systems for tracking patients and procedures. But experts believe between 1 and 4 percent of abortions are self-managed, Farah Diaz-Tello, senior counsel at the reproductive justice legal group If/When/How, told Vox.

Despite these low numbers, there’s evidence that abortion restrictions could drive up interest in self-managed abortion — one recent study found that requests for abortion medication through an online service were higher in states with restrictive abortion laws.

Self-managed abortion can be a safe option for many people, experts say. In general, complications from medication abortion occur in less than 1 percent of cases. And while getting the medication online or elsewhere outside the medical system means the pills haven’t been through the FDA’s system for regulating medication content, one recent study by the reproductive research organization Gynuity of abortion pills ordered online found that most contained enough of the appropriate medication to be effective.

Ultimately, one of the biggest risks of self-managed abortion is not side effects from the medication, but criminal penalties for taking it. Five states — Delaware, South Carolina, Arizona, Idaho, and Oklahoma — have laws on the books that specifically ban the practice, and many others have laws against “feticide” or other crimes that can be used to prosecute people who self-manage. But If/When/How and other groups have been advocating for years to remove criminal penalties for self-managing, and they’ve had some successes — New York’s Reproductive Health Act, for example, passed in 2019, decriminalized self-managed abortion as part of a larger reform of the state’s abortion law.

Another part of the abortion landscape, in recent years as in decades past, has been community-based abortion providers who perform the procedure outside of a medical clinic. While some help people obtain and use abortion medication, others even perform surgical techniques like vacuum aspiration, as Nina Liss-Schultz reports at Mother Jones. And while their numbers are unknown due to the legal precarity of their work, one such provider told Mother Jones she knows as many as 75 people who provide at-home abortions or train others.

Providing abortions outside the medical system is even more legally risky than receiving them, since most abortion restrictions around the country target providers, not patients. But If/When/How and other groups have been advocating for their rights, as well as those of people who seek abortions. “It’s not enough for the law to simply not penalize people who end their own pregnancies,” Diaz-Tello said. “We have to make sure that communities aren’t destroyed by criminalization and that people aren’t removed from the community-based systems of care that help keep them safe.”

For many, a post-Roe future just means more of the work they’ve already been doing

While advocates and providers have mobilized in response to abortion restrictions in the past, the fall of Roe would require a new level of work.

Twenty-one states have laws on the books that could be used to criminalize abortion if the decision is overturned, according to the Guttmacher Institute. That includes 10 states, such as Louisiana and Mississippi, with “trigger bans” that are intended to prohibit abortion automatically if Roe falls. In those states, the reversal of Roe would likely have an immediate effect on clinics.

“It would almost be like if someone just one day came and snapped their fingers and all the legal abortion access went away,” Roberts said.

But that doesn’t mean abortion would end.

If/When/How, for example, will continue doing the same work it’s always done to decriminalize self-managed abortion. The group is “worried about the future of abortion rights jurisprudence, but for us, nothing changes,” Diaz-Tello said, “because, in many ways, Roe isn’t relevant to the question of whether people should avoid jail time for ending their own pregnancies.”

And the work that abortion funds and others have done in recent years could help prepare them for the end of Roe, many say. For example, the Covid-19 pandemic forced many funds to work even harder, since officials in states like Texas tried to suspend abortions, arguing that they were nonessential medical procedures.

“When Texas’s Governor Abbott exploited the Covid-19 pandemic to shut down abortion providers in Texas, we got a glimpse of a post-Roe state,” Williams, the Lilith Fund executive director, said. The group immediately “connected with abortion funds in other states facing similar crises, and we banded together to strategize, open lines of communication, share live-updates, and coordinate logistics.”

They’d do the same in the event of an end to Roe, Williams said: “we’d continue to strengthen our regional collaborations, and we’d continue to build out our infrastructure so that we can do whatever it takes to ensure people get the care they need.”

The hurdles ahead for many grassroots groups will be high. For one thing, advocates agree that self-managed abortion cannot and should not be patients’ only option — especially not while potential legal penalties remain in so many places. “SMA is not going to replace clinics,” Roberts said.

The collapse of Roe would likely mean a surge of patients from red states trying to get to blue states for care — perhaps something like what happened during the pandemic, when clinics in Colorado, New Mexico, and Nevada saw a 706 percent increase in patients coming from Texas. In a post-Roe future, though, it wouldn’t just be Texas — while it’s not yet clear how all state legislatures would respond, the states with trigger bans alone would create large “abortion wastelands,” as Roberts puts it. For example, patients across a region spanning Arkansas, Louisiana, Mississippi, Tennessee, and Kentucky could find themselves without a clinic in their state.

They might seek to travel to Illinois, where providers and advocates have already worked to expand care in preparation for future restrictions. But even if providers there and in other liberal states can absorb the influx, patients will need money to travel — a big obstacle when abortion funds in the places with the greatest need and fewest resources also often have the least cash on hand, Roberts said.

“I don’t know of any Southern fund, honestly, or any clinic that can really say we’re totally prepared for a post-Roe existence,” Roberts said. “None of us are funded enough.”

She explained they would need money, not just to fund patients in the months after Roe is overturned, but to fight for access in the years that follow: “We’re going to need money to organize to change state laws.”

Until and unless those laws are changed, the future of abortion without Roe could be, in some ways, a return to the past in which women performed the procedure at home or in their communities — but without the laissez-faire legal environment of the 17th and 18th centuries that allowed them to practice without fear. With the rise of self-managed abortion and community-based providers, abortion care is “being returned to women but under the specter of criminal punishment,” Goodwin said.

For many, the challenge now, and in any post-Roe future, is how to remove that specter — and how to make sure the many people who still want to have abortions in clinics are able to do so. It’s a difficult battle, but one many say they’ve had a lot of practice fighting.

“Abortion funds are experts in adapting to the ever-changing landscape of abortion access,” Williams said. “We’ve been flexing those muscles for years. I believe we’re ready for whatever comes next.”


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