We were listening to Ann Patchett’s book of essays “These Precious Days” when “There are no children here” started. It is a remarkable essay in 23 parts, explaining why Patchett is not a mother.

            One of the micro-essays upset me a bit. Patchett met a woman who had always known that she didn’t want children. The new friend said that it took her two years to find a doctor who would do her tubal ligation.

            At age 37, Patchett decided she wanted a tubal ligation. She told her fiancé, a physician, and he told her “no”; she was doing well on birth control pills, and there is risk to surgery. She asked her gynecologist for a tubal and she also said “no”; the pill has benefits that help women. If Patchett had her tubes tied, there was a big chance that she’d go back on the pill in order to have milder periods.

            I disagree with what her fiancé and doctor advised. The failure rate of the pill is higher than that of a tubal ligation, and (despite its safety), the risk of blood clots from the pill increases rapidly as women age.

            I like what her friend said, referring to doctors who refused to do tubal ligations: “They think we don’t know our own mind when we decide to have an abortion, but we also don’t know our own mind when we decide to put ourselves in a position where we’ll never have to have an abortion.” Patchett wrote that the doctors who refused to do tubal ligations on request, considered women to be fools who couldn’t be trusted.

            Common parlance distinguishes between women who want a child but are infertile, and those who are “childfree” by choice. The latter group has always existed, but is becoming more common now. Some of these women are so focused on their work that they don’t have the time or energy to parent. Others feel that they would not be good mothers. In addition, there is a new group—women who are concerned that the future is to bleak to subject a child to climate chaos, as well as those who realize that adding to the population will worsen the future of the planet.

            There are women who did not have children—voluntarily or not—throughout history. Roman Catholic nuns take a vow of chastity. One well-known group were the Vestal Virgins, priestesses of the Roman goddess Vesta. They were chosen before puberty and could retire—and even marry—after 30 years. However, if one were caught breaking her vow of chastity, she would be executed.

            The latest figures I could find show that about one in 6 women in the USA never gave birth. Of course, that could be either for reason of infertility or voluntary childlessness.

In most societies women experience pressure to get married and then have children. Although pressure for marriage seems to have decreased, women are still expected to have babies. Pronatalism is causing humans to reproduce at an untenable rate, thus increasing overpopulation and environmental damage.

            There are many organizations for people who are considering being childfree, or have already made that decision. “The Notmom” ( is unique because it supports women whether they are childless “by choice or by chance”. One nonprofit provides funding for sterilizations for both men and women. ChildFree by Choice ( uses donations to help people of all genders avoid unplanned pregnancies.

            If you would like to know more about pronatalism, I suggest Nandita Bajaj’s article: Recently she was recognized as an expert in the field by coauthoring an article in the preeminent journal, Science Progress: “World scientists’ warning: The behavioural crisis driving ecological overshoot”.

            We live in an era where it is possible to have a loving, heterosexual relationship without fear of an unintended pregnancy. Now there are global as well as personal reasons to be childfree.

© Richard Grossman MD, 2024

Abortion Reproductive Health

Self-Managed Abortion

Image from the Plan C website.

“A safe abortion with pills requires only three things: accurate information, quality medications, and mutual respect and trust.”                  Doctors Without Borders

            In the past there was a sharp division between safe (legal) abortions and unsafe (illegal) abortions. Recently that line has been blurred with Self-Managed Abortions (SMAs).

            Even when abortion was legal all over the USA, there were occasional women who would try to abort a pregnancy outside the medical system. Most commonly they would use herbs or misoprostol, the prescription-only medication that is sometimes available on the black market. Here’s an example:

            June, a 26-year-old woman, went to her doctor who only recommended that she continue her unplanned pregnancy to term. To paraphrase her quote in a study of SMA, “I did some stuff on my own because I didn’t think she would help me get the abortion I wanted.” She took antibiotic pills and ibuprofen after she had a positive pregnancy test, but ended up going to an abortion clinic when her SMA didn’t work.

            Other women in the same small study tried to abort unintended pregnancies using: vitamin C, parsley tea, multiple contraceptive tablets, dong quai, black cohosh, gingerroot and alcohol. Sometimes bleeding started and sometimes it didn’t. Since not all of the women had taken a pregnancy test before trying SMA, it is impossible to know the effectiveness of their attempts to abort. Fortunately, none of the woman had a bad effect from their attempts at SMA. Oil of pennyroyal is known to be an effective abortifacient; however, it has also known to sometimes be fatal for the woman who takes it.

            Fortunately, medication abortion using mifepristone and misoprostol is safe and effective. The combination was approved by the FDA in 2000. As more and more women used this combination it became clear that it is very safe—especially when compared to carrying a pregnancy to term.

            Recently the combination has been approved for “telemedicine”. Contact between a woman with an unintended pregnancy and her healthcare provider can be by electronic means, similar to Zoom. The provider asks questions such as when the woman’s last period was, as well as about her general health. If the person is a candidate for medication abortion, the appropriate pills can then be sent to her, with clear written instructions how they should be taken. The instructions also tell the woman what to expect, and when she should seek emergency care.

            How safe and effective are telemedicine abortions? In a study of over 6000 women who did not visit a clinic in person, they found no difference from women who had face-to-face contact with a healthcare provider. Only 2 of 1000 women had a serious adverse event, and the success rate of causing an abortion was almost 98%. These figures are similar to studies of medication abortion in which patients visited a clinic.

            Telemedicine has reduced the cost to obtain an abortion—the interview can be done from the woman’s home so little time and no travel are required. The pills are shipped by a delivery service or mail, and will arrive in a few days, allowing the woman to choose when to start her abortion. But the real advantage of telemedicine is for people who live in states where this necessary part of healthcare is severely limited or illegal.

            Doctors Without Borders has a series of videos on SMA, available at: Although DWB mainly works in developing countries, this information also applies to some states in the US. The nonprofit Plan C supports SMA by providing information about access to abortion pills, including their cost.

©Richard Grossman MD, 2024