UPDATE (June 24, 2022, 12:33 p.m.): On Friday, the Supreme Court overturned Roe v. Wade, which established the constitutional right to abortion in 1973, with five of the six Republican-appointed justices arguing that there was no basis for the constitutional right to abortion.

In an article we published earlier this month, we looked at the history of back-alley abortions in the U.S. with an eye to what they can tell us about a post-Roe future. A lot has changed since abortion was not legal in the U.S. in the 1970s, but a post-Roe future will still mean unequal access for women seeking abortion. You can read more about what we found below.

A metal coat hanger can’t speak, but it can send a message. Long a symbol of the dangers faced by people seeking to end pregnancies in the years before Roe v. Wade, coat hangers stand in for a whole inventory of physical horrors, most of which never involved coat hangers, specifically. Over the past few weeks, protesters have mailed hangers to the Supreme Court in an effort to evoke that past era — from the so-called back-alley butchers who botched surgical procedures and sexually harassed patients, to the terrible lengths individuals went through to give themselves an abortion at home. The message is simple and brutal: Without safe and legal abortion, the protesters believe, people will die.

In the years since Roe became the law of the land, the medical landscape of abortion has changed drastically. Today, abortion is extremely safe — safer than birth. So safe, in fact, that it’s not always obvious what made illegal abortions unsafe. Or, for that matter, what the coat hangers were for.

And this is why those objects still have important stories to tell us, historians told me. Because while the most physically violent abortion methods of the past have become medically obsolete, the march of scientific progress hasn’t eliminated the shame, fear and hopelessness experienced by people who are pregnant, don’t want to be, and live in a society where there is no simple, legal access to abortion. Coat hangers don’t just tell us about the dangers of bad medicine, practiced shoddily, these historians said. Instead, the hangers also speak volumes about the desperation that can lead people to those dangerous procedures in the first place.

“The whole phrase ‘back-alley butcher’ is an exaggeration because there were lots of good practitioners who were perfectly safe,” said Leslie J. Reagan, professor of history at the University of Illinois at Urbana-Champaign and author of “When Abortion Was a Crime.”

Even in the past, the dangers of illegal abortion weren’t about the abortion itself. No one knows how many illegal abortions were being performed annually, pre-Roe, but researchers in the early 1990s estimated it was on par with annual numbers of legal abortions at the time, so more than 1 million. People with money and connections could always get safe ones and plenty of people survived, the historians I spoke with said. Illegal abortions were primarily unsafe for the people who were blocked out of better options.

Legal abortions in hospitals, for example, happened with some regularity. These records were kept hospital by hospital, so it’s rare to have even city-wide data, but University of Vermont historian Felicia Kornbluh pointed me towards a 1965 paper that found hospital review boards in New York City had approved 4,703 so-called therapeutic abortions between 1951 and 1962.  In those cases, the technique actually being used was something called a dilation and curettage, or D&C. Also often referred to as a “surgical abortion” the D&C is still used today as a treatment for both abortion and miscarriage. Doctors dilate the cervix — making the opening between the vagina and uterus wider — and use a sharp tool to scrape out the contents of the uterus.

Before Roe, in the 1950s and 60s, getting a legal hospital abortion was not easy. A patient could get a D&C if they were already experiencing a natural miscarriage. Otherwise, patients who requested one would have to make a case to their doctors, who would then have to bring the situation before a hospital review board. The patient would likely be examined by other doctors and might have to answer questions — basically, they needed to prove the abortion was medically or psychologically necessary. But necessity wasn’t the only factor at play. “There are studies that show that almost all of them were done on people with private insurance,” Reagan said. Patients without insurance, as well as black and brown patients regardless of insurance status, had a much harder time getting approved. In her upcoming book, “A Woman’s Life is a Human Life,” Kornbluh records that Metropolitan Hospital in East Harlem approved five white women’s requests for every one Black woman’s. The hospital was even less likely to approve Puerto Rican women’s requests. And Reagan has documented instances of Black women being denied abortions even though they had rubella infections during pregnancy — something that can kill a fetus, or leave it with lifelong complications, including deafness, heart defects and intellectual disabilities. (Others were lied to and told they didn’t have it.)

People who were denied — or who never had a hope of getting — a hospital abortion were left with only illegal options. Both trained doctors and untrained practitioners offered D&C’s, but that procedure was considerably more dangerous in illegal settings. Without sterilized equipment and ready access to antibiotics and painkillers, doctors used furtive practices that optimized for speed and offered no room for follow-up care, and practitioners sometimes had no idea what they were doing. Carole Joffe, professor of obstetrics and gynecology at the University of California, San Francisco, interviewed trained doctors who practiced illegal abortion during this time and has written about their experiences. One doctor told her that he used to explain the challenges of performing a D&C by telling his residents that it was like being blindfolded and trying to scrape the inside of a wet paper bag without cutting through the paper. Possible, but not easy. “D&C’s in competent hands are safe, but in incompetent hands it’s very easy to perforate the uterus,” Joffe said. 

To avoid trying to perform the tricky D&C under clandestine circumstances, illegal abortionists sometimes opted instead to simply induce enough of a miscarriage that their patient could go to a hospital and get one without a problem. They did this often by inserting a foreign object — like a hollow tube catheter — through the cervix. In some cases, they might use a type of catheter with a balloon on one end. Filled with saline, it would put pressure on the cervix, like a fetus’s head would towards the end of pregnancy, causing it to fully dilate. Just sticking any catheter in could prompt a miscarriage as the body tried to expel the object. These methods didn’t work all the time, though. They could cause hemorrhages and embolisms. And catheters had to be left in for a while, along with gauze packed into the patient’s vagina to staunch the blood. This could cause infection and with patients trying to hide from authorities, they often didn’t seek treatment until near death.

People who couldn’t find or afford an illegal abortion often tried to give one to themselves. It’s impossible to say how many of these happened every year, but there are records showing thousands of people coming into emergency rooms with septic infections of the uterus and reproductive organs in the 1960s, Reagan said. This is where the coat hangers come in, Joffe said, as one of many objects people would try to insert through their own cervical openings. The goal was not necessarily to complete an abortion at home but rather to induce enough bleeding and symptoms of miscarriage that the person could go to a hospital, say they were having a miscarriage naturally, and get a hospital D&C. But perforation, hemorrhage, and infection were all risks. 

Even less reliable, and more dangerous, were an array of suppositories, tinctures, herbs and home remedies that plenty of people tried. One doctor told Joffe about treating a patient who had gotten a catheter into her cervix and poured turpentine through it, literally cooking the inside of her uterus, which had to be removed. Others told stories about potassium permanganate tablets, sold over the counter, which people would put in their vaginas to induce bleeding and get their hospital D&C. But the tablets could easily eat through the vaginal lining, causing hemorrhage and destroying the cervix. 

It’s very unlikely that anyone will go back to performing back-alley D&Cs or catheter abortions, Reagan and Joffe said. Even if Roe is overturned, doctors and other people who want to defy it are much more likely to offer patients abortion pills. While abortion via pill can be a physically painful and psychologically intense experience for some people, the existence of these pills drastically changes the calculus when it comes to the risks of illegal abortion. They’re much easier to get and conceal, much safer to use, and if a patient is worried about side effects they can seek treatment knowing no one will be able to tell the difference between the effects of a pill and a natural miscarriage.

But both Reagan and Joffe said the existence of abortion pills won’t eliminate risk if abortion becomes illegal. Just as there were some people who could get abortions more easily than others before Roe, there will be those who can do so after, as well. Meanwhile, some of the most vulnerable people — poor people, people living in very rural areas, people who can’t take time off to drive to another state in search of pills — will still end up with only desperate options left. Reagan was particularly worried that websites selling fake abortion pills will deceive people who have no idea they aren’t getting the real thing. And both she and Joffe worried about how illegality and increased stigma could drive more people towards dangerous at-home methods, with social media becoming the new back alley. Even with abortion still legal, there are occasional instances of people — usually young — trying to abort on their own, Reagan said. 

The methodology of abortion has improved, Reagan and Joffee told me. But as long as desperation for an abortion exists — and easy access does not — some people will still be in danger.