Self-Managed Medication Abortion in Global Perspective: Increasing Access but Adding Legal Risks for Pregnant Women

Dean M. Harris, J.D. -  Associate Professor, Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, USA, Dean_Harris@unc.edu

 9 October 2019

          In many countries, the use of self-managed medication abortion is increasing, because of practical and legal barriers for access to abortion. Even in countries that allow abortion as a matter of law, it can be very difficult to obtain an abortion as a practical matter. One type of practical barrier is that many doctors refuse to perform abortion on the ground of the doctor’s religion or conscience. Italy is one example of a European Union member state that has practical barriers for access to abortion. 

          Under these circumstances, it is likely that the use of medication abortion will increase significantly in the future, and it has the potential to improve access to reproductive health care. However, medication abortion raises additional legal risks for pregnant women.

          Historically, doctors who performed surgical abortions might be charged (or threatened with charges) under criminal law, if the doctors violated legal restrictions on abortion. However, the pregnant women who obtained surgical abortions were usually not charged with a crime. In contrast, women who self-manage their medical abortions are more likely to be charged with a crime. Therefore, the projected increase in utilization of medication abortion will also increase the legal risks for pregnant women.

          This paper will explain the facts about medication abortion as well as the trend toward increased use of self-managed medication abortion. The paper reviews the literature about prosecution of pregnant women for abortion or suspected abortion. Finally, the paper describes the types of laws that might be used to prosecute pregnant women, and makes a recommendation for more effective provisions to provide immunity from prosecution for pregnant women.  

The facts about medication abortion           

            Unlike abortions performed by surgical procedures, medication abortion is performed with drugs that are often referred to as “abortion pills.” Specifically, mifepristone is an abortion drug which is also known as RU-486 or by its brand name Mifeprex. Misoprostol is sold under a variety of trade names as an ulcer medication.[1]

          The standard protocol is a combination medication abortion, in which the patient first takes mifepristone and then takes misoprostol a day or two later. Mifespristone blocks the hormone progesterone, which is necessary for continuation of pregnancy, and then misoprostol terminates the pregnancy with contractions, cramping, and bleeding like a miscarriage.[2] The combination of mifepristone and misoprostol has been shown to be safe and effective for use up to 10 weeks (70 days) from the date of the last menstrual period.[3]

          Unfortunately, mifepristone is unavailable to many women, and using only misoprostol is less effective.[4] As explained by Singh et al, the standard protocol of combination medication abortion “is essentially out of reach for the 687 million women of reproductive age who live where abortion is severely restricted. In these countries, only misoprostol … is likely to be available.”[5] Misoprostol is much less expensive and is much more accessible than mifepristone, but using only misoprostol is more likely to fail in terminating the pregnancy.[6]

         In many countries, the use of medication abortion has increased significantly, while the use of surgical abortion has decreased. For example, in nine European countries, about 60 to 90 percent of all induced abortions are combination medication abortion rather than surgical abortion. In France, combination medication abortion increased from 30 percent to almost 60 percent of all abortions between 2001 and 2012. In Sweden in 2014, more than 80 percent of all abortions were combination medication abortion. However, as of 2014, medication abortion was used much less than surgical abortion in other European countries such as Netherlands, Belgium, Germany, and Italy.[7]

           In the United States, medication abortion had increased to 31 percent of all abortions by 2014.[8] India had an even higher percentage of medication abortions at 81 percent of all abortions in 2015.[9] However, in Japan, mifepristone is not approved, and the government prohibits buying abortion pills from other countries.[10] Even though medication abortion is not approved by law in Japan, a study published in 2018 found that some foreign migrants living in Japan had medication abortions without the supervision of a health care provider.[11]

            In their comprehensive analysis of worldwide data and trends on abortion, Singh and colleagues recognized the connection between the increased use of medication abortion and the safety of abortion services.[12] “One of the most important developments in terms of the safety of abortion is the steady increase in the use of medication abortion, which is likely having an important impact on abortion-related morbidity and mortality.”[13]

Self-managed medication abortion

            Many medication abortions are performed in a clinic or health care facility under the direct supervision of doctor or other health care professional. In that situation, the abortion is performed with medications that were prescribed by that health care professional. However, some women manage their own medication abortion at home with little or no involvement by a health care professional. In that situation, they might use medications which they obtained by mail and the internet.

            There are several reasons that a woman who wants to terminate her pregnancy might choose a self-managed medication abortion. Many people live in countries or states where abortion is prohibited by law even at an early stage of pregnancy, or abortion is allowed only under very limited circumstances. Even if abortion is allowed by law, it might be inaccessible as a practical matter because of cost, lack of providers within a reasonable distance, or the refusal of health care professionals to perform abortion on the ground of religious or ethical beliefs. Moreover, as Megan Donovan wrote, “some people, such as those who have reason to distrust the medical system, may opt to self-manage abor­tion for reasons other than lack of access to a clinic, such as increased privacy and autonomy.”[14]

            If a woman chooses the alternative of a self-managed medication abortion, there are several reliable sources online to obtain advice and abortion pills. One of the most respected sources for information and ordering pills is Women on Web.[15] That organization was founded by a Dutch physician, Dr. Rebecca Gomperts, who is licensed to practice medicine in Austria. According to that organization’s website, “This website refers you to licensed doctor who can provide you with abortion pills. After you complete the following online consultation and if there are no contraindications, the medical abortion (with the pills mifepristone and misoprostol) will be delivered to you by post.  A medical abortion can be done safely at home as long as you have good information and have access to emergency medical care in the rare case that there are complications.”[16]

              Does a woman who resides in a European Union (EU) member state have a legal right to obtain authentic abortion pills, using a prescription that she obtained by telemedicine from a licensed doctor in another EU member state? In a recent article, Tamara Hervey and Sally Sheldon analyzed the rights of the patient and the health professional under EU laws about trade and human rights, and they considered whether the interest of a member state could justify a restriction on this type of cross-border trade in services.[17] As Hervey and Sheldon explained, both doctors and patients have rights under EU trade laws to provide and receive abortion by telemedicine from a licensed doctor in one EU member state to a patient in another EU member state. However, a member state has authority to impose barriers to trade which are necessary to protect the state’s interests in public policy, morality, health, and human rights. Hervey and Sheldon made a very persuasive argument that a member state’s restrictive abortion laws would not be sufficient to justify a restriction on trade for abortion by telemedicine within the EU.[18] However, those authors recognized that there is some uncertainty about the scope of a member state’s authority to limit abortion by telemedicine. “This is not to deny that any relevant litigation would raise a range of difficult legal questions that have not been fully tested in the courts. As such, the legal pathway to challenging an attempt to prevent the prescription of abortion pills for a patient in one country from a prescribing doctor in another would inevitably be long, expensive, and contested.”[19] Moreover, Hervey and Sheldon carefully limited their analysis to cross-border telemedicine abortion within the EU by prescription from a licensed doctor, and their analysis does not apply to obtaining abortion pills online without a prescription or to countries outside the EU such as the United States.[20]

             In fact, Women on Web does not help patients in the United States to obtain pills, because of concerns that strong anti-abortion groups in the U.S. would try to shut down the organization’s activities throughout the world.[21] Therefore, Dr. Gomperts created a separate organization called Aid Access.[22] On March 8, 2019, the U.S. Food and Drug Administration (FDA) sent Aid Access a warning letter to immediately stop “causing the introduction of these violative drugs into U.S. commerce.”[23] Aid Access has refused to comply with the FDA’s request, and the lawyer for Aid Access sent the FDA a detailed legal response.[24] According to Dr. Gomperts, “I will not be deterred. When U.S. women seeking to terminate their pregnancies prior to 9 weeks consult me, I will not turn them away. I will continue to protect the human and constitutional right of my patients to access safe abortion services…. As a physician, I have the obligation to provide medical care to people in need.”[25]

         Is it lawful for individuals in the United States to import drugs for their personal use? According to the U.S. FDA, "[i]n most circumstances, it is illegal for individuals to import drugs into the United States for personal use."[26] However, the FDA's Regulatory Procedures Manual provides that "FDA personnel may allow entry of shipments when the quantity and purpose are clearly for personal use, and the product does not present an unreasonable risk to the user."[27] Under some circumstances, FDA personnel may use their discretion to permit importation for personal use of drugs that appear to violate the law, provided that "the product is not known to represent a significant health risk."[28]

          However, it is unlikely that FDA personnel would use their discretion to allow individuals to import mifepristone for personal use, because the FDA considers mifepristone to represent a risk to health. Mifepristone is not available in the U.S. over-the-counter (OTC) without a prescription. Even if a patient has a prescription, mifepristone is not available in pharmacies like most prescription medicines. For mifepristone, the FDA has imposed a higher level of restriction, which is called a Risk Evaluation and Mitigation Strategy (REMS).[29] Pursuant to the REMS, mifepristone is only available from providers in medical facilities or clinics who register with the government, although critics of the FDA policy argue that the REMS for mifepristone is not justified in light of the low risks.[30] According to a news report, an FDA representative stated that "Mifepristone ... for termination of pregnancy is not legally available over the Internet."[31] Under these circumstances, the FDA is unlikely to use its discretion to permit individuals to import mifepristone for their personal use, and such importation might violate U.S. federal law. 

            Despite these obstacles, it is likely that recent trends will continue, and self-managed medication abortion will be used more frequently in the future. While some countries have changed their laws to make abortion more available, other countries such as the U.S. are moving toward placing more restrictions on access to abortion. Under these circumstances, self-managed medication abortion could provide a “safety valve.” As Michelle Oberman wrote, “[i]n the internet age, trying to stop abortion by closing clinics is like trying to eradicate pornography by seizing magazines.”[32]

Review of the literature on prosecution of women for abortion

            When the U.S. Supreme Court considered the landmark case of Roe v. Wade, the Court examined the history of abortion and legal prohibitions against abortion.[33] The Court noted that in many U.S. states “the pregnant woman herself could not be prosecuted for self-abortion ….”[34] Thus, the law in those states provided an immunity from prosecution for the pregnant woman.[35]

            As Mary Ziegler explained, the historic view that pregnant women were immune from prosecution for self-abortion was based on the traditional view that women who obtained abortions were victims rather than perpetrators.[36] “[P]rosecutors, members of law enforcement, and the press framed women as victims, duped into both sexual relationships and abortion. These cases drew heavily on sex stereotypes about women’s interest in sex and ability to operate competently outside the home.”[37]

            Doctors may be prosecuted for performing abortions outside the limitations imposed by law, such as gestational limits or restrictions on the grounds for obtaining an abortion. However, in self-managed medication abortion, the role of a doctor could be significantly reduced, and, in some cases, might be eliminated entirely. As Michelle Oberman wrote, “When no doctor is involved, the woman who uses abortion drugs might seem less like a ‘second victim’ and more like a criminal.”[38] Andrea Rowan reached a similar conclusion about the greater risk of prosecution for women in self-managed medication abortion.[39] “The advent of medication abortion has further allowed some women to take matters into their own hands; however, doing so has exposed them to the risk of criminal prosecution.”[40]

            Under these circumstances, it is not surprising that prosecutions of pregnant women have increased in recent years. According to Ziegler, state governments in the U.S. have been punishing more women for abortions.[41] Ziegler has connected the increased punishment of pregnant women, at least in part, to the innovation of abortion pills. “Lawmakers took on the issue of punishing women partly because it had become much easier for women to terminate their own pregnancies using abortion drugs….As more women got their hands on abortion medication, lawmakers and prosecutors cracked down on those who terminated their own pregnancies.”[42] Rowan went a step further in her analysis, by linking the availability of abortion pills to the prosecution of women who had miscarriages.[43] “[T]he mere existence of medication abortion is providing some legal authorities reason to conduct fishing expeditions to go after not only women who have clearly ter­minated a pregnancy, but also women whom they suspect have done so.”[44]

            In the future, it is likely that even more pregnant women will be prosecuted for self-abortion or for miscarriages that authorities suspect were caused by self-abortion. Ziegler predicted that prosecutions of pregnant women would increase because of both the availability of abortion pills and the increasing restrictions on abortion by physicians.[45] “With the spread of abortion drugs and the rising number of restrictions on access to abortions performed by doctors, it seems likely that more women will face prison time for having illegal abortions.”[46]

            Several scholars have noted that the women most likely to be prosecuted are disadvantaged women who are poor or members of racial or ethnic minorities.[47] Oberman explained that prosecuting disadvantaged women for abortion will follow and increase “an existing pattern of charging poor minority women with crimes arising from miscarriages, stillbirths or perceived risks taken while pregnant.”[48]

            Despite legal and ethical standards for confidentiality, some health care providers have contacted the police when women sought medical treatment after a self-managed abortion or a miscarriage.[49] The risk of being reported to the police has a “chilling effect” on the willingness of women to seek necessary medical care after an abortion or miscarriage.[50] For this reason, some organizations that promote safe medication abortion recommend that women who need post-abortion care should only tell health care providers that they had a miscarriage.[51] According to the web site of Women on Web, “You do not have to tell the medical staff that you tried to induce an abortion; you can tell them that you had a spontaneous miscarriage.…The symptoms of a miscarriage and an abortion with pills are exactly the same and the doctor will not be able to see or test for any evidence of an abortion, as long as the pills have completely dissolved.”[52] 

            Again, the risk is greatest for poor and disadvantaged women, who are most likely to be reported to the police.[53] In El Salvador, where many women have been sent to prison after miscarriages that were suspected of being self-abortions, the government told doctors to report women who the doctors suspect of intentionally ending their pregnancies. However, a study found that only women who seek care at government health facilities in El Salvador were reported to the police, whereas private hospitals and doctors did not report any of their patients to the police.[54]

            Women who are arrested and prosecuted for alleged self-abortion face severe consequences, even if they are not convicted or their convictions are eventually reversed on appeal or they plead guilty to lesser charges. For example, in the U.S. State of Indiana, Bei Bei Shuai lost her pregnancy after attempting suicide. She was jailed for more than a year without bail, before she eventually plead guilty to a lesser charge in exchange for a sentence of the time she had already served.[55] In El Salvador, Teodora del Carmen Vasquez was sentenced to thirty years in prison after having a miscarriage. After she served over ten years in prison, she was released on February 15, 2018 and her sentence was commuted. The court in that case concluded that the scientific evidence could not support a conclusion that she had voluntarily ended her pregnancy.[56] According to an advocacy organization called If/When/How, “someone doesn’t have to go to jail for it to do harm. Even misdemeanor charges can mean that a person loses their job, especially for people doing low-wage care work like child care and home medical assistance. In many states, records searches used by employers will show an arrest and what the arrest was for, even if the person is never formally charged. There is often no way to get this mark off their record.”[57]

            Even if a jurisdiction’s criminal law does not explicitly prohibit self-managed medication abortion, police officers and prosecutors might try to find some other legal theory on which to arrest women for alleged self-abortion. As Donovan wrote, “law enforcement officials who seek to take a political stand against abortion would rely on any laws that might be applicable to arrest and potentially prosecute people who self-manage abortion.”[58] Similarly, the legal advocates at If/When/How stated that “when a prosecutor wants to punish someone, they will find a way to do it.”[59] Therefore, the next part of this paper uses examples of cases from the United States to analyze the types of charges that police officers and prosecutors might try to assert in cases of alleged self-abortion.

Types of laws that might be used to prosecute women for alleged self-abortion

            A common format for state-level abortion statutes in the United States is to set forth a general rule that abortion is prohibited and subject to criminal punishment, unless the abortion fits within one of the exceptions which are set forth in the statutes.[60] In fact, state abortion statutes might be part of a state’s criminal law, rather than part of a state’s statutes about health care or the practice of medicine.[61]

         Some state abortion laws are unclear about whether a pregnant woman may be prosecuted for undergoing an abortion or performing a self-managed medication abortion. According to a May 2019 analysis by the legal advocates at If/When/How, 14 of the 50 U.S. states have “criminal abortion laws susceptible to misapplication against pregnant people.”[62] Even if a pregnant woman is clearly immune from prosecution under a state’s criminal abortion law, she still might be subject to prosecution under other laws of that state, as discussed below. Moreover, people who assist the pregnant woman might be subject to prosecution. Therefore, a state’s criminal abortion statute should explicitly provide immunity under all laws of that state for a pregnant woman, as well as for any person who assists her, including in cases of self-managed medication abortion.

           If a state tries to prosecute a woman for allegedly performing her own abortion, she might have legal defenses under the terms of the state statute, such as limitations on applicability of the statute and requirements for the prosecution to prove the element of intent. Another potential defense is the right of a pregnant woman under the U.S. Constitution to make her own decision about termination of pregnancy prior to the point of viability, pursuant to decisions of the U.S. Supreme Court in Roe v. Wade[63] and Planned Parenthood of Southeastern Pennsylvania v. Casey.[64] For example, the State of Idaho tried to prosecute Jennie McCormack, who admitted that she had self-managed a medication abortion.[65] Later, the state decided not to pursue the prosecution, but McCormack was still subject to the risk of prosecution in the future. Together with a physician, who was also her attorney, McCormack succeeded in obtaining a ruling from the federal Court of Appeals for the Ninth Circuit that specific provisions of Idaho’s abortion statute violated the U.S. Constitution.[66]

         In some U.S. states, abortion laws interfere with access to medication abortion. According to the May 2019 analysis by If/When/How, six states have “criminal prohibitions on self-managed abortion.”[67] In addition, many states prohibit telemedicine for self-managed medication abortion by requiring the physical presence of a health care professional during the abortion procedure. As explained in a 2019 publication of the Guttmacher Institute, “18 states require the clinician providing a medication abortion to be physically present during the procedure, thereby prohibiting the use of telemedicine to prescribe medication for abortion remotely.”[68]

            Aside from state criminal abortion laws, many states have separate statutes that prohibit the crime of “feticide” for an act against a pregnant woman that causes the termination of her pregnancy.[69] Originally, these state laws were enacted to provide an additional criminal charge--and additional punishment--for a person who attacked a pregnant woman and thereby caused the loss of her pregnancy. Some state feticide laws clearly provide immunity from prosecution for the pregnant woman, but other state feticide laws do not clearly provide immunity.[70] The May 2019 analysis by If/When/How identified several states “where fetal harm laws fail to adequately protect pregnant people from criminalization.”[71] Like criminal abortion laws, feticide statutes should clearly provide immunity under all laws of that state for pregnant women as well as for anyone who assists them.

            There are several other categories of laws that police and prosecutors might try to use against women who self-manage a medication abortion, as well as against the people who assist them. In some circumstances, federal or state laws prohibit the [unauthorized purchase, possession, or importation of drugs.[72] Prosecutors could also charge women for allegedly violating laws that require abortions to be reported to the local coroner[73] or laws that impose specific requirements for disposal of human remains.[74] In addition, prosecutors could charge individuals who help pregnant women with self-managed medication abortion, including relatives, friends, and doulas.[75] For example, a mother who bought abortion pills online for her daughter was charged with “providing an abortion without a license, dispensing drugs without a license, assault, and endangering the welfare of a child.”[76] 

Conclusion

            The use of self-managed medication abortion has increased, and it will probably continue to increase. In places that impose legal or practical barriers to access, self-managed medication abortion could provide a “safety valve” for access to abortion. However, the use of self-managed medication abortion will increase the legal risks for pregnant women. Therefore, laws should be amended to clearly provide protection against prosecution of pregnant women--and the people who help them--under any and all laws.

[1] International Women’s Health Coalition/Gynuity Health Projects, “Abortion with Self-Administered Misoprostol: A Guide for Women,” https://31u5ac2nrwj6247cya153vw9-wpengine.netdna-ssl.com/wp-content/uploads/2010/10/Miso_fact_sheet_ENG-2016.pdf

[2] Kaiser Family Foundation, “Medication Abortion” (June 2018), https://www.kff.org/womens-health-policy/fact-sheet/medication-abortion/ ; Donovan, M, “Self-Managed Medication Abortion: Expanding the Available Options for U.S. Abortion Care,” Guttmacher Policy Review, (2018), vol. 21, https://www.guttmacher.org/gpr/2018/10/self-managed-medication-abortion-expanding-available-options-us-abortion-care

[3] Kaiser Family Foundation, supra note 2.

[4] Singh S, et al, “Abortion Worldwide 2017: Uneven Progress and Unequal Access,” (2018), [Singh, et al, 2018-1], https://www.guttmacher.org/sites/default/files/report_pdf/abortion-worldwide-2017.pdf

[5] Id. at 27. 

[6] Id. 

[7] Id. at 24-25. 

[8] Donovan, supra note 2, at 42.

[9] Singh, S, et al, “The incidence of abortion and unintended pregnancy in India, 2015,” Lancet Global Health, (2018) 6: e111–20 [Singh, et al, 2018-2].  

[10] Tsukahara, Kumi, “A long and winding road to safer abortion in Japan,” 4th International Congress on Women’s Health and Unsafe Abortion-IWAC 2019, (Feb. 21, 2019).

[11] Shah, R, et al, “Use of modern contraceptive methods and its association with QOL among Nepalese female migrants living in Japan,” PLoS ONE, (2018), 13(5): e0197243, at 7 and 10, https://doi.org/10.1371/journal.pone.0197243  

[12] Singh, et al, (2018-1), supra note 4, at 6.

[13] Id.

[14] Donovan, supra note 2, at 41.

[15] https://www.womenonweb.org/en/page/521/about-women-on-web

[16] https://www.womenonweb.org/en/i-need-an-abortion

[17] Hervey, T and S Sheldon, “Abortion by telemedicine in the European Union,” International Journal of Gynecology and Obstetrics, (2019), 145: 125–128. 

[18] Id. at 127-28.

[19] Id. at 128. See also id. at 127.  

[20] Id. at 125, 128.

[21] Khazan, O, “Illegal Abortion Will Mean Abortion By Mail,” The Atlantic (July 18, 2018). 

[22] https://aidaccess.org/en/page/561  See also Khazan, O, “Women in the U.S. Can Now Get Safe Abortions by Mail,” The Atlantic (October 18, 2018).

[23] https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/warning-letters/aidaccessorg-575658-03082019

[24] https://aidaccess.org/en/media/inline/2019/5/16/19_05_16_gomperts_letter_and_exhibit_a.pdf

[25] https://aidaccess.org/en/page/561

[26] https://www.fda.gov/about-fda/fda-basics/it-legal-me-personally-import-drugs

[27] FDA Regulatory Procedures Manual, (December 2017), Section 9-2-5, at page 9-23, https://www.fda.gov/media/71776/download

[28] Id. at pages 9-24. 

[29] Donovan, supra note 2, at 42-43. 

[30] Id.

[31] Khazan, (October 18, 2018), supra note 22. 

[32] Oberman, M, “What Happens When Abortion Is Banned?” New York Times, (May 31, 2018),  https://www.nytimes.com/2018/05/31/opinion/sunday/abortion-banned-latin-america.html

[33] Roe v. Wade, 410 U.S. 113 (1973).

[34] 410 U.S. at 151.

[35] Id. at 151, note 49.

[36] Ziegler, M, “Some Form of Punishment: Penalizing Women for Abortion,” William & Mary Bill of Rights Journal, (2018), 26(3): 735-788. https://scholarship.law.wm.edu/cgi/viewcontent.cgi?article=1851&context=wmborj

[37] Id. at 740-41 (footnotes omitted).

[38] Oberman, supra note 32.

[39] Rowan, A, “Prosecuting Women for Self-Inducing Abortion: Counterproductive and Lacking Compassion,” Guttmacher Policy Review (Summer 2015), 18(3): 70-76, https://www.guttmacher.org/sites/default/files/article_files/gpr1807015.pdf  

[40] Id. at 71.

[41] Ziegler, supra note 36, at 779.

[42] Id. at 772-73 (footnotes omitted). 

[43] Rowan, supra note 39, at 73.

[44] Id.

[45] Ziegler, supra note 36, at 781.

[46] Id. (footnote omitted).

[47] Oberman, supra note 32, at 4; Donovan, supra note 2, at 46; Ziegler, supra note 36, at 782.

[48] Oberman, supra note 32, at 4.

[49] Donovan, supra note 2, at 45; Rowan, supra note 39, at 73.

[50] Rowan, supra note 39, at 74.

[51] Khazan, (July 18, 2018), supra note 21.

[52] https://www.womenonweb.org/en/page/485/in-collection/6907/how-do-you-know-if-you-have-complications-and-what-should-you-do

[53] Oberman, supra note 32, at 3-4.

[54] Id. 

[55] Rowan, supra note 39, at 73.

[56] Inter-American Commission on Human Rights (IACHR), “IACHR Urges El Salvador to End the Total Criminalization of Abortion,” Press Release, (March 7, 2018), https://www.oas.org/en/iachr/media_center/PReleases/2018/042.asp 

[57] If/When/How, “Making Abortion a Crime (Again),” (undated), at 1, https://www.ifwhenhow.org/resources/making-abortion-a-crime-again/

[58] Donovan, supra note 2, at 46.

[59] If/When/How, supra note 57, at 1.

[60] See, e.g. North Carolina General Statutes, sections 14-44 to 145-45.1.

[61] Id.

[62] If/When/How, “Fulfilling Roe’s Promise: 2019 Update,” at 2, https://www.ifwhenhow.org/resources/roes-unfinished-promise-2019-update/ 

[63] 410 U.S. 113 (1973).

[64] 505 U.S. 833 (1992).

[65] McCormack v. Herzog, 788 F.3d 1017 (9th Cir. 2015).]

[66] Id. at 1033.

[67] If/When/How (2019), supra note 62, at 1 (with map).

[68] Guttmacher Institute, “Medication Abortion,” (October 1, 2019), https://www.guttmacher.org/state-policy/explore/medication-abortion

[69] See, e.g. Patel v. State of Indiana, 60 N.E. 3d 1041(Indiana Court of Appeals, 2016). 

[70] Ziegler, supra note 36, at 772 & 779. 

[71] If/When/How (2019), supra note 62, at 3 (with map). 

[72] If/When/How (undated), supra note 57, at 2.

[73] Rowan, supra note 39, at 71.

[74] Donovan, supra note 2, at 45.

[75] If/When/How (undated), supra note 57, at 2.

[76] Ziegler, supra note 36, at 773-74.