This story has been updated to reflect news developments.
On Tuesday, Alabama lawmakers approved a measure that effectively bans almost all abortions.
Last week, Georgia became the fifth state to ban abortion at six weeks after a last menstrual period, before many people even realize they are pregnant. Its ban goes further than the others, criminalizing doctors and others who help induce abortions, as well as making those who are pregnant, potentially liable for murder if they prompt a pregnancy loss. They could be liable if they do it in another state.
This is where we are headed on abortion.
Now that two more conservatives have ascended to the Supreme Court, and the Senate has elevated dozens of new right-wing judges to the federal bench, Americans face an increasing likelihood that courts will uphold such de facto bans on abortion, and some states will effectively ban induced pregnancy loss for the first time since 1973.
A return to illegal abortion will not look like a return to the era or coat hangers. More likely, it'll make our system of abortion rights even more lopsided. Even now, while people with resources generally have access to safe, clinic-based abortions, vulnerable people – particularly those in conservative states – may experience forced pregnancy or risk prosecution for pregnancy loss that they may or may not have had a role in causing.
Forced pregnancies and prosecutions are not our only possible future, though. If Americans who believe abortion should be safe and accessible work together, we can significantly reduce the risks inherent in making abortion illegal. We must start by shifting our mind-set away from the perception that a self-managed abortion is a dangerous last resort, to a recognition that medication abortion is an empowering tool that allows us to privately control whether we carry a pregnancy to term.
I have spent years working in places where abortion is always, or almost always, illegal. What I've learned may be surprising. I've come to understand that self-induced abortion with misoprostol, often called miso, can be a safe, reliable way to end unwanted pregnancy in legally restricted settings.
Experts credit this drug as an important factor in reducing harm and death from unsafe abortions around the globe. Even women in incredibly difficult situations, like those who have fled civil wars in Myanmar, who are at grave risk of sexual violence or who face obstacles to formal medical care, are safe and effective using that medication to prompt miscarriages.
In Chile, which until last year banned abortion without exception, an all-volunteer safe abortion hotline coaches women on how to use the drug correctly. In El Salvador, similar networks facilitate the successful use of misoprostol, even among those who are illiterate and living on less than $ 5 a day. Researchers have documented that, with the help of trusted community networks, misoprostol's success rates for early abortion can exceed 90 percent.
This medicine is not perfect. It works less well alone than in the two-drug combination American clinic use. But it is on the World Health Organization's essential medicine list because, in the developing world, it helps to save the lives of women who might otherwise have bled to death after giving birth. But unlike the other medicine used in clinic-based abortions, it is a regular prescription drug, with many important indications, including ulcer prevention, miscarriage management, induction of labor and prevention and treatment or post-partum hemorrhage.
Yet the use of this drug can be illegal: A handful of states outlaw self-induced abortion, and other states have found ways to use existing laws to criminalize people who share misoprostol or use it to prompt a miscarriage.
There is little doubt that banning abortion in parts of the country will lead to more home-based abortions with medication. The only question is how much harm will result. We know which Americans are most at risk: those who are poor, young, geographically isolated and minorities. Instead of manning the impending loss or legal abortion while leaving marginalized people alone to take on the risks of self-managed pregnancy loss, those of us who are more privileged can organize to reduce the potential harms.
First, we can work to fully decriminalize self-induced abortions. This is an area where all Americans, including pro-life Americans, can work together. The pro-life movement has insisted for decades that women should not be prosecuted for self-abortion, although this position is shifting in the face of safe, cheap abortion medications.
Pro-life people who sincerely care about women and babies should insist that women not be punished for pregnancy losses. Health care providers must also continue to oppose prosecuting women, knowing that doing so will create barriers to seeking treatment and undermine the doctor-patient relationship. Prosecutions for pregnancy loss invariably target the poorest, most marginalized people in society, including those who suffer unintended miscarriages and stillbirths. Working together to decriminalize self-managed abortion will curb these risks.
We should also work on expanding access to misoprostol. It should remain a prescription drug, and no additional restrictions should be placed on its distribution. We might start by normalizing possession and use of the drug. Just as we keep EPI pens on hand for potential life threatening allergic reactions or emergency contraception for when a condom breaks, we should start seeing it as a prophylactic drug that deserves a place in our medicine cabinets. We should ask our clinicians for prescriptions before we need it.
Those with the means should buy and share misoprostol, so our most vulnerable community members don't have to rely on foreign websites to send them drugs, and so on .
In fact, those of us with social privilege should consider openly carrying or displaying medicine – something Irish activists did during Ireland's recent successful campaign to legalize abortion. Imagine if those old coat hanger pins warning against unsafe abortion were replaced by pins with pills on them to show that we have access to this medicine and can help others? Maybe "open carry" isn't only for guns?
And finally, we can strengthen existing abortion funds and referral networks so they can better support the small percentage of people for whom this type of medication does not work; they will need follow-up care and clinical abortions in progressive states. The National Network of Abortion Funds will be their lifeline.
I continue to support colleagues fighting to ensure that those who are pregnant can access safe, legal, affordable abortions. But it is clear to me that the future of abortion in the United States will most likely include formal or de facto abortion bans that will result in forced pregnancies, unsafe abortions and the prosecution of miscarriages. With access to misoprostol, we can insulate ourselves against disaster.