When Layidua Salazar showed up at the Oakland Planned Parenthood eight years ago, she thought she was going to get a wellness exam. 

Then the nurse walked in. They couldn’t do Salazar’s Pap smear after all — she was pregnant. The clinic knew she was on birth control, but the positive result wasn’t a mistake. They had checked three times.

“As soon as she closed the door, I broke down into tears,” Salazar recalled. “I definitely was not intending to be pregnant.”

For Salazar, the timing couldn’t have been worse. 

She was 28 and battling to stay in California. But things were looking grim — only two days earlier, Salazar, who was born in Mexico, had received her federal deportation letter. She didn’t have health insurance or a job. 

“I did not see children fitting into my life at the time,” Salazar said.

She decided to get an abortion. Salazar was already 10 weeks pregnant, which meant she had two options for the procedure: She could get a surgical abortion at the clinic. Or she could take two pills — mifepristone and misoprostol — that would end the pregnancy.

The choice was obvious. Her husband didn’t support her abortion and wouldn’t drive her to or from a clinic. She picked the pills — it seemed easier, more discreet. She would take the first at the clinic, and the second at home 24 hours later. If she took medication, she could even take public transit, since the bulk of symptoms wouldn’t sink in until she had taken the second pill.

Salazar took the pills and her pregnancy was terminated. Years later, she doesn’t regret it. She just wishes someone had warned her about the “severe pain” she would feel.

“I was not prepared for how much pain I would be in,” Salazar said. “I went through a huge deal of pain physically. I was nauseous nonstop.”

The medication abortion pills are the future of abortion access in America. The Supreme Court is poised to overturn Roe v. Wade, the 1973 case that guarantees the right to an abortion up until a fetus can live outside the womb. So far, 13 states have passed laws to ban abortion once the federal protection is undone; still more have abortion prohibitions on the books that predate 1973 and that could be newly enforced. And even more states have passed laws that would prohibit abortions after six weeks of pregnancy, early enough that many people don’t know they are pregnant.

If that happens, reproductive rights activists and physicians are pointing to self-managed abortion — people terminating their pregnancies on their own, outside of the medical system. Medication abortion offers the options of pills that are safe and effective in terminating a pregnancy and can be taken from home. The World Health Organization advises that people can safely self-manage abortions up to 12 weeks using the two-pill combination, as long as they have access to appropriate information and a health care professional for support. Legally, there are risks of criminal prosecution, even in states that have not explicitly banned the practice.

But even if the pills are safe, every patient experiences it differently. For some, the pain resembles cramps from a menstrual cycle. For others it can be excruciating — and difficult to manage without a nurse or doctor’s support. Some patients will even turn to the emergency room just to make sure everything is OK. 

“There’s a lot of bleeding and cramping, and some people get scared. It’s a totally natural response,” said Ushma Upadhyay, an associate professor at the University of California San Francisco who has studied self-managed abortion. “When there’s that much bleeding you want to make sure everything is going as expected.” 

The 19th spoke with multiple people who have taken medication abortion pills — some had them provided by an abortion clinic, and others procured them outside the medical system, because they could no longer get a legal abortion in their home state. For all of them, the relief of no longer being pregnant outweighed all other concerns. Still, like Salazar, they wished they had been warned about just how intense and painful the abortion process could be. If self-managed abortion becomes more common, some said, providers need to make sure patients know just how painful the medication abortion could be and make sure patients have the proper supports in place. 

“It’s extremely difficult,” said Emma in Texas, who has had multiple medication abortions. The 19th is using only her first name because Texas’ laws prohibit abortions after six weeks of pregnancy. “It’s going to be more and more the only option for people in certain communities. We want people to not be so afraid of the pain that they continue with an unwanted pregnancy. But we want to be real about what they will experience.”

In 2021, medication abortions constituted the majority of abortions performed in the United States. It’s a method that is growing in popularity — the privacy and convenience of taking pills at home is a huge factor.

It’s not the right choice for everyone, doctors noted, but in a post-Roe world, it will be the only reliable method for people in almost half the country. 

“This obviously is a situation where patient preference goes out the window and people are going to be left really stripped down to the question of, ‘Can I or can I not have this abortion?’” said Dr. Jennifer Kerns, an associate professor at the University of California San Francisco who provides abortions in California and Oklahoma. “It’s a sad reality.” 

Salazar took her first pill at the Richmond clinic. The nurse at Planned Parenthood had prescribed her heavy-duty painkillers and told her that she could pick up anti-nausea medication if she chose. But everything Salazar had read or heard suggested it would feel like a heavy period.

Salazar filled the painkiller prescription. And she needed it — she spent three days in bed with cramps. Even after the abortion was over, it took a week and a half to recover physically. 

Still, “despite the physical pain I felt, I still felt safe,” she said. “I was at home. I knew that if something went wrong, I could go to a hospital. It was physically taxing. I was going through a lot emotionally. But at the same time it felt safe.”

Because Salazar had no insurance, she didn’t fully consider going to the emergency room. But if the pain yielded other issues — such as a high sustained fever —  she figured it was still an option. And she had other medical system support, like the painkillers prescribed from the clinic. 

That looks different for people who take medication abortion pills outside the health care system, which is likely to become more common in a post-Roe world. It’s still safe, and still effective. But those medical supports — a physician’s advice, prescription painkillers if needed, and the prospect of an emergency care if needed — are harder to access, though anonymous doctor hotlines do exist for people using medication abortions on their own. 

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Three states have laws on the books prohibiting someone from inducing their own abortion. Still others have used laws to criminalize people for terminating a pregnancy at home. Research suggests that people of color are more likely to be prosecuted.

That was the fear for Emma. When she found out she was pregnant in February,  she thought she knew what she was getting into. Her first medication abortion took place when she was a college student and seven weeks pregnant. A Planned Parenthood affiliate gave her the pills, one of which she took in the clinic, and the other one which she took at home. She was able to manage the cramping with Ibuprofen the clinic had given her. 

“That initial abortion, it was painful but it was manageable,” she said.

But this past February, when she was pregnant once again, everything was harder.

When Emma’s test came back positive, she was already past six weeks, the cutoff in Texas. The symptoms she had written off as maybe a winter cold, or a reaction to her adult acne medication, were actually the early stages of pregnancy. 

She knew she couldn’t get a legal abortion in Texas. And her nausea was already too intense for her to stomach the idea of traveling to New Mexico — the closest option for her to find an abortion clinic. She looked into Aid Access, a company headquartered in Austria that ships pills from India to U.S. states that restrict access but was nervous about the idea of waiting two weeks for medication to arrive. So Emma texted a friend who had recently crossed the border to Mexico. Did they have anything she could use?  

Her friend dropped off some misoprostol, which can end a pregnancy even without mifepristone, though it’s far less effective. Both pills together successfully end pregnancy 95 percent of the time; research suggests when someone takes just misoprostol, 22 percent will require surgical evacuation to get the uterus emptied.  

Emma thought she was set. She asked her boyfriend to pick up some takeout and leave her with some “Love is Blind.” 

Soon after she took the pills, the cramping began. She knew she needed to go to the bathroom, but Emma could hardly walk from the pain. Her boyfriend had to come back so he could physically steer her to the toilet.

Two hours of blood and cramps later, she thought she was done. A week and a half later, though, she still felt nauseous and constantly exhausted. So she got another pregnancy test. It was still positive.

She texted her friend again. It was a bigger lift, but could they find her both the abortion pills — not just one?  

Emma was close to 10 weeks pregnant when she tried another medication abortion, using both mifepristone and misoprostol. The window was closing for when she could safely use pills on her own, which are far less effective after 12 weeks of pregnancy. 

This time, the pills worked. And she even had painkillers: some heavy-duty ibuprofen from her boyfriend’s mother, who has arthritis. But it was still far worse than anything she could have imagined.

“That medication abortion was the most painful experience I’ve ever had in my life,” she said. “I literally said to my boyfriend — who, that time, knew better and just stayed with me the entire time — I said, ‘I just want to die.’”

Emma watched videos online from Doctors Without Borders about what a medication abortion should feel like and what kinds of symptoms she might experience. She texted an anonymous doctor hotline. Still, the cramps persisted. Both Emma and her boyfriend were worried. 

“A lot of the content we see online, tends to be about, like, ‘Self-managed abortion, it’s so easy and with medication abortion, this is definitely a thing you can do,’” Emma said. “It is a thing you can do, but it’s also going to be a painful thing you can do.”

The cramps lasted just past five hours. If they had gone any longer, her boyfriend said, he would take her to the emergency room. That terrified Emma even more. She knew she’d be fine. But if they went to the hospital, she feared that she or her boyfriend could be arrested.

That’s a real fear, and one that will become only more prevalent once more states ban abortion. There is no law compelling physicians to report patients to state authorities — and in fact, the after-effects of a medication abortion resemble that of a miscarriage. Patients can, Upahdhyay noted, tell doctors they have experienced a miscarriage, and doctors shouldn’t be able to tell the difference. But enough people have been reported to create a real, legitimate fear. 

“They’re right to be scared to seek help when they need it,” Upadhyay said. 

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As self-managed abortion becomes more common, physicians voiced other concerns beyond just patients having medical support. For one, there is the question of whether patients will be able to find the correct pills, and be comfortable navigating the process outside of the established medical system.

“It’s appropriate for people to be afraid to go outside the medical system. And they don’t know if the person who’s prescribing them the medications are medically qualified. They don’t know who to trust,” Upadhyay said. “Aid Access, we know it’s good. But how will they know the difference between Aid Access and other online sellers?”

Jamie Benoit, an American expat in Canada, has been trying to understand what those barriers would feel like. For him, needing an abortion isn’t an abstract issue. He got his abortion when he was 23 — seven years ago. Originally from the United States, he had moved to Montreal. But he wasn’t a legal Canadian resident and didn’t qualify for the national health insurance. 

Jamie was eight weeks pregnant when he found out. The condom had broken, and the emergency contraception hadn’t worked. So the clinic offered him a choice: surgery or medication. But for him, the idea of taking the pill felt too prolonged, too invasive. He didn’t want to sit at home on a toilet for hours. 

“I just wanted to go get it done and get out. I didn’t want to have to think about it,” he said. “I just wanted it to happen.”

Even just having that option to choose what type of abortion he would get was critical. And losing that level of medical freedom, Jamie said, is difficult to process.

He’s read about what is happening at home, and the likely end of federal abortion protections. He’s thought about what he would do if he still lived here and he lost the right to an abortion. If he needed to end a pregnancy, he said, he’d do whatever it took — including finding pills online and inducing an abortion at home.

“I’d have gone to those lengths,” he said. “I was very lucky that I didn’t have to. But the fact that those are the only options that someone would have? I don’t know. That’s really shitty.”