2022.04.04 美国堕胎的未来可能是什么样子的

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IDEAS
THE END OF ROE
What the future of abortion in America could look like

By Jessica Bruder
The shadow of a woman against a blank wall
Photo Illustration by Oliver Munday. Source: Deborah Spronk / EyeEm / Getty
APRIL 4, 2022
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Updated at 9:22 a.m. ET on April 5, 2022.

i.
one bright afternoon in early January, on a beach in Southern California, a young woman spread what looked like a very strange picnic across an orange polka-dot towel: A mason jar. A rubber stopper with two holes. A syringe without a needle. A coil of aquarium tubing and a one-way valve. A plastic speculum. Several individually wrapped sterile cannulas—thin tubes designed to be inserted into the body—which resembled long soda straws. And, finally, a three-dimensional scale model of the female reproductive system.

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The two of us were sitting on the sand. The woman, whom I’ll call Ellie, had suggested that we meet at the beach; she had recently recovered from COVID-19, and proposed the open-air setting for my safety. She also didn’t want to risk revealing where she lives—and asked me to withhold her name—because of concerns about harassment or violence from anti-abortion extremists.


Ellie snugged the rubber stopper into the mason jar. She snipped the aquarium tubing into a pair of foot-long segments and attached the valve to the syringe’s plastic tip. In less than 10 minutes, Ellie had finished the project: a simple abortion device. It looked like a cross between an at-home beer-brewing kit and a seventh-grade science experiment.

The two segments of tubing protruded from the holes in the stopper. One was connected to a cannula, the other to the syringe. Holding the anatomical model, Ellie traced a path with the tip of the cannula into the vagina and through the cervix, positioning it to suction out the contents of the uterus. Next, to show more clearly how the suction process works, she placed the cannula into her coffee. When she drew back the plunger on the syringe, dark fluid coursed through the aquarium tubing and into the mason jar, collecting slowly within the diamond-patterned glass.

I had read about such devices before. But watching the scene on the beach towel brought history into focus with startling clarity: Women did this the last time abortion was illegal.

Ellie didn’t invent this device. That distinction goes to Lorraine Rothman, an Orange County public-school teacher and activist. In 1971, members of her feminist self-help group had been familiarizing themselves with the work of an illegal abortion clinic in Santa Monica. The owner, a psychologist named Harvey Karman, had designed a slender, flexible straw—now known as a Karman cannula, and a standard piece of medical equipment—which he used to draw the contents of a uterus into a large syringe. Karman’s method took only a few minutes and had been nicknamed a “lunch-hour abortion” because patients could return to regular activities afterward. It was less invasive than dilation and curettage, a procedure that uses a surgical instrument to scrape the uterine walls.


Two years before the Supreme Court’s decision in Roe v. Wade changed the legal landscape for abortion in the United States, Rothman was developing her own version of Karman’s apparatus, rummaging around aquarium stores and chemistry labs for parts. She added a bypass valve to prevent air from accidentally being pumped back into the uterus, and a mason jar to increase the holding capacity. The result was an abortion device that was easy to make and suitable for ending pregnancies during most of the first trimester.

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For purposes of plausible deniability, Rothman promoted the device as a tool for what she referred to as “menstrual extraction”: a technique a woman could use to pass her entire period at once, rather than over several days. In October 1971, she embarked on a Greyhound-bus tour with a fellow activist, Carol Downer, to spread the word. In six weeks, they visited 23 cities, traveling from Los Angeles to Manhattan and calling themselves the West Coast Sisters. Soon women all over the country were making the device, which Rothman and Downer had called a Del-Em. (When I met Downer, now 88, earlier this year, I asked her about the meaning of the name; she said it was an “inside thing” and “not to be shared.”)

One might have expected the Del-Em to have disappeared after Roe affirmed the constitutional right to an abortion everywhere in America. Yet the Del-Em remained quietly in use here and there, conveyed from one generation to the next. This was in part because of continued fears that abortion rights would again be curtailed—an event that may now be imminent if the Supreme Court upholds statewide bans. But it was also because of a desire among some women to maintain control over their bodies, without oversight from the medical profession, regardless of Roe’s status.

black and white photo of a Del-Em device: sealed mason jar with two flexible tubes into stopper, one connected to syringe, one connected to cannula
Tubing, stopper, cannula, syringe: the makings of a Del-Em, a device created for early-stage abortions in the pre-Roe era (Hannah Whitaker for The Atlantic)
Activists are still tinkering with Rothman’s design. One added a second valve. Another upgraded the suction using a penis pump (a vacuum device used to stimulate an erection), explaining, “It’s like going from a pogo stick to a Lamborghini.” An American midwife living in Canada told me about repurposing an automotive brake-bleeding kit: “You just add a cannula onto the end.” She estimated that she had performed hundreds of abortions, using the Del-Em but also other methods, including medical-grade manual vacuum-aspiration kits and pharmaceuticals. The midwife is part of a network of self-described “community providers”—a term for people who perform abortions and offer other reproductive-health-care services outside the medical system. Before the coronavirus pandemic, she traveled and taught in-person workshops throughout the U.S. and Canada. She now teaches online. Ellie learned to build a Del-Em in one of her classes.

For Ellie, the Del-Em was more symbolic than pragmatic—an amulet from the past to carry into an uncertain future. After all, pharmaceuticals can now be used to end pregnancies in the first trimester, when more than 90 percent of legal abortions occur. (Almost 99 percent of abortions occur within the first 20 weeks.) There are also modern, mass-produced manual vacuum-aspiration devices for doing what the Del-Em does. Community providers have talked about stockpiling such supplies in case Roe falls. Ellie has coined a term for people who share that outlook: “vaginal preppers.”

For many Americans, Roe already feels meaningless. Nearly 90 percent of U.S. counties lack a clinic that offers abortions.
Given the uncertainties, she suggested, it couldn’t hurt to have a do-it-yourself tool like the Del-Em. “Just knowing the people who came before you had other ways of managing these things, not necessarily through a doctor or condoned by a government—there’s something really powerful in that,” she said.

As Ellie packed her supplies back into a tote bag, she told me to take the Del-Em. She gave me the speculum, too.

Listen to The Experiment podcast: As the Supreme Court prepares to hear a case that could overturn Roe v. Wade in June, the reporter Jessica Bruder speaks with activists prepared to take abortions into their own hands.


Listen and subscribe: Apple Podcasts | Spotify | Stitcher | Google Podcasts

ii.
there is a lot of talk about prepping these days. Roe v. Wade could well be further weakened or overturned by late June, when the Supreme Court is expected to hand down a decision in Dobbs v. Jackson Women’s Health Organization. At issue is a Mississippi law banning nearly all abortions past 15 weeks of pregnancy. This is a direct challenge to both Roe and the Court’s follow-on decision, nearly two decades later, in Planned Parenthood v. Casey. In these two decisions, the Court has held that states can ban abortion (except when the mother’s health or life is threatened) only past the point of fetal viability, which Casey found to be when a woman is roughly 23 to 24 weeks pregnant. Prior to that point, the Court’s holdings permit states to impose limited restrictions on abortion, so long as they don’t pose an “undue burden” on a woman’s right to an abortion. The Court now has a 6–3 conservative majority. By upholding the Mississippi ban, it would, in essence, nullify Roe’s recognition of the constitutional right to an abortion prior to viability. According to a 2021 Gallup poll, fewer than one in three Americans supports that outcome. The legality of abortion would largely be left to the states. Thirteen states have “trigger bans” on the books—laws that will take effect the moment Roe is overturned.* More than half of all states are certain or likely to attempt to ban abortion if the Supreme Court provides legal space to do so, according to the Guttmacher Institute, a pro-abortion-rights research organization.

For many Americans, Roe already feels meaningless. Nearly 90 percent of U.S. counties lack a clinic that offers abortions. States have passed more than 1,300 restrictions on abortion since it was made a constitutional right; for people struggling to get by, those restrictions can be insurmountable. Obtaining an abortion often means traveling long distances, which also means finding money for transportation, lodging, and child care, not to mention taking time off from work. In some states, people may reach a clinic only to learn that they are legally required to make two visits—one for counseling, the second for the abortion—with a mandatory waiting period of up to three days in between. The cost of an in-clinic abortion ranges from about $500 in the first trimester to more than $1,000 if the pregnancy is further along; that expense is ineligible for federal funding under a long-standing restriction called the Hyde Amendment, which makes abortions inaccessible for many low-income people.

A sprawling grassroots infrastructure has already grown in the cracks created by such challenges, even with Roe still the law of the land. More than 90 local organizations known as abortion funds raise money to pay for procedures and related expenses. Practical-support groups offer rides to medical facilities, along with housing, child care, and translation services. Clinic escorts guide patients past throngs of angry protesters. Doctors and other abortion providers travel hundreds of miles to work in underserved areas that are openly hostile to abortion.


This improvised safety net doesn’t catch everyone, though. Below the grass roots is the underground: a small network of community providers who connect with abortion seekers by word of mouth. This network, too, is growing. Its ranks include midwives, herbalists, doulas, and educators. When necessary, they are often willing to work around the law.

Even before the pandemic, with state restrictions mounting, the grass roots and the underground struggled to meet the demand for help. Then, as the coronavirus was first surging, a dozen states—most of them in the South, but also including Alaska, Iowa, and Ohio—moved to suspend nearly all access to abortion, describing it as a nonessential procedure. A handful of those efforts were temporarily successful, creating what felt to some like a dress rehearsal for the end of Roe. That feeling returned last fall when Texas used a creative legal strategy to ban most abortions after roughly six weeks’ gestation. Legal challenges to the law have so far failed.

The impact of the Texas law was immediate. Neighboring states experienced a swell of people seeking help, creating bottlenecks and forcing local patients to go out of state themselves in a secondary wave of migration. A term gained currency: “abortion refugees.”

Ellie told me she was disgusted by the developments in Texas. “Our reproductive rights are not given to us by the government,” she said. “They’re not given to us by anyone. We inherently have them.” Her belief in that sort of independence was formed long before the current debate; her family, she explained, was always interested in alternative medicine and, by age 7 or 8, she wanted to become a midwife. As a preteen, she read a novel called The Red Tent, set in biblical times, whose title refers to a place where women find refuge during menstruation and childbirth. In high school, classmates brought her their awkward questions about sex. After college, Ellie attended a retreat for sex educators that rekindled her old interests. She took jobs providing midwives and doulas with logistical support and eventually started a business in reproductive health—a red tent of her own.


iii.
it seems hard to imagine now, but America was not always so sharply divided over abortion. In the early decades of American independence, the states drew guidance from traditional British common law, which did not recognize the existence of a fetus until the “quickening”: the moment a woman felt the fetus move, usually during the second trimester. Before that, even if pregnancy was suspected, there was no way to confirm it. Women could legally seek relief from what doctors characterized as an “obstructed menses,” soliciting treatments from midwives or home-health manuals and in many cases making use of herbs that had been employed since antiquity (and that are sometimes used today).

Read: Bringing down the flowers: The controversial history of abortion

Through the first third of the 19th century, as the historian James Mohr has noted, abortion was widely seen as the last resort of women desperate to avoid the disgrace of an illegitimate child. Over the next few decades, the incidence of abortion rose. Mohr explains that the impetus came largely from “white, married, Protestant, native-born women of the middle and upper classes who either wished to delay their childbearing or already had all the children they wanted.” By mid-century, newspapers were full of advertisements for patent medicines such as Dr. Vandenburgh’s Female Renovating Pills and Madame Drunette’s Lunar Pills, which claimed—with a knowing arch of the eyebrow—to restore menstrual cycles. Some of the commercial preparations were dangerous; the first abortion statutes, passed in the 1820s and ’30s, were mostly poison-control measures aimed at regulating these products.

The effort to regulate abortion more explicitly, which began some years later, was less civic-minded. At the time, American physicians were working to organize and consolidate their profession. After forming the American Medical Association, in 1847, they began lobbying against abortion—ostensibly on moral grounds but also in part to neutralize some of the competition from midwives and homeopaths. Within a generation, every state had laws criminalizing the practice, pushing it into a netherworld and inviting dangerous procedures. In 1930, some 2,700 women died from abortions, according to the Guttmacher Institute. While some providers—including physicians—managed to offer safe, sometimes clandestine care, many women resorted to shady practitioners or self-managed abortions. By 1965, fatalities caused by illegal abortions still accounted for nearly a fifth of maternal deaths.

As the women’s-rights movement gained momentum, doctors, lawyers, and public-health advocates began lobbying to reform abortion laws. Some activists, tired of waiting for change, took matters into their own hands. Underground abortion-referral services began to operate across the country. The Army of Three, a trio of California activists, traveled nationwide, holding workshops; they also distributed lists of well-vetted abortion providers in other countries. The Clergy Consultation Service—a group numbering 1,400, mainly Protestant ministers but also including rabbis and Catholic priests—connected countless women with abortion providers. Their work is a reminder that the abortion debate, often presented in stark terms of religious faith versus personal freedom, has always been one where people weigh competing values in complex ways.

From the December 2019 issue: Caitlin Flanagan on the dishonesty of the abortion debate

Women like Lorraine Rothman and Carol Downer, meanwhile, were spreading the news about the Del-Em; before Roe, menstrual-extraction groups were active all across the country. Such work was part of a larger mission that activists called self-help: teaching women how to take charge of their own reproductive health. In Chicago, volunteers with a group called the Jane Collective started out by referring patients to abortion providers, then learned how to perform the procedure themselves. The group performed about 12,000 abortions from 1969 to 1973.

American women weren’t alone in pushing back against abortion restrictions. In Brazil, where abortion has been a crime since the late 19th century, women found another way to resist. In the 1980s, they discovered an off-label use for a drug called misoprostol, sold under the brand name Cytotec, which was marketed for treating stomach ulcers. It had a potent side effect: heavy uterine contractions that could expel an early pregnancy. This discovery led to misoprostol’s adoption as an abortifacient by the medical community. In 2005, the World Health Organization added misoprostol to its list of essential medicines, along with another abortifacient, mifepristone, better known as RU-486. The drugs have become a major focus of the American abortion underground today.

iv.
one december afternoon on a Zoom call conducted from Cambridge, Massachusetts, a dozen participants tucked Skittles and M&M’s into their cheeks, then looked at one another awkwardly. I was among them. We had been told to position the Skittles and M&M’s with care: two on each side of the lower jaw, nestled into the buccal cavity, the pouch running along the gums. This is a method for taking misoprostol. Absorbing the drug in this manner—or alternatively, by means of vaginal insertion—means it bypasses the digestive system, going directly into the bloodstream. Chipmunk-faced, we awaited further instructions.

Read: Women in the U.S. can now get safe abortions by mail

“Keep them there for 30 minutes,” instructed Susan Yanow, a reproductive-rights advocate. “What we’re going to learn right now is that’s easier said than done—to not chew, to not swallow.” In real life, she added, the pills would melt even more slowly than the candies. And they would taste like cardboard.

The audience had logged on from eight states, as well as from Poland and Peru, to learn about ending pregnancies with legal drugs and without medical supervision. In other words: self-managed abortion by means of pharmaceuticals. “The knowledge you’re going to get today is very empowering,” Yanow told the group. “But the real power is in sharing it.” If Roe is overturned, she said, more people will need access to this information, and fast. Part of Yanow’s job is spreading the word. She is the spokesperson for SASS—Self-Managed Abortion; Safe and Supported—a project of the global advocacy group Women Help Women, which had developed the day’s curriculum. The class was designed to self-replicate with a model called “train the trainer,” turning students into future teachers.

Abortion pills—mifepristone and misoprostol, colloquially called “mife” (pronounced “miffy”) and “miso”—are remarkably effective and medically safer than acetaminophen and Viagra. They’re FDA-approved for ending pregnancies up to 10 weeks’ gestation. The WHO has protocols for using them to end pregnancies up to 12 weeks’ gestation, and even later. (Taking them further along, however, can raise the risk of complications.) Misoprostol is often used on its own to induce an abortion. But the most effective protocol calls for both drugs in sequence, and with time in between—first mifepristone, then misoprostol. The combination is available online, for prices that typically range from $150 to as much as $600, depending on one’s state and insurance. In many states, it can legally be prescribed by telemedicine and delivered by mail.

Some reproductive-rights activists point to pharmaceuticals as the best fallback plan for a post-Roe era. Ending a pregnancy with pills, also known as medication abortion, already accounts for more than half of all abortions in the U.S. But most American adults don’t even know the option exists. Only about one in five has heard of medication abortion, according to a Kaiser Family Foundation survey published in 2020. Among adult women of reproductive age, it’s about one in three.

That knowledge gap can have serious consequences. Laurie Bertram Roberts is the executive director of the Alabama-based Yellowhammer Fund, which offers financial support for abortion seekers. In recent years, she told me, she has encountered or heard about situations in which pregnant women drink bleach or turpentine, “jab a coat hanger up into themselves,” or “ask their boyfriends to beat them up.” She believes that if more people knew about abortion pills—particularly women of color and the poor, who will be disproportionately affected by a Roe reversal—they would be far safer. “To me, as a Black person, it just makes sense,” she said.

black and white photo of four hexagonal pills and one round pill
A round mifepristone pill and hexagonal misoprostol pills—
the pharmaceuticals used in medication abortion (Hannah Whitaker for The Atlantic)
Pills are not a one-size-fits-all solution—no drug or medical procedure ever is. Any form of intervention requires care and common sense, and attention to other health issues. People with certain medical conditions, including bleeding disorders and adrenal failure, are unable to use abortion pills. And not everyone reacts to the medication the same way. In most cases, the contents of the uterus are expelled within four hours, and almost certainly within two days, but the process can take as long as a week. (In contrast, vacuum-aspiration methods are also used for terminating early pregnancies, but typically take less than 30 minutes.)

Laws governing access to the medications are in constant flux and differ wildly around the country; erecting roadblocks to abortion is a clear motivation behind much of the legislation. Thus, 19 states bar the use of telehealth for medication abortion or require patients to consume mifepristone in the physical presence of a clinician; some do both. That eliminates the cheaper and more convenient option: a consultation online or by phone, then receiving pharmaceuticals in the mail. In Texas, patients seeking a medication abortion must make three in-person visits: one for counseling, another to receive the pills, and a third for a medical check afterward.

Self-managed abortion is currently banned outright in three states. Its status is legally murky in many others. At the start of her three-hour class, Yanow opened a PowerPoint presentation. She showed us a map of the U.S. with 22 states shaded in orange. In those places, Yanow said, self-managed abortion had led to people being investigated. Some were charged with felonies under laws that were not actually intended to target abortion, including murder in Georgia and abuse of a corpse in Arkansas. In Indiana, a woman named Purvi Patel was convicted of feticide and given a 20-year sentence. The conviction was later overturned, but only after Patel had already served three years in prison. Yanow drove the message home: Anyone who helped those people could have been charged, too, as accessories to a crime.

If it were possible to feel the air go out of a Zoom room, we would have felt it then. But, Yanow continued, there was a simple way to stay safe legally. That was to only share information, rather than give explicit advice, encouragement, or assistance.

Yanow described the availability of misoprostol and mifepristone. Mife is tightly regulated and can cost more than $100 a pill. Miso is much cheaper and easier to find. It is used to treat stomach ulcers in humans as well as in cats, dogs, and horses. Pharmacies in Mexico sell misoprostol under its Cytotec brand name. The pills come in blue-and-white boxes with fuchsia accents and have a shelf life of about two years. “The last time I was in Nuevo Progreso, a tiny border town, they were stacked up on the counter like chocolate bars would be here,” Yanow recalled. “As if for an impulse buy.”

Yanow matter-of-factly described what people taking the two-drug combination can expect. The regimen starts with mife, a progesterone blocker that stops the pregnancy from growing. It continues one or two days later with miso, which makes the uterus contract and expel gestational tissue. The experience is like having a spontaneous miscarriage. There can be heavy cramping and bleeding, with the possibility of passing clots up to the size of a lemon. The possible side effects include nausea, vomiting, diarrhea, and fatigue. Complications are very rare, and generally resemble those associated with a miscarriage; there is a small risk of hemorrhage or retaining tissue (which may have to be removed by a medical provider). Bleeding through more than two maxi pads in an hour for more than two hours is considered excessive, warranting medical attention.* For the unprepared, a hospital visit could mean legal complications, too.


Yanow told the story of a woman named Jennifer Whalen, in Pennsylvania, who bought mife and miso online for her pregnant 16-year-old daughter. After the teenager took the pills, her miscarriage began. She became frightened when stomach pains hit, so Whalen drove her to an emergency room and told doctors about the pills. The daughter was fine, but Whalen was charged and pleaded guilty to offering medical advice without a license. She was given a jail sentence of nine to 18 months.

People in similar situations need to know how to present themselves to doctors, Yanow said. “They can say they’re having a miscarriage, or they’re bleeding and they don’t know why,” she explained. According to Paul Blumenthal, a professor emeritus of obstetrics and gynecology at Stanford University, it is safe for patients to self-report this way; a medication abortion is clinically indistinguishable from a spontaneous miscarriage and treated in the same fashion.

Later in the class, it was time to role-play. Yanow gave each of us a part. Some of us were six weeks pregnant and seeking abortion pills. Others had information to share and a mission: Pass it along. The goal was to avoid giving direct advice, because that could be construed as the unauthorized practice of medicine, a criminal offense. The key, Yanow said, was avoiding “that forbidden three-letter word: y-o-u.”


v.
no matter how the word is passed, more autonomy is coming, at least eventually—both in places that attempt outright bans and also where abortion remains legal. The weakening or overturning of Roe would of course have an impact, and it would be significant. Statewide bans on abortion would cause a rise in maternal deaths—of women with complicating health issues and of women who resort to dangerous methods. Maternal deaths will also rise because women who want an abortion can’t get one—childbirth is far riskier than ending a pregnancy.

But other forces are also at play. A post-Roe world will not resemble a pre-Roe world. Women already have different options. In Blumenthal’s view, the future doesn’t lie in Planned Parenthood (which in addition to education and advocacy offers abortion services through a network of clinics). “I think the future lies in more self-managed care and alternative distribution schemes,” he told me. Pharmaceuticals are a big part of that future—the work-around of first resort and one that’s hard for authorities to stop. Blumenthal’s confidence in the safety of medication abortion, including when it is self-managed, is the medical consensus, supported by the WHO, the FDA, and numerous studies.

In circumstances where pharmaceuticals may not be appropriate, he believes that laypeople can be instructed to wield manual vacuum-aspiration devices, including the Del-Em, with little risk of infection. Technicians without medical degrees, he added, have been using such tools safely for decades in South and Southeast Asia. “This is not a complicated procedure,” Blumenthal said. Vacuum aspiration outside a clinical setting is not “self-managed” the way pills can be—it requires assistance. Although specific studies are few, they suggest that outcomes involving trained nonphysicians are comparable to those involving physicians (and in either case, the risks are very low).


Even clinical abortion providers who work directly with patients acknowledge that the future may involve them less. Asked about this, Danika Severino Wynn, the vice president of abortion access for Planned Parenthood, replied in a written statement: “Some people may choose to self-manage their abortion with pills, and this may become more common as laws increasingly restrict access to legal care. Planned Parenthood honors and respects this decision and will provide education, support, and any needed clinical care to anyone who seeks it—no matter what.”

Some patients can’t—or don’t want to—manage their own abortions. For them, and for those seeking the dilation-and-evacuation abortions that are most commonly used in the second trimester, the services provided by Planned Parenthood and independent clinics will remain necessary. But for a variety of reasons, including legal restrictions on abortion, the number of brick-and-mortar clinics has been dwindling for years.

Efforts to prepare for a post-Roe future have been undertaken in unexpected places. In 2020, a hackers’ convention called HOPE included talks on coding and digital privacy along with something quite different: A speaker using the alias Maggie Mayhem showed how to build and operate a Del-Em in a workshop titled “Hackers in a Post Roe v. Wade World.” In her presentation, Mayhem employed a demonstration method that has been used for training clinicians and medical residents: evacuating a papaya. (According to research published in the journal Family Medicine, “Papayas resemble the early pregnant uterus in size, shape, and consistency, and their softness makes them somewhat more realistic models than durable plastic devices.”)

The van was being bulletproofed. It would be retrofitted with an ultrasound machine and a gynecological-exam table.
In December, when the Supreme Court heard oral arguments in Dobbs, post-Roe prepping intensified. Volunteers across the country handed out thousands of boxes labeled abortion pills. (Rather than actual medication, they contained cards with a link to shareabortionpill.info, a website that does what the name suggests.) The pro-pill message was amplified with posters, yard signs, stencils, a mural, a digital-billboard truck, and a plane towing a banner over Arizona. The campaign was run by Shout Your Abortion, a nonprofit that aims to destigmatize the procedure by helping people speak publicly about their experiences.

Whatever the laws may say, history has shown that women will continue to have abortions. The spread of pills and devices like the Del-Em—discreet, inexpensive, and fast—could, if nothing else, help ensure that abortions are done safely and, because of their accessibility, on average earlier in a pregnancy than is the norm today.

Even so, pill proselytizers and Del-Em makers are not the only ones prepping. A nonprofit called Abortion Delivered is planning to deploy mobile abortion vans. The first one was being readied when I spoke with a staff member at the organization who, like Ellie, did not wish to use her name. I’ll call her Angela. The van was being bulletproofed, Angela told me. It would then be retrofitted with an ultrasound machine and a gynecological-exam table, so a doctor with a manual vacuum-aspiration device could perform first-trimester abortions inside. Abortion Delivered, which originated in Minnesota, planned to dispatch the van—and a second one, stocked with abortion pills—to just outside the Texas border.

“They are small and inconspicuous,” Angela said. “Part of the appeal of it is that we can pass unnoticed and not draw attention.” She did worry about clinicians’ and patients’ safety along the edge of a heavily armed, anti-abortion state. Local FBI agents had been advising on security procedures, she said.

I asked Angela what Abortion Delivered would do with the vans if the Supreme Court weakened or overturned Roe. “Well, we’re going to need more,” she said. A cluster of nearby states—Wyoming, North and South Dakota, Nebraska—would likely also curtail abortion access. “We will just be driving up and down the borders,” she explained. “With four fleets, we think we could cover them.” She already has road experience, having delivered abortion pills throughout rural Minnesota in a rented Winnebago. “We would be in one town for 20 minutes,” Angela said, and then the Winnebago would move on. “And no one knew our route.” This may sound like the public-health version of Mad Max meets Station Eleven, but it’s easy to see how such a scene could become part of the future. Abortion providers have been traveling from state to state for decades—they used to be called “circuit riders”—to work at understaffed abortion clinics, often in hostile territory.

If the abortion deserts of the Midwest and the South become even more arid than they already are, people will take to the road in ever-greater numbers. Clinicians got a preview of the abortion diaspora after Texas—home to one in 10 reproductive-aged American women—passed its ban. According to a study published earlier this year, clinics as far as Maryland and Washington State saw a rise in patients from Texas. The resulting backlog also created longer wait times. Pregnancies progressed. Some patients who would have otherwise been eligible for abortion pills or manual vacuum aspiration ended up requiring second-trimester surgeries instead.

Other abortion seekers found themselves stuck in Texas. Some ended up having to give birth, unless they were among the lucky few to stumble on an underground provider network. One California activist described mailing misoprostol—something she’d never done before—after getting a panicked request from Texas. “A friend of a friend of a friend reached out and said, ‘There’s a 13-year-old girl who needs access, like, right now. And I know that the timing is bad, but can you help?’ ” Her package, which also included a greeting card, some coffee, and Naomi Alderman’s novel The Power, about women taking over the world, arrived the day the ban took effect.

vi.
more of america may soon look like Texas—but in a post-Roe world, states where abortion remains accessible could look quite different too. The new infrastructure being put into place extends beyond the grassroots efforts of American abortion activists. California and New York—the two states with the most abortion clinics—have been preparing for an influx of patients. “We’ll be a sanctuary,” California Governor Gavin Newsom stated in December. Planned Parenthood clinics in Orange and San Bernardino Counties are already staffing up, according to the Los Angeles Times. Political leaders pushed for public funds to cover the costs of low-income, out-of-state women visiting for abortions. In New York, Attorney General Letitia James proposed a similar fund to make the state a “safe haven.”

black and white photo of firefighters and person in safety vest talking in front of burned building with roof caved in behind a chain link fence
Firefighters at the Planned Parenthood office in Knoxville, Tennessee, after an arson attack on New Year’s Eve (Caitie McMekin / Knoxville News Sentinel / AP)
Activists in Mexico, whose Supreme Court decriminalized abortion last year, have been planning to help Americans with access. Some are already getting misoprostol into the U.S., by foot and by mail. Aid Access, an Austrian nonprofit, now offers “advance provision,” allowing Americans who aren’t pregnant to order mife and miso for possible future use. The organization serves all 50 states, including those with restrictions on medication abortion. The founder of Aid Access is Rebecca Gomperts, a physician who first gained prominence for creating the organization Women on Waves, which sailed to countries where abortion was illegal, picked up patients, then administered abortion pills in international waters. Similar methods—floating clinics in the Gulf of Mexico’s federal waters; a cruise ship turned clinic anchored outside U.S. jurisdiction—are on the minds of American activists.


In late January, I visited three women from a West Coast menstrual-extraction group founded in 2017 by a sex educator I’ll call Norah, who had organized it as a response to President Donald Trump’s election on an anti-Roe platform. The four of us sat in a backyard bungalow, eating cheese and crackers as a fireplace crackled on a wall-mounted television. The group members talked about abortion access—which they hoped to expand by teaching menstrual extraction to activists in heavily regulated states. They had already trained visitors from Kentucky and Texas and had plans to host someone from Ohio.

After talking for almost two hours, we filed into a bedroom for a demonstration. A woman I’ll call Kira attached a Del-Em to a pink Spectra S2 breast pump. Once switched on, the machine began to purr and click at regular intervals; it sounded like a robot snoring.

Norah, who was not pregnant but was menstruating, undressed from the waist down and lay on the bed. She expertly installed a speculum in her vaginal canal, creating a direct route to her cervix. Kira began to insert the cannula. “I’m at your os,” she said, referring to the cervical opening. “Is it okay to enter?”

“Go for it,” Norah said. The group chatted to pass the time—why do faxes still exist?—until blood appeared in the aquarium tube.


After 15 minutes of extraction, a small clot, nothing unusual, clogged the cannula. Because this was just a demonstration and Norah was getting crampy, they decided to stop. Kira removed the cannula and let the tube drain into the mason jar, where the contents settled: an inch of blood. And then it was over.

I thought back to an afternoon I’d spent interviewing Carol Downer, who toured the Del-Em across America with Lorraine Rothman more than 50 years ago. On her porch in a quiet Los Angeles suburb, we talked about what might happen if the constitutional right to abortion was lost. Downer was glad pharmaceuticals had been added to the feminist toolbox, she told me, though she was concerned about the government finding a way to take them out of women’s hands and she worried about people taking pills in isolation, without a context of friendly support. Downer still kept a Del-Em in her library, sitting on a table. She was confident the device would remain available. (“It’s a lot harder to ban mason jars,” she observed.) She reflected on the new underground that was growing, and the variety of tools it was employing: “We need all of these things,” she explained.

vii.
efforts are expanding to provide the kind of friendly support spoken of by Downer. On a Saturday evening in early January, some 40 participants trickled into a conference room on Jitsi Meet, an encrypted, open-source Zoom alternative favored by the anti-surveillance set. We had been instructed beforehand: No real names. No audio, except for the presenters. No video. The screen filled up with blacked-out squares and aliases: Jolly Broccoli. Astronaut Witch. Blue Dinosaur. Tulip Jones. Adventurous Fern.


Zane (a pseudonym) was a volunteer with Autonomous Pelvic Care, an Appalachia-based reproductive-health organization that teaches courses for community-care providers on subjects such as self-managed abortion with pills, menstrual extraction, fertility tracking, and digital security. It had been a fraught week. Eight days earlier, on New Year’s Eve, an arsonist had burned down the Planned Parenthood office in Knoxville, Tennessee. Ever since, Zane told me, they’d been preparing to host this evening while fielding panicky messages from community members asking, “What do we do now?”

I ordered the pills on Saturday night. I didn’t have to speak with anyone directly. An online questionnaire took less than 15 minutes.
Tonight’s session featured four educators and was aimed at community providers and anyone else who might be supporting someone through a self-managed abortion. Zane started the session by talking through a protocol for mifepristone and misoprostol. One of the evening’s presenters, an herbalist and doula with Holistic Abortions, offered ways to ease the process—before, during, and after—with the goal of improving the whole abortion experience.


Next came a volunteer from Mountain Access Brigade, which runs a secure voice-and-text support line for abortion seekers in eastern Tennessee and Appalachia who need logistical, emotional, and financial assistance. She shared a website called Plan C, which includes a state-by-state directory for ordering pills online.

The last presenter was from If/When/How, a reproductive-justice legal-advocacy group that had recently announced a $2 million defense fund to cover bail, expert witnesses, and attorneys’ fees for people who get arrested after managing their own abortions. Prosecutors, she noted, have been known to repurpose obscure laws—including some from the 18th century—that were not meant to criminalize self-managed abortion.

Much of the material in this workshop and Susan Yanow’s session was new to me. But the tone felt familiar: Two years into the pandemic, we’ve all become public-health preppers. We’re more keenly attuned to threats and better stocked with the tools—hand sanitizer, antigen tests—to meet them.

No matter what happens to Roe, my own freedoms seemed unlikely to change much, at least for the foreseeable future; after all, I was living at the time in Los Angeles and make my permanent home in New York City. Even so, I decided to order some pills. I went online to Plan C and scrolled through the drop-down menu to California. There was a buffet of choices: Six telehealth providers, including Aid Access and start-ups called Hey Jane and Choix, offered mifepristone and misoprostol together beginning at $150.


For preppers—people who wouldn’t need the pills immediately—the best choice appeared to be ordering them from Aid Access, the only service offering advance provision. I placed my order on Saturday night, a few hours after the Autonomous Pelvic Care session wrapped up. I didn’t have to speak with anyone directly. An online questionnaire took less than 15 minutes and ended by asking the reason for my order, with a litany of mostly depressing options: Stigma. Cost. Having to deal with protesters. The need to keep my treatment a secret. Legal restrictions. Risk of abuse from my partner. The next day, my order was approved and I made an online payment of $150.

Four days later, a U.S. Postal Service package arrived. It came from an online pharmacy called Honeybee Health, just seven miles from where I was living. Inside, a plastic sleeve patterned with festive dots held the goods: a few leaflets, a box of mifepristone, and a teal bottle with hexagonal tablets inside. I tipped them into my palm and counted eight misoprostol pills. They looked utilitarian and chalky, nothing like M&M’s.

The instructions were printed on a double-sided flyer. A cartoon showed two pills tucked inside a cheek. Another showed a woman lying on her side, barefoot, eyes closed. Her arms were wrapped around her midsection. Her knees were drawn up to her chest. The caption said, “Expect bleeding.” Looking at the drawing made me feel queasy, even a bit afraid. I wanted to draw a friend next to her.


Instead, I rewrapped the package. Then I tucked it away, wondering if the contents would look any different in June.

This article appears in the May 2022 print edition with the headline “The Abortion Underground.”

* This article originally misstated the level of bleeding considered excessive after a medication abortion. It has also been updated to reflect a “trigger ban” law passed in Wyoming last month.

Jessica Bruder is a Brooklyn-based journalist and the author of three books, including Nomadland: Surviving America in the Twenty-First Century.



理念
ROE的终结
美国堕胎的未来可能是什么样子的

作者：杰西卡-布鲁德
一个女人在空白墙上的影子
照片插图：奥利弗-蒙代。来源。Deborah Spronk / EyeEm / Getty
2022年4月4日


更新于美国东部时间2022年4月5日上午9点22分。

i.
1月初的一个明亮的下午，在南加州的一个海滩上，一个年轻女子在一条橙色圆点毛巾上铺开了一个看起来非常奇怪的野餐。一个梅森罐。一个有两个孔的橡胶塞。一个没有针头的注射器。一卷水族馆的管子和一个单向阀。一个塑料窥镜。几个独立包装的无菌插管--设计用于插入人体的细管--类似于长的苏打水吸管。最后，还有一个女性生殖系统的三维比例模型。

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我们两个人坐在沙滩上。这个女人，我叫她埃莉，建议我们在海边见面；她最近刚从COVID-19中恢复过来，为了我的安全，她提议在露天环境下见面。她也不想冒险透露她的住处，并要求我隐瞒她的名字，因为担心反堕胎极端分子的骚扰或暴力。


艾丽把橡胶塞子塞进了泥瓦罐里。她将水族馆的管子剪成一对一英尺长的片段，并将阀门连接到注射器的塑料头。不到10分钟，艾莉就完成了这个项目：一个简单的流产装置。它看起来就像一个家用啤酒酿造工具和七年级科学实验之间的交叉。

两段管子从塞子上的孔里伸出来。一根连接着插管，另一根连接着注射器。艾莉拿着解剖模型，用插管的尖端描画出一条进入阴道并穿过子宫颈的路径，将其定位为吸出子宫内容物。接下来，为了更清楚地展示抽吸过程是如何进行的，她将插管放入她的咖啡。当她抽回注射器上的活塞时，深色的液体穿过水族馆的管子，进入梅森罐，在菱形图案的玻璃中慢慢收集。

我以前读过关于这种装置的文章。但是，看着沙滩巾上的这一幕，历史变得清晰得令人吃惊。在上一次堕胎非法的时候，妇女就这样做了。

艾莉并没有发明这种装置。这一殊荣要归功于洛林-罗斯曼（Lorraine Rothman），她是橙县的一名公立学校教师和活动家。1971年，她的女权主义自助小组的成员一直在熟悉圣莫尼卡的一家非法堕胎诊所的工作。诊所老板是一位名叫哈维-卡曼的心理学家，他设计了一根细长、灵活的吸管--现在被称为卡曼插管，是一种标准的医疗设备--他用它来把子宫里的东西抽到一个大注射器里。卡曼的方法只需几分钟，并被戏称为 "午餐时间流产"，因为病人之后可以恢复正常活动。这种方法比扩张和刮宫术的侵入性要小，后者是一种使用手术器械刮除子宫壁的手术。


在最高法院对罗伊诉韦德案的裁决改变了美国堕胎的法律格局的两年前，罗斯曼正在开发她自己版本的卡曼仪器，在水族馆和化学实验室里翻找零件。她添加了一个旁通阀，以防止空气意外地被抽回子宫，并添加了一个梅森罐以增加容纳量。结果是一个容易制造的堕胎装置，适合在头三个月的大部分时间内结束妊娠。

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为了达到合理推诿的目的，罗斯曼将该设备作为她所说的 "月经提取 "的工具进行宣传：妇女可以使用这种技术一次性排出整个月经，而不是分几天。1971年10月，她与一位积极分子卡罗尔-唐纳（Carol Downer）开始了灰狗巴士之旅，以传播这一信息。在六个星期内，他们访问了23个城市，从洛杉矶到曼哈顿，并称自己为西海岸姐妹。很快，全国各地的妇女都在制造这种设备，罗斯曼和唐纳称之为Del-Em。(今年早些时候，当我见到现年88岁的唐纳时，我问她这个名字的含义；她说这是一个 "内部的东西"，"不能分享"）。

人们可能会认为，在罗肯定了美国各地的堕胎宪法权利之后，德尔-埃姆就会消失了。然而，Del-Em仍然悄悄地在这里和那里使用，从一代传到另一代。部分原因是人们继续担心堕胎权会再次受到限制--如果最高法院支持全州的禁令，这一事件现在可能迫在眉睫。但这也是因为一些妇女希望保持对自己身体的控制，不受医学界的监督，不管罗的地位如何。

德尔-埃姆装置的黑白照片：密封的泥瓦罐里有两根插入塞子的软管，一根与注射器相连，一根与插管相连
管子、塞子、插管、注射器：Del-Em的构成，这是在前罗伊时代为早期堕胎而创造的装置（汉娜-惠特克为《大西洋》撰写）。
活动人士仍在对罗斯曼的设计进行修补。一个人增加了第二个阀门。另一个人使用阴茎泵（一种用于刺激勃起的真空装置）升级了吸力，他解释说："这就像从摩天大楼到兰博基尼一样。" 一位住在加拿大的美国助产士告诉我，他重新利用了一个汽车刹车放血工具。"你只需在末端加一个插管"。她估计，她已经进行了数百次堕胎，使用了Del-Em，但也使用了其他方法，包括医疗级别的手动真空吸管套件和药品。这位助产士是自称的 "社区提供者 "网络的一部分--这个术语指的是在医疗系统之外进行堕胎和提供其他生殖保健服务的人。在冠状病毒大流行之前，她在美国和加拿大各地旅行并亲自教授讲习班。现在她在网上授课。艾丽在她的一堂课上学会了制作Del-Em。

对艾莉来说，Del-Em的象征意义大于实际意义--一个来自过去的护身符，可以带入不确定的未来。毕竟，现在药品可以用来终止妊娠的前三个月，而90%以上的合法堕胎都发生在这个阶段。(几乎99%的堕胎发生在前20周。)也有现代的、大规模生产的手动真空吸引装置，可以做Del-Em的工作。社区提供者已经谈论过储存这种用品，以备罗伊倒台。艾莉为那些赞同这一观点的人创造了一个术语。"阴道预备者"。

对许多美国人来说，罗伊已经感觉毫无意义。美国近90%的县都没有提供堕胎的诊所。
鉴于这种不确定性，她建议，有一个像Del-Em这样的自己动手的工具也无妨。"她说："只要知道在你之前的人有其他方法来处理这些事情，不一定要通过医生或政府的纵容--这里面有一些非常强大的东西。

当艾莉把她的用品装回一个手提袋时，她告诉我带上Del-Em。她还把窥镜给了我。

请听The Experiment播客。当最高法院准备在6月审理一个可能推翻罗伊-韦德案的案件时，记者杰西卡-布鲁德与准备将堕胎掌握在自己手中的活动家进行了交谈。


收听和订阅。Apple Podcasts | Spotify | Stitcher | Google Podcasts

II.
这几天有很多关于准备工作的讨论。罗伊诉韦德案很可能在6月底被进一步削弱或推翻，届时最高法院将对多布斯诉杰克逊妇女健康组织案做出裁决。争论的焦点是密西西比州的一项法律，它禁止几乎所有怀孕15周以上的堕胎。这是对罗伊案和近二十年后法院对计划生育诉凯西案的后续裁决的直接挑战。在这两项裁决中，法院认为各州可以禁止堕胎（除非母亲的健康或生命受到威胁），但只能超过胎儿的生存能力，而凯西案认为这时妇女大约怀孕23至24周。在这之前，法院的裁决允许各州对堕胎施加有限的限制，只要它们不对妇女的堕胎权构成 "不适当的负担"。法院现在有一个6-3的保守派多数。通过支持密西西比州的禁令，它在本质上将使罗伊对宪法规定的在生存能力之前进行堕胎的权利失效。根据2021年的盖洛普民意调查，只有不到三分之一的美国人支持这一结果。堕胎的合法性将在很大程度上留给各州。根据支持堕胎权利的研究组织古特马赫研究所（Guttmacher Institute）的数据，如果最高法院提供法律空间，超过一半的州肯定或可能会尝试禁止堕胎，而这些法律将在罗伊被推翻时生效。

对许多美国人来说，罗伊已经感觉毫无意义。美国近90%的县都没有提供堕胎的诊所。自从堕胎成为一项宪法权利以来，各州已经通过了1300多项限制；对于挣扎求生的人来说，这些限制可能是不可逾越的。获得堕胎往往意味着长途跋涉，这也意味着要找钱买交通、住宿和儿童护理，更不用说请假了。在一些州，人们可能在到达诊所后才得知，法律上要求他们进行两次就诊，一次是咨询，另一次是堕胎，中间有长达三天的强制等待时间。诊所内堕胎的费用从怀孕前三个月的500美元到怀孕后的1000多美元不等；根据一项名为 "海德修正案 "的长期限制，这笔费用没有资格获得联邦资助，这使得许多低收入人群无法获得堕胎。

一个庞大的基层基础设施已经在这种挑战造成的裂缝中成长起来，即使罗伊仍然是国家的法律。90多个被称为堕胎基金的地方组织筹集资金来支付手术和相关费用。实用支持团体提供前往医疗机构的交通工具，以及住房、儿童护理和翻译服务。诊所的护送人员引导病人避开愤怒的抗议者人群。医生和其他堕胎服务提供者跋涉数百英里，在对堕胎公开持敌意的服务不足的地区工作。


不过，这个临时组成的安全网并不能覆盖所有人。在草根阶层之下的是地下组织：一个由社区提供者组成的小型网络，他们通过口口相传与寻求堕胎者联系。这个网络也在不断壮大。它的队伍包括助产士、草药师、杜拉拉和教育家。必要时，他们往往愿意绕过法律。

甚至在大流行之前，随着国家限制的增加，基层和地下组织也在努力满足帮助的需求。然后，当冠状病毒首次涌现时，十几个州--其中大部分在南方，但也包括阿拉斯加、爱荷华和俄亥俄州--着手暂停几乎所有的堕胎服务，将其描述为非必要的程序。其中一些努力暂时取得了成功，在一些人看来，这就像是罗伊法案终结的一次彩排。去年秋天，当德克萨斯州使用创造性的法律策略禁止大多数妊娠六周后的堕胎时，这种感觉又回来了。到目前为止，对该法律的法律挑战已经失败。

德州法律的影响是直接的。邻近各州出现了大量寻求帮助的人，造成了瓶颈，并迫使当地病人在第二轮移民潮中自己到州外去。一个术语得到了流行。"堕胎难民"。

艾丽告诉我，她对德克萨斯州的发展感到厌恶。她说："我们的生殖权利不是政府给我们的，"她说。"它们不是由任何人赋予我们的。我们天生就有这些权利。" 她对这种独立性的信念是在目前的辩论之前很久就形成的；她解释说，她的家庭一直对替代医学感兴趣，在7、8岁时，她想成为一名助产士。十几岁时，她读了一本名为《红帐篷》的小说，故事背景是圣经时代，书名指的是妇女在月经和分娩期间的一个避难所。在高中时，同学们把他们关于性的尴尬问题带给她。大学毕业后，艾莉参加了一个性教育工作者的静修会，重新点燃了她的旧兴趣。她从事为助产士和杜拉拉提供后勤支持的工作，并最终开始了生殖健康方面的业务--她自己的红色帐篷。


III.
现在看来很难想象，但美国在堕胎问题上的分歧并不总是那么尖锐。在美国独立的最初几十年里，各州以传统的英国普通法为指导，在 "胎动 "之前不承认胎儿的存在：妇女感觉到胎儿移动的时刻，通常是在怀孕的第二个季度。在此之前，即使是怀疑怀孕，也没有办法确认。妇女可以合法地寻求缓解医生所说的 "月经受阻"，向助产士或家庭保健手册寻求治疗，在许多情况下，使用自古以来就被使用的草药（有时至今仍在使用）。

阅读：把花弄倒了。有争议的堕胎历史

正如历史学家詹姆斯-莫尔（James Mohr）所指出的那样，在19世纪的前三分之一，堕胎被广泛视为妇女为避免私生子的耻辱而不顾一切的最后手段。在接下来的几十年里，堕胎的发生率上升。莫尔解释说，这种推动力主要来自 "白人、已婚、新教徒、土生土长的中上层妇女，她们要么希望推迟生育，要么已经有了她们想要的所有孩子。" 到了本世纪中叶，报纸上充斥着专利药品的广告，如范登堡医生的女性革新药丸和德鲁内特夫人的月经药丸，这些药丸声称--用眉毛拱起的方式来恢复月经周期。一些商业制剂是危险的；19世纪20年代和30年代通过的第一批堕胎法规，主要是旨在管制这些产品的毒物控制措施。

几年后开始的更明确地规范堕胎的努力，则没有那么多的公民意识。当时，美国的医生们正在努力组织和巩固他们的职业。在1847年成立美国医学协会后，他们开始游说反对堕胎--表面上是出于道德原因，但也有一部分是为了消除来自助产士和顺势疗法的一些竞争。在一代人的时间里，每个州都制定了法律，将这种做法定为犯罪，将其推入阴曹地府，招致危险的程序。根据古特马赫研究所的数据，1930年，约有2700名妇女死于堕胎。虽然一些提供者--包括医生--设法提供安全的、有时是秘密的护理，但许多妇女求助于黑心医生或自我管理的堕胎。到1965年，非法堕胎造成的死亡人数仍占孕产妇死亡人数的近五分之一。

随着妇女权利运动的发展，医生、律师和公共卫生倡导者开始游说改革堕胎法。一些活动家厌倦了等待变革，把事情交给了自己。地下堕胎转介服务开始在全国各地运作。由加利福尼亚活动家组成的三人小组 "三军 "在全国范围内旅行，举办研讨会；他们还分发了其他国家经过严格审查的堕胎提供者名单。教士咨询服务组织--一个人数达1400人的团体，主要是新教牧师，但也包括拉比和天主教牧师，为无数妇女与堕胎提供者建立了联系。他们的工作提醒我们，经常以宗教信仰与个人自由的鲜明术语呈现的堕胎辩论，一直是人们以复杂的方式权衡相互竞争的价值观。

来自2019年12月号。凯特琳-弗拉纳根谈堕胎辩论的不诚实性

与此同时，像洛林-罗斯曼(Lorraine Rothman)和卡罗尔-唐纳(Carol Downer)这样的妇女正在传播关于德尔-埃姆的消息；在罗伊之前，全国各地都有活跃的月经提取团体。这种工作是活动家称为自助的更大任务的一部分：教妇女如何掌握自己的生殖健康。在芝加哥，一个名为 "Jane Collective "的团体的志愿者开始时将病人介绍给堕胎提供者，然后自己学习如何进行堕胎手术。从1969年到1973年，该团体进行了大约12,000次堕胎。

并不是只有美国妇女在反对堕胎限制。在巴西，自19世纪末以来，堕胎一直是一种犯罪，妇女们找到了另一种反抗的方式。20世纪80年代，她们发现了一种名为米索前列醇的药物的标签外用途，该药物以Cytotec的品牌名称出售，在市场上被用于治疗胃溃疡。它有一个强大的副作用：子宫剧烈收缩，可以排出早孕。这一发现导致医学界将米索前列醇作为一种堕胎药使用。2005年，世界卫生组织将米索前列醇和另一种堕胎药米非司酮（又称RU-486）一起列入其基本药物清单。这些药物已经成为今天美国地下堕胎的一个主要焦点。

iv.
12月的一个下午，在马萨诸塞州剑桥市进行的一次网络电话会议上，十几位与会者把巧克力和M&M糖塞进他们的脸颊，然后尴尬地相互对视。我也在其中。我们被告知要小心翼翼地摆放Skittles和M&M的位置：下颌两侧各放两颗，依偎在口腔内，小袋沿牙龈运行。这是一种服用米索前列醇的方法。以这种方式吸收药物--或者通过阴道插入的方式--意味着它绕过消化系统，直接进入血液中。花栗鼠脸，我们等待着进一步的指示。

阅读。美国的妇女现在可以通过邮件获得安全的堕胎。

"让他们在那里呆30分钟，"生殖权利倡导者苏珊-亚诺指示道。"我们现在要学习的是说起来容易做起来难--不要咀嚼，不要吞咽。" 她补充说，在现实生活中，这些药丸会比糖果融化得更慢。而且它们的味道像纸板。

听众们从八个州以及波兰和秘鲁登陆，了解在没有医疗监督的情况下用合法药物结束怀孕的情况。换句话说：通过药物进行自我管理的堕胎。"亚诺告诉大家："你们今天将得到的知识是非常有力量的。"但真正的力量在于分享它"。她说，如果罗伊被推翻，更多的人将需要获得这些信息，而且要快。亚诺的部分工作是传播这个消息。她是SASS--自我管理的堕胎；安全和支持--全球倡导组织 "妇女帮助妇女 "的项目的发言人，该组织制定了当天的课程。该课程旨在通过一种名为 "培训培训师 "的模式进行自我复制，将学生变成未来的教师。

堕胎药--米非司酮和米索前列醇，俗称 "米菲"（发音为 "miffy"）和 "米索"--非常有效，在医学上比醋氨酚和伟哥更安全。它们被美国食品和药物管理局批准用于终止妊娠10周以内的妊娠。世卫组织有使用它们来结束妊娠12周甚至更长时间的妊娠的协议。(米索前列醇通常被单独用于诱导流产。但是最有效的方案要求依次使用这两种药物，而且中间要有时间间隔--首先是米非司酮，然后是米索前列醇。这种组合在网上可以买到，价格通常从150美元到高达600美元不等，取决于个人的州和保险。在许多州，它可以合法地通过远程医疗开具处方，并通过邮件发送。

一些生殖权利活动家指出，药品是后罗伊时代的最佳后备计划。用药片结束妊娠，也被称为药物流产，已经占到了美国所有流产的一半以上。根据凯撒家庭基金会在2020年发表的一项调查，大约只有五分之一的人听说过药物流产。在成年育龄妇女中，大约三分之一的人知道。

这种知识差距可能会产生严重的后果。劳里-伯特伦-罗伯茨（Laurie Bertram Roberts）是位于阿拉巴马州的Yellowhammer基金的执行董事，该基金为寻求堕胎者提供财政支持。她告诉我，近年来，她遇到或听说过这样的情况：孕妇喝漂白剂或松节油，"把衣架插到自己身上"，或者 "要求她们的男朋友打她们"。她认为，如果更多的人知道堕胎药--特别是有色人种和穷人，他们将受到罗伊案逆转的不成比例的影响--他们会安全得多。"她说："对我来说，作为一个黑人，这只是有意义的。

四个六角形药丸和一个圆形药丸的黑白照片
圆形的米非司酮药片和六边形的米索前列醇药片--在药物流产中使用的药品。
用于药物流产的药品（Hannah Whitaker for The Atlantic）
药片不是万能的解决方案--任何药物或医疗程序都不是。任何形式的干预都需要谨慎和常识，并注意其他健康问题。患有某些疾病的人，包括出血性疾病和肾上腺功能衰竭，是不能使用堕胎药的。而且不是每个人对药物的反应都一样。在大多数情况下，子宫内容物在四小时内被排出，几乎可以肯定在两天内被排出，但这一过程可能需要长达一周。(相比之下，真空吸引法也被用于终止早期妊娠，但通常需要不到30分钟）。

有关获取药物的法律在不断变化，全国各地的情况也大不相同；为堕胎设置路障是许多立法背后的一个明显动机。因此，19个州禁止使用远程医疗进行药物流产，或要求病人在临床医生在场的情况下服用米非司酮；有些州两者都有。这就排除了更便宜、更方便的选择：在网上或通过电话进行咨询，然后通过邮件接收药品。在德克萨斯州，寻求药物流产的病人必须进行三次面谈：一次是咨询，另一次是领取药丸，第三次是事后的医疗检查。

目前有三个州完全禁止自我管理的堕胎。在其他许多州，其地位在法律上是模糊的。在她三个小时的课程开始时，亚诺打开了一个PowerPoint演示文稿。她向我们展示了美国的地图，其中有22个州用橙色的阴影表示。亚诺说，在这些地方，自我管理的堕胎导致了人们被调查。一些人被指控犯有重罪，而这些法律实际上并不是针对堕胎的，包括佐治亚州的谋杀和阿肯色州的虐待尸体。在印第安纳州，一位名叫Purvi Patel的妇女被判定犯有堕胎罪，并被判处20年监禁。该判决后来被推翻，但只是在帕特尔已经在监狱中服刑3年之后。亚诺将这一信息带回家。任何帮助这些人的人也可能被指控为犯罪的从犯。

如果有可能感觉到变声室里的空气消失，我们当时就会感觉到。但是，亚诺继续说，有一个简单的方法可以在法律上保持安全。那就是只分享信息，而不是给予明确的建议、鼓励或帮助。

亚诺描述了米索前列醇和米非司酮的可用性。米菲是受到严格管制的，价格可能超过100美元一粒。米索要便宜得多，而且更容易找到。它可用于治疗人类以及猫、狗和马的胃溃疡。墨西哥的药店以Cytotec的品牌名称销售米索前列醇。这些药丸装在有紫红色装饰的蓝白盒子里，保质期约为两年。亚诺回忆说："上次我在新普罗格雷索（Nuevo Progreso）这个边境小城时，这些药片被堆放在柜台上，就像这里的巧克力棒一样，"。"好像是为了冲动购买。"

亚诺实事求是地描述了服用这两种药物组合的人可以期待什么。该方案从米菲开始，米菲是一种黄体酮阻断剂，可以阻止妊娠的生长。一两天后继续使用味噌，它使子宫收缩并排出妊娠组织。这种经历就像自然流产。可能会有严重的痉挛和出血，有可能排出多达柠檬大小的血块。可能的副作用包括恶心、呕吐、腹泻和疲劳。并发症非常罕见，一般与流产相关的并发症相似；有少量出血或保留组织的风险（可能必须由医疗机构切除）。一小时内出血超过两块特大号护垫并持续两小时以上被认为是过度出血，需要就医。*对于没有准备的人来说，去医院看病也可能意味着法律上的并发症。


Yanow讲述了宾夕法尼亚州一位名叫Jennifer Whalen的妇女的故事，她在网上为她怀孕的16岁女儿购买了mife和味噌。这名少女服用药丸后，她开始流产。当胃痛发作时，她变得很害怕，所以惠伦开车把她送到急诊室，并告诉医生这些药丸的情况。女儿没事，但惠伦被指控无证提供医疗建议并认罪。她被判处9至18个月的监禁。

亚诺说，处于类似情况的人需要知道如何向医生介绍自己。她解释说："他们可以说他们流产了，或者他们在流血，他们不知道为什么，"。据斯坦福大学妇产科名誉教授保罗-布卢门撒尔（Paul Blumenthal）说，病人以这种方式自我报告是安全的；药物流产在临床上与自然流产没有区别，并以同样的方式对待。

在课堂的晚些时候，是进行角色扮演的时候。亚诺给了我们每个人一个角色。我们中的一些人已经怀孕六周，正在寻找堕胎药。其他人则有信息要分享，还有一个任务。传递信息。我们的目标是避免直接提供建议，因为这可能被理解为未经授权的行医，是一种刑事犯罪。亚诺说，关键是要避免 "那个被禁止的三个字母的词：Y-O-U"。


v.
无论这个词如何通过，至少最终会有更多的自主权--无论是在试图直接禁止的地方还是在堕胎仍然合法的地方。削弱或推翻罗伊法案当然会有影响，而且影响很大。全州禁止堕胎将导致产妇死亡人数增加--有复杂健康问题的妇女和诉诸危险方法的妇女。孕产妇死亡人数也会增加，因为想要堕胎的妇女不能得到堕胎，分娩的风险远远大于终止妊娠。

但其他力量也在发挥作用。后罗伊时代的世界将不会与前罗伊时代的世界相似。妇女已经有了不同的选择。在布卢门撒尔看来，未来并不在于计划生育（除了教育和宣传，它还通过诊所网络提供堕胎服务）。"他告诉我："我认为未来在于更多的自我管理的护理和替代性分配方案。药品是这一未来的重要组成部分--这是首选的变通办法，也是当局难以阻止的办法。布卢门撒尔对药物流产的安全性有信心，包括在自我管理的情况下，这是医学界的共识，得到了世界卫生组织、美国食品和药物管理局以及众多研究的支持。

在药物可能不合适的情况下，他认为可以指导非专业人士挥舞手动真空吸引器，包括Del-Em，而且感染的风险很小。他补充说，没有医学学位的技术员在南亚和东南亚已经安全地使用这种工具几十年了。"Blumenthal说："这不是一个复杂的程序。在临床环境之外的真空抽吸并不像药片那样可以 "自我管理"，它需要协助。虽然具体研究不多，但它们表明，涉及训练有素的非医生的结果与涉及医生的结果相当（而且在任何一种情况下，风险都很低）。


即使是直接与病人打交道的临床流产提供者也承认，未来他们可能会减少参与。在被问及这个问题时，计划生育协会负责堕胎服务的副总裁Danika Severino Wynn在一份书面声明中回答。"有些人可能会选择用药片来自我管理他们的堕胎，而且随着法律越来越多地限制获得合法护理，这种情况可能会变得更加普遍。计划生育协会尊重这种决定，并将向任何寻求这种决定的人提供教育、支持和任何需要的临床护理--无论如何。"

一些病人不能或不想管理他们自己的堕胎。对于他们，以及那些寻求在怀孕后三个月最常使用的扩张和疏散流产的人来说，计划生育和独立诊所提供的服务仍然是必要的。但由于各种原因，包括对堕胎的法律限制，多年来实体诊所的数量一直在减少。

为后罗伊时代的未来做准备的努力已经在意想不到的地方展开。2020年，一个名为 "HOPE "的黑客大会包括关于编码和数字隐私的讲座，以及一些非常不同的东西。一位化名为Maggie Mayhem的演讲者在题为 "后罗伊诉韦德时代的黑客 "的研讨会上展示了如何建造和操作一台Del-Em。在她的演讲中，Mayhem采用了一种已经被用于培训临床医生和住院医生的示范方法：疏散木瓜。(根据发表在《家庭医学》杂志上的研究，"木瓜在大小、形状和粘性上与早期怀孕的子宫相似，而且它们的柔软性使它们在某种程度上比耐用的塑料装置更真实的模型"）。

这辆面包车正在进行防弹处理。它将被改装成一台超声波机和一个妇科检查台。
12月，当最高法院听取多布斯案的口头辩论时，"后罗伊 "的准备工作加强了。全国各地的志愿者分发了数以千计的标有堕胎药的盒子。(这些盒子里装的不是真正的药物，而是带有Shareabortionpill.info链接的卡片，这个网站的作用正如其名）。支持堕胎药的信息通过海报、院子里的标志、模板、壁画、数字广告牌卡车和一架拖着横幅的飞机在亚利桑那州上空放大。该活动由 "呼喊你的堕胎"（Shout Your Abortion）发起，这是一个非营利组织，旨在通过帮助人们公开讲述他们的经历来消除堕胎的耻辱。

无论法律如何规定，历史已经表明，妇女将继续进行堕胎。像Del-Em这样的药片和设备的传播--隐蔽、廉价和快速--如果没有其他原因，可以帮助确保堕胎的安全，并且由于其可获得性，在怀孕期间平均比今天的标准要早。

即便如此，药片宣传者和Del-Em制造商也不是唯一在做准备的人。一个名为 "堕胎服务 "的非营利组织正计划部署流动堕胎车。当我与该组织的一名工作人员交谈时，第一辆车正在准备中，她和艾莉一样，不希望使用自己的名字。我就叫她安吉拉。安吉拉告诉我，这辆车正在进行防弹处理。然后，它将被改装成一台超声波机和一个妇科检查台，这样，一个带着手动真空吸引器的医生就可以在里面进行第一个月的堕胎手术。发源于明尼苏达州的 "堕胎服务 "计划将这辆车和第二辆储存有堕胎药的车派往德克萨斯州边境外。

"安吉拉说："它们很小，不显眼。"它的部分吸引力在于，我们可以在不被注意的情况下通过，不引起注意。" 她确实担心在一个全副武装的反堕胎州的边缘，临床医生和病人的安全问题。她说，当地的联邦调查局特工已经就安全程序提供了建议。

我问安吉拉，如果最高法院削弱或推翻罗伊法案，"送子观音 "将如何处理这些面包车。她说："好吧，我们将需要更多，"她说。附近的几个州--怀俄明州、北达科他州和南达科他州、内布拉斯加州--也可能会削减堕胎服务。"我们将只是在边境上来回行驶，"她解释说。"有四个车队，我们认为我们可以覆盖他们。" 她已经有了公路经验，曾在明尼苏达州的农村地区用租来的温尼贝戈车运送堕胎药。"安吉拉说："我们会在一个城镇停留20分钟，然后温尼贝戈车会继续前进。"而且没有人知道我们的路线。这可能听起来像是公共卫生版的《疯狂的麦克斯》与《十一号车站》的结合，但很容易看出这样的场景会成为未来的一部分。几十年来，堕胎服务提供者一直在从一个州到另一个州--他们曾经被称为 "巡回骑手"--在人手不足的堕胎诊所工作，往往是在敌对地区。

如果中西部和南部的堕胎沙漠变得比现在更加干旱，那么人们就会越来越多地上路了。得克萨斯州每10个育龄妇女中就有1人居住在该州，在该州通过禁令后，临床医生提前了解了堕胎移民的情况。根据今年早些时候发表的一项研究，远在马里兰州和华盛顿州的诊所看到来自德克萨斯州的病人增多。由此产生的积压也造成了更长的等待时间。怀孕的进展。一些本来有资格接受堕胎药或人工真空吸引术的病人，最终却需要进行第二个月的手术。

其他寻求堕胎的人发现自己被困在了德克萨斯州。有些人最终不得不生下孩子，除非他们是少数幸运儿，偶然发现了一个地下供应商网络。一位加利福尼亚的活动家描述了在收到来自德克萨斯州的恐慌性请求后邮寄米索前列醇的情况--这是她以前从未做过的。"一个朋友的朋友的朋友联系我说，'有一个13岁的女孩需要使用，比如，现在。我知道时机不好，但你能帮忙吗？" 她的包裹中还包括一张贺卡、一些咖啡和纳奥米-阿尔德曼的小说《权力》（关于女性接管世界），在禁令生效的当天到达。

vi.
更多的美国可能很快就会像德克萨斯州一样，但在后罗伊时代，那些仍然可以进行堕胎的州也可能看起来很不一样。正在建立的新的基础设施超出了美国堕胎活动家的基层努力范围。加州和纽约这两个拥有最多堕胎诊所的州一直在为病人的涌入做准备。"加州州长加文-纽森（Gavin Newsom）在12月表示："我们将成为一个庇护所。据《洛杉矶时报》报道，奥兰治县和圣贝纳迪诺县的计划生育诊所已经在配置人员。政治领导人推动公共资金，以支付低收入、州外妇女前来堕胎的费用。在纽约，总检察长莱蒂西亚-詹姆斯（Letitia James）提议设立类似的基金，使该州成为 "安全港"。

黑白照片：消防员和穿着安全背心的人在被烧毁的建筑物前交谈，建筑物的屋顶在铁丝网后面塌陷了。
新年前夕，田纳西州诺克斯维尔的计划生育办公室发生纵火事件后，消防员在该办公室（Caitie McMekin / Knoxville News Sentinel / AP)
墨西哥最高法院去年将堕胎非刑罪化，该国的活动人士一直在计划帮助美国人获得堕胎。一些人已经通过步行和邮寄的方式将米索前列醇送入美国。奥地利的一个非营利组织Aid Access现在提供 "预先提供"，允许未怀孕的美国人订购米夫和米索，以便将来可能使用。该组织为所有50个州服务，包括那些对药物流产有限制的州。Aid Access的创始人是Rebecca Gomperts，她是一名医生，最初因创建 "Women on Waves "组织而声名鹊起，该组织航行到堕胎非法的国家，接走病人，然后在国际水域实施堕胎药。类似的方法--在墨西哥湾的联邦水域漂浮的诊所；在美国管辖范围外停泊的游轮变成的诊所--都是美国活动家的想法。


1月下旬，我访问了西海岸的一个月经提取小组的三名妇女，该小组由一位性教育家（我称之为诺拉）于2017年成立，她组织该小组是为了回应唐纳德-特朗普总统在反罗伊平台上的当选。我们四个人坐在后院的平房里，吃着奶酪和饼干，壁挂电视上的壁炉噼啪作响。小组成员谈到了堕胎的问题--他们希望通过向管制严格的各州的活动家传授月经提取术来扩大堕胎范围。他们已经培训了来自肯塔基州和德克萨斯州的访客，并计划接待来自俄亥俄州的人。

在交谈了近两个小时后，我们排队进入一间卧室进行演示。一位我称之为基拉的女士将Del-Em连接到一个粉红色的Spectra S2吸乳器上。一旦打开，机器就开始以一定的间隔发出咕噜咕噜的声音；听起来就像一个机器人在打鼾。

诺拉没有怀孕，但有月经，她从腰部以下脱掉衣服，躺在床上。她熟练地将窥阴器安装在她的阴道里，为她的子宫颈创造了一条直达的通道。基拉开始插入插管。"我在你的os，"她说，指的是宫颈口。"可以进入吗？"

"去吧。"诺拉说。这群人通过聊天来打发时间--为什么传真仍然存在？--直到血液出现在水族箱管中。


经过15分钟的提取，一个小血块，没有什么异常，堵塞了插管。因为这只是一个示范，而且诺拉开始痉挛，他们决定停止。基拉拔出插管，让管子里的血流到泥瓦罐里，里面的东西沉淀下来：一英寸的血。然后就结束了。

我想起了我采访卡罗尔-唐纳的一个下午，她在50多年前与洛林-罗斯曼一起在美国各地巡演德尔-埃姆。在她位于洛杉矶郊区的门廊上，我们谈论了如果宪法规定的堕胎权被剥夺会发生什么。唐纳很高兴药品被添加到女权主义的工具箱中，她告诉我，尽管她担心政府会找到一种方法把它们从妇女手中夺走，而且她担心人们会在没有友好支持的情况下孤立地吃药。唐纳仍然在她的图书馆里放着一个Del-Em，放在一张桌子上。她相信这种设备将继续可用。("禁止使用梅森瓶要难得多，"她说。)她回顾了正在成长的新地下组织，以及它所使用的各种工具。她解释说："我们需要所有这些东西"。

她解释说："我们需要所有这些东西。"七。
我们的努力正在扩大，以提供唐纳所说的那种友好支持。在1月初的一个周六晚上，大约40名参与者挤进了Jitsi Meet的一个会议室，这是一个加密的、开源的Zoom替代品，受到反监视组织的青睐。我们事先得到了指示。没有真实姓名。除了演讲者，没有音频。没有视频。屏幕上满是涂黑的方块和别名。Jolly Broccoli。宇航员女巫。蓝恐龙。郁金香-琼斯。冒险的蕨类。


赞恩（化名）是自主盆腔护理的一名志愿者，这是一个位于阿巴拉契亚的生殖健康组织，为社区护理人员讲授诸如用药丸进行自我管理的堕胎、月经提取、生育力跟踪和数字安全等课程。那是一个充满矛盾的一周。八天前，在新年前夕，一名纵火犯烧毁了田纳西州诺克斯维尔的计划生育办公室。赞恩告诉我，从那时起，他们就一直在为今晚的活动做准备，同时处理社区成员的恐慌性留言，"我们现在该怎么办？"

我在星期六晚上订购了药丸。我不需要和任何人直接交谈。一份在线调查问卷花了不到15分钟。
今晚的会议有四位教育工作者参加，对象是社区提供者和其他可能支持某人进行自我管理的堕胎的人。赞恩在会议开始时讲述了米非司酮和米索前列醇的协议。当晚的演讲者之一，即Holistic Abortions的草药师和助产士，提供了缓解这一过程的方法，包括之前、期间和之后，目的是改善整个堕胎经历。


接下来是一位来自山区援助队的志愿者，该队为田纳西州东部和阿巴拉契亚地区需要后勤、情感和财政援助的寻求堕胎者提供安全的语音和短信支持热线。她分享了一个名为Plan C的网站，其中包括一个用于在线订购药丸的各州目录。

最后一位发言人来自If/When/How，这是一个生殖正义的法律宣传团体，最近宣布了一项200万美元的辩护基金，用于支付在管理自己的堕胎后被捕的人的保释金、专家证人和律师费。她指出，检察官已经知道重新利用模糊的法律--包括18世纪的一些法律--这些法律并不是为了将自我管理的堕胎定为犯罪。

这次研讨会和苏珊-亚诺的会议中的许多材料对我来说是新的。但语气却让人感到熟悉。大流行病发生两年后，我们都成了公共卫生的准备者。我们对威胁有了更敏锐的认识，也有了更好的工具来应对这些威胁，如洗手液、抗原测试。

不管罗发生了什么，我自己的自由似乎不太可能改变，至少在可预见的未来；毕竟，我当时住在洛杉矶，而我的永久家在纽约市。即便如此，我还是决定订购一些药丸。我上了Plan C的网站，在下拉菜单中滚动到加利福尼亚。这里有很多选择。六家远程保健供应商，包括Aid Access和名为Hey Jane和Choix的新公司，提供米非司酮和米索前列醇，起价150美元。


对于准备者--那些不会立即需要这些药片的人来说，最好的选择似乎是向Aid Access订购，这是唯一提供提前供应的服务。我在周六晚上下了订单，在自主盆腔护理会议结束后几个小时。我不需要和任何人直接交谈。一份在线调查问卷花了不到15分钟，最后询问了我订购的原因，其中有一连串令人沮丧的选项。污名。成本。必须与抗议者打交道。需要对我的治疗保密。法律限制。遭受我的伴侣虐待的风险。第二天，我的订单被批准，我在网上支付了150美元。

四天后，美国邮政局的一个包裹到了。它来自一家名为Honeybee Health的网上药店，离我住的地方只有7英里。里面有一个塑料套，上面有喜庆的圆点图案，装着货物：几张传单，一盒米非司酮，还有一个茶色瓶子，里面装着六角形药片。我把它们倒在我的手掌上，数了数有八颗米索前列醇药片。它们看起来很功利，而且是白垩质的，一点也不像M&M的。

说明书印在一张双面的宣传单上。一幅漫画显示两颗药丸被塞在脸颊里。另一幅是一个女人侧卧在地上，赤脚，闭着眼睛。她的双臂环绕着她的腹部。她的膝盖被拉到胸部。标题说："预计会有出血"。看着这幅画让我感到恶心，甚至有点害怕。我想在她身边画一个朋友。


相反，我重新包装了包裹。然后我把它收了起来，想知道里面的东西到了六月会不会有什么不同。

这篇文章出现在2022年5月的印刷版上，标题为 "地下堕胎"。

* 本文最初误报了药物流产后被认为是过度出血的程度。本文也已更新，以反映怀俄明州上个月通过的一项 "触发禁令 "法律。

杰西卡-布鲁德（Jessica Bruder）是一名驻布鲁克林的记者，也是三本书的作者，包括《游牧地》（Nomadland）。二十一世纪的美国生存》。