Self-induction of abortion among women in the United States

Prior knowledge and experience with self-managed abortion among people seeking abortion care in US Midwestern states

OBJECTIVES

This study seeks to understand what methods people use and/or have heard of others using for self-managed abortion (SMA) prior to coming to a health facility for abortion care.

STUDY DESIGN

We collected survey data on sociodemographics, gestational stage, and SMA awareness and methods from patients seeking care in 17 abortion facilities in Ohio, West Virginia, Kentucky, Pennsylvania, and Illinois from April 2020 to April 2022. We used descriptive statistics to examine the proportion of participants who had attempted SMA and, separately, who had heard of people attempting SMA.

RESULTS

In total, 71 respondents (4.2%) had attempted SMA, and 416 (25.5%) had heard of others attempting SMA. The most frequently attempted methods for self-management were taking herbs and/or vitamins (31% each) or hitting oneself/being hit (22.5%). About a third of those who tried SMA reported trying more than one method (30%).

CONCLUSIONS

Our findings suggest that people who attempt SMA are committed to self-managing their abortion. More research is needed to better understand sociodemographic characteristics of people who have attempted or heard of people attempting SMA research.

Self-Managed Abortion Attempts Before vs After Changes in Federal Abortion Protections in the US

Importance

With decreasing access to facility-based abortion in the US, an increase in self-managed abortion (SMA) using various methods is anticipated. To date, no studies have examined changes in SMA in the shifting policy landscape.

Objective

To estimate changes in SMA prevalence among the general US population from before to after the Supreme Court's June 2022 decision overturning federal abortion protections.

Design, Setting, and Participants

Serial cross-sectional surveys were administered throughout the US from December 10, 2021, to January 11, 2022, and June 14 to July 7, 2023. Participants included online panel members assigned female sex at birth, ages 18 to 49 years (or ages 15-17 years if a household member), who were English- or Spanish-speaking.

Exposure

Year of the survey (2021-2022 vs 2023).

Main Outcome and Measures

Participants were asked whether they had "ever taken or done something on their own, without medical assistance, to try to end a pregnancy" and, if so, details of their experience. Changes in the weighted SMA prevalence between survey years were examined, factors associated with SMA experience were identified, and projected lifetime SMA prevalence was calculated using discrete-time event history models, accounting for abortion underreporting.

Results

Median age of the participants was 32.5 (IQR, 25-41) years in 2021-2022 (n = 7016) and 32.0 (IQR, 24-40) in 2023 (n = 7148). Across both years, approximately 14% were non-Hispanic Black, 21% were Hispanic, and 54% were non-Hispanic White. The weighted adjusted proportion that ever attempted SMA was 2.4% (95% CI, 1.9%-3.0%) in 2021-2022 and 3.4% (95% CI, 2.8%-4.0%) in 2023-an increase of 1.0% (95% CI, 0.2%-1.7%; P = .03). Projected lifetime SMA prevalence accounting for abortion underreporting was 10.7% (95% CI, 8.6%-12.8%). In adjusted analyses, SMA experience was higher among non-Hispanic Black (4.3%; 95% CI, 2.8%-5.8%) vs other racial and ethnic (2.7%; 95% CI, 2.2%-3.1%) groups (P = .04) and sexual and gender minority (5.0%; 95% CI, 3.4%-6.6%) vs heterosexual or cisgender (2.5%; 95% CI, 2.0%-2.9%) participants (P < .001). Approximately 4 in 10 (45.3% in 2021 and 39.0% in 2023) SMA attempts occurred before age 20 years. The methods used included herbs (29.8% [2021-2022] vs 25.9% [2023]), physical methods (28.6% [2021-2022] vs 29.7% [2023]), or alcohol or other substances (17.9% [2021-2022] vs 18.6% [2023]). Few participants (7.1% [2021-2022] vs 4.7% [2023]) sought emergency care for a complication.

Conclusions and Relevance

In this serial nationally representative survey study, increased SMA was observed following the loss of federal abortion protections. The findings revealed increased SMA use among marginalized groups, most often with ineffective methods. These findings suggest the need to expand access to alternative models of safe and effective abortion care and ensure those seeking health care post-SMA do not face legal risks.

Supported at-home abortion: An exploratory study of methods, outcomes, and motivations of community-led abortion care in the United States and Canada

OBJECTIVES

This an exploratory study aimed to describe methods and outcomes of comprehensive community-led abortion care in the United States and Canada.

STUDY DESIGN

This community-based participatory research study recruited community abortion providers from the United States and Canada through existing confidential networks. They participated through in-person and online collaboration to design and implement a data collection tool for abortion methods, outcomes, and motivations from clients. We implemented significant security measures to protect participant confidentiality.

RESULTS

Thirty community providers were recruited, five withdrew, and 12 provided data for 167 at-home abortions. Most abortions occurred between 6 and 10 weeks (104 [62%]). Abortions between 13 and 21 weeks represent 39 cases (23%). Misoprostol only was the most common method (n = 125 [75%]), followed by herbs alone (n = 12 [7%]) and aspiration (n = 12 [7%]). Complications were rare (n = 3 [1.8%]), with 163 complete abortions (98%). The primary motivation for seeking community-led abortion care was avoiding a clinic.

CONCLUSIONS

Community providers employed various abortion methods with safety and effectiveness profiles comparable to those reported for clinical and community-based abortion care. Clients wanting a different model of abortion care seek out community-led abortions, regardless of whether clinics are legal and accessible.

IMPLICATIONS

Community-led abortion is a viable choice for patients. Community providers should be recognized for their contributions to abortion access and high-quality, person-centered care. This study demonstrates a broader range of abortion providers and diverse options meeting the need for individualized abortion care.

Perspectives on Alternative Models of Medication Abortion Provision Among Abortion Patients in the United States

OBJECTIVE

Restrictions on the availability of medication abortion are a barrier to accessing early abortion. People seeking medication abortion may be interested in obtaining the medications through alternative models. The purpose of this study was to explore patient perspectives on obtaining abortion medications in advance of pregnancy or over the counter (OTC).

STUDY DESIGN

Between October 2017 and August 2018, we conducted 30 in-depth interviews with abortion patients who indicated support for alternative models. We recruited patients from 10 abortion clinics in states with a range of policy environments. We analyzed interviews using inductive and deductive iterative techniques.

RESULTS

Participants identified logistical benefits of these alternative models, including eliminating travel to a clinic and multiple appointments, and increased privacy around decision-making. Participants were interested in advance provision for its convenience and the sense of preparedness that would come with having the pills available at home, yet some had concerns about the pills being found or stolen. Privacy was the key factor considered for OTC access, including both the privacy benefits of avoiding a clinic and the concern of having one's privacy compromised within the community if purchasing the medications in public.

CONCLUSIONS

People who have previously had a medication abortion are interested in alternative methods of provision for reasons concerning convenience, privacy, and avoiding burdens related to hostile policy environments, such as long travel distances to clinics and multiple appointments. Concerns around these models were primarily safety concerns for young people. Further research is needed to evaluate the safety, effectiveness, acceptability, and feasibility of these alternative models of providing medication abortion.

Self-Sourced Medication Abortion, Physician Authority, and the Contradictions of Abortion Care

The growing acknowledgment of the phenomenon of individuals terminating their pregnancies by obtaining the medications necessary for an abortion-which this article refers to as "self-sourced medication abortion" (SSMA)-has shed light on the current contradictions in the world of abortion provision. This article offers a brief historical overview of the relationship between abortion provision and mainstream medicine, pointing to the factors that have led to the marginalization of abortion care. It then discusses interviews with 40 physicians who provide abortions about their perspectives on SSMA, and it explores how this group responds to the contradictions presented by SSMA. In doing so, it interrogates the changing meaning of "physician authority" among this subset of physicians. The authors suggest that these interviewees represent an emergent sensibility among this generation of abortion physicians, a sensibility strongly tied to a commitment to social justice.

A narrative review of illegal online pharmacies and contemporary issues with restricting FDA-approved medication access

The rapid growth of technology has transformed the way the public purchases many products, including medications. Online medication purchasing has become a convenient and confidential route for patients to access healthcare without leaving their homes. Online pharmacies have many benefits but also present an increased risk for patient harm caused by unintentionally purchasing from illegal online pharmacies. Illegal online pharmacies are those that operate online without the requisite valid licenses or supply drugs not approved by the Food and Drug Administration (FDA). As obtaining certain medications has become restricted, either due to policy or drug shortages, more patients are relying on services provided by Internet pharmacies. The overturning of Roe versus Wade has caused an emerging drug restriction that may coerce the public to turn to Internet pharmacies for purchasing medications. A narrative review was conducted to analyze both the past and present effects of medications sold by illegal online pharmacies to help recognize the implications of restricting access to FDA-approved medications. Several large science and health literature databases were searched to find relevant references. Resulting resources, which referenced the connection between restricting access to FDA-approved medications and the increase in illegal online sales, were included in this review. The information evaluated in this article will help inform healthcare providers and policymakers of the inadvertent effects of restricting access to FDA-approved medications.

Association of Availability of State Medicaid Coverage for Abortion With Abortion Access in the United States

OBJECTIVE

To evaluate the association between state Medicaid coverage for abortion and abortion access measures among U.S. patients.

METHODS

We analyzed data from the Guttmacher Institute's 2014 Abortion Patient Survey. Respondents were included if they reported being enrolled in Medicaid, regardless of whether Medicaid covered the abortion. The exposure was self-report of residence in a state where Medicaid can be used to pay for abortion. Access outcomes included more than 14 days' wait time between decision for abortion and abortion appointment, presentation at more than 10 weeks of gestation when in the first trimester, and travel time more than 60 minutes to the clinic. Multivariable regression was performed to test the association between state Medicaid abortion coverage and dichotomous access outcomes, controlling for patient demographics.

RESULTS

Of 2,579 respondents enrolled in Medicaid who reported state of residence, 1,694 resided in states with Medicaid coverage for abortion and 884 resided in states without Medicaid coverage for abortion. Patients residing in states with Medicaid coverage for abortion had lower odds and rates of waiting more than 14 days between deciding to have an abortion and the appointment (adjusted odds ratio [aOR] 0.70; 95% CI 0.57-0.85, 66.8% vs 74.1%, P <.001), having abortions at more than 10 weeks of gestation when in the first trimester (aOR 0.62; 95% CI 0.49-0.80, 13.6% vs 20.1%, P <.001), and traveling more than 60 minutes to the abortion clinic (aOR 0.63; 95% CI 0.51-0.78, 18.7% vs 27.6%, P <.001) when compared with patients residing in states without Medicaid coverage for abortion.

CONCLUSION

Availability of state Medicaid coverage for abortion is associated with increased abortion access. Our findings support repealing the Hyde Amendment to promote equitable access to reproductive health care, particularly in the post-Roe era.

A cross-sectional study examining consideration of self-managed abortion among people seeking facility-based care in the United States

Introduction

With increasing restrictions on abortion across the United States, we sought to understand whether people seeking abortion would consider ending their pregnancy on their own if unable to access a facility-based abortion.

Methods

From January to June 2019, we surveyed patients seeking abortion at 4 facilities in 3 US states. We explored consideration of self-managed abortion (SMA) using responses to the question: “Would you consider ending this pregnancy on your own if you are unable to obtain care at a health care facility?” We used multivariable Poisson regression to assess associations between individual sociodemographic, pregnancy and care-seeking characteristics and prevalence of considering SMA. In bivariate Poisson models, we also explored whether consideration of SMA differed by specific obstacles to abortion care.

Results

One-third (34%) of 741 participants indicated they would definitely or probably consider ending the pregnancy on their own if unable to obtain care at a facility. Consideration of SMA was higher among those who reported no health insurance (adjusted prevalence ratio [aPR] = 1.66; 95% Confidence Interval [CI] 1.12–2.44), described the pregnancy as unintended (aPR = 1.53; 95% CI 1.08–2.16), were seeking abortion due to concerns about their own physical or mental health (aPR = 1.50, 95% CI 1.02, 2.20), or experienced obstacles that delayed their abortion care seeking (aPR = 2.26, 95% CI 1.49, 3.40). Compared to those who would not consider SMA, participants who would consider SMA expressed higher difficulty finding an abortion facility (35 vs. 27%, p = 0.019), figuring out how to get to the clinic (29 vs 21%, p = 0.021) and needing multiple clinic visits (23 vs 17%, p = 0.044).

Conclusions.

One in three people seeking facility-based abortion would consider SMA if unable to obtain abortion care at a facility. As abortion access becomes increasingly restricted in the US, SMA may become more common. Future research should continue to monitor people’s consideration and use of SMA and ensure that they have access to safe and effective methods.

Abortion attempts without clinical supervision among transgender, nonbinary and gender-expansive people in the United States

BACKGROUND

Transgender, nonbinary and gender-expansive (TGE) people face barriers to abortion care and may consider abortion without clinical supervision.

METHODS

In 2019, we recruited participants for an online survey about sexual and reproductive health. Eligible participants were TGE people assigned female or intersex at birth, 18 years and older, from across the United States, and recruited through The PRIDE Study or via online and in-person postings.

RESULTS

Of 1694 TGE participants, 76 people (36% of those ever pregnant) reported considering trying to end a pregnancy on their own without clinical supervision, and a subset of these (n=40; 19% of those ever pregnant) reported attempting to do so. Methods fell into four broad categories: herbs (n=15, 38%), physical trauma (n=10, 25%), vitamin C (n=8, 20%) and substance use (n=7, 18%). Reasons given for abortion without clinical supervision ranged from perceived efficiency and desire for privacy, to structural issues including a lack of health insurance coverage, legal restrictions, denials of or mistreatment within clinical care, and cost.

CONCLUSIONS

These data highlight a high proportion of sampled TGE people who have attempted abortion without clinical supervision. This could reflect formidable barriers to facility-based abortion care as well as a strong desire for privacy and autonomy in the abortion process. Efforts are needed to connect TGE people with information on safe and effective methods of self-managed abortion and to dismantle barriers to clinical abortion care so that TGE people may freely choose a safe, effective abortion in either setting.

Integrating self-managed medication abortion with medical care

In this commentary, we distill key messages from a new framework for self-managed medication abortion developed by Global Doctors for Choice. Since Global Doctors for Choice supports doctors working in different contexts around the world, the document also highlights clinical concerns and advocacy opportunities for clinicians in both low- and high-resource settings, and in places with varying legal and administrative restrictions on abortion.

Racial and Ethnic Abortion Disparities Following Georgia's 22-Week Gestational Age Limit

INTRODUCTION

Georgia's 2012 House Bill 954 (HB954) prohibiting abortions after 22 weeks from last menstrual period (LMP) has been associated with a significant decrease in abortions after 22 weeks. However, the policy's effects by race or ethnicity remain unexplored. We investigated whether changes in abortion numbers and ratios (per 1,000 live births) in Georgia after HB954 varied by race or ethnicity.

METHODS

Using Georgia Department of Public Health induced terminations of pregnancy data from 2007 to 2017, we examined changes in number of abortions and abortion ratios (per 1,000 live births) by race and ethnicity following HB954 implementation.

RESULTS

After full implementation of HB954 in 2015, the number of abortions and abortion ratios at or after 22 weeks (from last menstrual period) decreased among White (b_Number = -261.83, p < .001; b_Ratio = -3.31, p < .001), Black (b_Number = -416.17, p < .001; b_Ratio = -8.84, p < .001), non-Hispanic (b_Number = -667.00, p = .001; b_Ratio = -5.82, p < .001), and Hispanic (b_Number = -56.25, p = .002; b_Ratio = -2.44, p = .002) people. However, the ratio of abortions before 22 weeks increased for Black people (b_{LessThan22Weeks} = 44.06, p = .028) and remained stable for White (b_{LessThan22Weeks} = -6.78, p = .433), Hispanic (b_{LessThan22Weeks} = 21.27, p = .212), and non-Hispanic people (b_{LessThan22Weeks} = 26.93, p = .172).

CONCLUSION

The full implementation of HB954 had differential effects by race/ethnicity and gestational age. Although abortion at 22 weeks or more decreased for all groups, abortion at less than 22 weeks increased among Black people. Additional research should elucidate the possible causes, consequences, and reactions to differential effects of abortion restrictions by race and ethnicity.

Understanding abortion seeking care outside of formal health care settings in Cape Town, South Africa: a qualitative study

Background

Although abortion was legalized in South Africa in 1996, barriers to safe, legal abortion services remain, and women continue to seek abortions outside of the formal healthcare sector. This study explored the decision-making processes that women undertake when faced with an unintended pregnancy, the sources of information used to make their decisions and the factors that contribute to their seeking of informal sector abortion in Cape Town, South Africa.

Methods

We conducted 15 semi-structured in-depth interviews in English with women who had accessed an abortion outside of the formal health care sector. Women were recruited with the assistance of a community-based key informant. Data was analyzed using a thematic analysis approach.

Results

Participants were aware that abortions were legal and accessible in public clinics, however they were concerned that others would find out about their unintended pregnancy and abortion if they went to legal providers. Women were also concerned about judgment and mistreatment from providers during their care. Rather than seek care in the formal sector, women looked past concerns around the safety and effectiveness of informal sector abortions and often relied on their social networks for referrals to informal providers.

Conclusions

The findings highlight the decision-making processes employed by women when seeking abortion services in a setting where abortion is legal and demonstrate the role of institutional and societal barriers to safe abortion access. Abortion service delivery models should adapt to women’s needs to enhance the preferences and priorities of those seeking abortion care-including those who prefer facility-based care as well as those who might prefer self-managed medical abortions.

Although abortion was legalized in South Africa in 1996, barriers to safe, legal abortion services remain, and women continue to seek abortions outside of the formal healthcare sector. This study explored the decision-making processes that women undertake when faced with an unintended pregnancy, who they discuss and seek help from, and the factors that influence their decision to seek an abortion outside of the formal health care sector. We interviewed 15 women who had obtained an abortion outside of the health care sector in Cape Town, South Africa. Women were aware that abortions were legal and available in public clinics, but they were concerned about negative and judgmental attitudes from health care providers even though some women were aware of the possible health safety issues related to seeking an abortion outside of the clinic setting. Abortion services should adapt to women’s needs and offer them options of facility-based care but also self-managed medical abortions under the guidance of health care providers.

Barriers to abortion care and incidence of attempted self-managed abortion among individuals searching Google for abortion care: A national prospective study

OBJECTIVE

Studies on self-managed abortion conducted at abortion clinics may exclude those facing the greatest barriers to care. We aimed to assess association of attempted self-managed abortion with reported barriers to abortion care.

STUDY DESIGN

We used data from the Google Ads Abortion Access Study, a prospective cohort study that recruited people searching for abortion care on Google between August 2017 and April 2018. We used a stratified sampling design recruiting by state to ensure representation from all 50 states. Participants completed an online baseline survey and follow-up 4 weeks later. We modeled the adjusted odds of attempting self-managed abortion using multivariable logistic regression, with random effects for state of residence. We assessed attempted self-managed abortion at follow-up by asking: "Did you take or try to do any of the following to try to end this pregnancy?" with a closed-ended list of methods.

RESULTS

Among 856 participants with follow-up data, 28% (95% confidence interval [95% CI]: 25%-31%) reported attempting self-managed abortion. Most common methods used were: herbs, supplements, or vitamins (52%); emergency contraception or many contraceptive pills (19%); mifepristone and/or misoprostol (18%); and abdominal or other physical trauma (18%). Participants still seeking abortion at 4 weeks were more likely to attempt self-management (33%) than those planning to carry to term (20%, p < 0.001). Reporting having to keep the abortion a secret, fearing for one's safety/well-being, needing to gather money for travel or the abortion, or living further from an abortion facility as barriers were associated with higher odds of attempts.

CONCLUSIONS

Attempted self-managed abortion is higher among people facing barriers to abortion care.

IMPLICATIONS

Reducing financial and distance barriers, such as by removing legal restrictions on abortion, could help reduce attempted self-managed abortion. Additionally, removing restrictions on telehealth for abortion could reduce attempted self-managed abortion. Efforts are needed to permanently remove United States Food and Drug Administration (FDA) regulations and state policies prohibiting telehealth for medication abortion, thereby allowing individuals to end their pregnancies without a clinic visit.

Access experiences and attitudes toward abortion among youth experiencing homelessness in the United States: A systematic review

Objectives

We sought to review the literature on the access experiences and attitudes toward abortion among youth experiencing homelessness in the United States.

Methods

We conducted a systematic review of peer‐reviewed literature published from 2001 to 2019. We included qualitative studies involving US participants that focused on access experiences, views, or accounts of unintended pregnancy and/or abortion among youth experiencing homelessness. We excluded studies published before 2001 as that was the year mifepristone medication abortion was made available in the US and we aimed to investigate experiences of access to both medical and surgical abortion options.

Results

Our thematic analysis of the data resulted in five key themes that characterize the abortion attitudes and access experiences of youth experiencing homelessness: (1) engaging in survival sex and forced sex, (2) balancing relationships and autonomy, (3) availability does not equal access, (4) attempting self-induced abortions using harmful methods, and (5) feeling resilient despite traumatic unplanned pregnancy experiences.

Conclusions

Youth experiencing homelessness experience barriers to abortion access across the US, including in states with a supportive policy context and publicly funded abortion services. In the absence of accessible services, youth may consider harmful methods of self-induced abortion. Improved services should be designed to offer low-barrier abortion care with the qualities that youth identified as important to them, including privacy and autonomy.

Medical abortion offered in pharmacy versus clinic-based settings

BACKGROUND

Medical abortion is usually offered in a clinic or hospital, but could potentially be offered in other settings such as pharmacies. In many countries, pharmacies are a common first point of access for women seeking reproductive health information and services. Offering medical abortion through pharmacies is a potential strategy to improve access to abortion.

OBJECTIVES

To compare the effectiveness and safety of medical abortion offered in pharmacy settings with clinic-based medical abortion.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, four other databases, two trials registries and grey literature websites in November 2020. We also handsearched key references and contacted authors to locate unpublished studies or studies not identified in the database searches.

SELECTION CRITERIA

We identified studies that compared women receiving the same regimen of medical abortion or post-abortion care in either a clinic or pharmacy setting. Studies published in any language employing the following designs were included: randomized trials and non-randomized studies including a comparative group.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed both retrieved abstracts and full-text publications. A third author was consulted in case of disagreement. We intended to use the Cochrane risk of bias tool, RoB 2, for randomized studies and used the ROBINS-I tool (Risk Of Bias In Non-randomized Studies of Interventions) to assess risk of bias in non-randomized studies. GRADE methodology was used to assess the certainty of the evidence. The primary outcomes were completion of abortion without additional intervention, need for blood transfusion, and presence of uterine or systemic infection within 30 days of medical abortion.

MAIN RESULTS

Our search yielded 2030 records. We assessed a total of 89 full-text articles for eligibility. One prospective cohort study met our inclusion criteria. The included study collected data on outcomes from 605 women who obtained a medical abortion in Nepal from either a clinic or pharmacy setting. Both sites of care were staffed by the same auxiliary nurse midwives. Over all domains, the risk of bias was judged to be low for our primary outcome. During the pre-intervention period, the study's investigators identified a priori appropriate confounders, which were clearly measured and adjusted for in the final analysis. For women who received medical abortion in a pharmacy setting, compared to a clinic setting, there may be little or no difference in complete abortion rates (adjusted risk difference (RD)) 1.5, 95% confidence interval (CI) -0.8 to 3.8; 1 study, 600 participants; low certainty evidence). The study reported no cases of blood transfusion, and a composite outcome, comprised mainly of infection complications, showed there may be little or no difference between settings (adjusted RD 0.8, 95% CI -1.0 to 2.8; 1 study, 600 participants; very low certainty evidence). The study reported no events for hospital admission for an abortion-related event or need for surgical intervention, and there may be no difference in women reporting being highly satisfied with the facility where they were seen (38% pharmacy versus 34% clinic, P = 0.87; 1 study, 600 participants; low certainty evidence).

AUTHORS' CONCLUSIONS

Conclusions about the effectiveness and safety of pharmacy provision of medical abortion are limited by the lack of comparative studies. One study, judged to provide low certainty evidence, suggests that the effectiveness of medical abortion may not be different between the pharmacy and clinic settings. However, evidence for safety is insufficient to draw any conclusions, and more research on factors contributing to potential differences in quality of care is needed. It is important to note that this study included a care model where a clinician provided services in a pharmacy, not direct provision of care by pharmacists or pharmacy staff. Three ongoing studies are potentially eligible for inclusion in review updates. More research is needed because pharmacy provision could expand timely access to medical abortion, especially in settings where clinic services may be more difficult to obtain. Evidence is particularly limited on the patient experience and how the care process and quality of services may differ across different types of settings.

Differences in Abortion Rates between Asian Populations by Country of Origin and Nativity Status in New York City, 2011-2015

Despite the size of the Asian population in New York City (NYC) and the city’s robust abortion surveillance system, abortion-related estimates for this population have not been calculated previously. This study examined the use of abortion services among specific Asian groups in NYC from 2011–2015. Using NYC surveillance data, we estimated abortion rates for Asians, disaggregated by five country of origin groups and nativity status, and for other major racial/ethnic groups. We compared rates between groups and over time. From 2014–2015, the abortion rate for Asian women in NYC was 12.6 abortions per 1000 women aged 15–44 years, lower than the rates for other major racial/ethnic groups. Among country of origin groups, Indian women had the highest rate (30.5 abortions per 1000 women), followed by Japanese women (17.0), Vietnamese women (13.0), Chinese women (8.8), and Korean women (5.1). Rates were higher for U.S.-born Asian groups compared to foreign-born groups, although the differential varied by country of origin. The abortion rate declined or remained steady for nearly all Asian groups from 2011–2015. These findings reinforce the importance of disaggregating data on this population at multiple levels and begin to provide much-needed evidence on the use of abortion services among Asian groups.

"I'll just deal with this on my own": a qualitative exploration of experiences with self-managed abortion in the United States

Background

A growing body of evidence indicates that some people seek options to terminate a pregnancy without medical assistance, but experiences doing so have largely been documented only among people accessing a clinic-based abortion. We aim to describe self-managed abortion (SMA) experiences of people recruited outside of clinics, including their motivations for SMA, pregnancy confirmation and decision-making processes, method choices, and clinical outcomes.

Methods

In 2017, we conducted 14 in-depth interviews with self-identified females of reproductive age who recently reported in an online survey administered to Ipsos’ KnowledgePanel that, since 2000, they had attempted SMA while living in the United States. We asked participants about their reproductive histories, experiences seeking reproductive health care, and SMA experiences. We used an iterative process to develop codes and analyzed transcripts using thematic content analysis methods.

Results

Motivations and perceptions of effectiveness varied by whether participants had confirmed the pregnancy prior to SMA. Participants who confirmed their pregnancies chose SMA because it was convenient, accessible, and private. Those who did not test for pregnancy were motivated by a preference for autonomy and felt empowered by the ability to try something on their own before seeking facility-based care. Participants prioritized methods that were safe and available, though not always effective. Most used herbs or over-the-counter medications; none used self-sourced abortion medications, mifepristone and/or misoprostol. Five participants obtained facility-based abortions and one participant decided to continue the pregnancy after attempting SMA. The remaining eight reported being no longer pregnant after SMA. None of the participants sought care for  SMA complications; one participant saw a provider to confirm abortion completion.

Conclusions

There are many types of SMA experiences. In addition to those who pursue SMA as a last resort (after facing barriers to facility-based care) or as a first resort (because they prefer homeopathic remedies), our findings show that some individuals view SMA as a potential interim step worth trying after suspecting pregnancy and before accessing facility-based care. These people in particular would benefit from a medication abortion product available over the counter, online, or in the form of a missed-period pill.

Some people in the United States (US) attempt to end a pregnancy on their own without medical supervision. What we know about this experience comes from studies focused on people who go to clinics. In this study, we conducted 14 interviews with self-identified women ages 18–49 who recently reported attempting to end a pregnancy on their own and who were recruited outside of the clinic setting. We asked participants about their fertility histories, experiences seeking reproductive health care, and experiences ending a pregnancy without medical assistance. Those who took a pregnancy test and then chose to end the pregnancy on their own did so because it was convenient, accessible, and private. Those who did not test for pregnancy felt empowered by the ability to try something on their own before seeking facility-based care. All participants prioritized methods that were safe and available, though not always effective. After they attempted to end the pregnancy on their own, five participants accessed abortion care in facilities, one decided to continue the pregnancy, and eight were no longer pregnant. Our findings show that, in addition to people who end a pregnancy on their own as a last resort (after facing barriers to facility-based care) or as a first resort (because of preferences for homeopathic methods), a third group values having an interim step to try after suspecting pregnancy and before accessing facility-based care. These people would particularly benefit from a medication abortion product available over the counter, online, or in the form of a missed-period pill.

Factors Associated With Use of an Online Telemedicine Service to Access Self-managed Medical Abortion in the US

IMPORTANCE

People in the US have been seeking self-managed abortions outside the formal health care system using medications obtained through online telemedicine. However, little is known about this practice, including potential motivating factors.

OBJECTIVE

To examine individual reasons for accessing medication abortion through an online telemedicine service as well as associations between state- and county-level factors and the rate of requests.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study examined all requests for self-managed medication abortion through an online consultation form available from Aid Access, a telemedicine service in the US, between March 20, 2018, and March 20, 2020.

MAIN OUTCOMES AND MEASURES

Individual-level reasons for accessing the telemedicine service were examined as well as the rate of requests per 100 000 women of reproductive age by state. Zip code data provided by individuals making requests were used to examine county-level factors hypothesized to be associated with increased demand for self-managed abortion: distance to a clinic (calculated using location data for US abortion clinics) and the population proportion identifying as a member of a racial/ethnic minority group, living below the federal poverty level, and having broadband internet access (calculated using census data).

RESULTS

During the 2-year study period, 57 506 individuals in 2458 counties in 50 states requested self-managed medication abortion; 52.1% were aged 20 to 29 years (mean [SD] age, 25.9 [6.7] years), 50.0% had children, and 99.9% were 10 weeks' pregnant or less. The most common reasons cited by individuals making requests were the inability to afford in-clinic care (73.5%), privacy (49.3%), and clinic distance (40.4%). States with the highest rate of requests were Louisiana (202.7 per 100 000 women) and Mississippi (199.9 per 100 000 women). At the county level, an increase of 1 SD (47 miles) in distance to the nearest clinic was significantly associated with a 41% increase in requests (incidence rate ratio, 1.41; 95% CI, 1.31-1.51; P < .001), and a 10% increase in the population living below the federal poverty level was significantly associated with a 20% increase in requests (incidence rate ratio, 1.20; 95% CI, 1.13-1.28; P < .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, clinic access barriers were the most commonly cited reason for requesting self-managed medication abortion using an online telemedicine service. At the county level, distance to an abortion clinic and living below the federal poverty level were associated with a higher rate of requests. State and federal legislation could address these access barriers.

Greasing the wheels: The impact of COVID-19 on US physician attitudes and practices regarding medication abortion

OBJECTIVE

To explore US provider perspectives about self-sourced medication abortion and how their attitudes and clinic practices changed in the context of the COVID-19 pandemic.

STUDY DESIGN

We conducted a multi-method study of survey and interview data. We performed 40 baseline interviews and surveys in spring 2019 and 36 follow-up surveys and ten interviews one year later. We compared pre- and post-Likert scale responses of provider views on the importance of different aspects of standard medication abortion assessment and evaluation (e.g., related to ultrasounds and blood-typing). We performed content analysis of the follow-up interviews using deductive-inductive analysis.

RESULTS

Survey results revealed that clinics substantially changed their medication abortion protocols in response to COVID-19, with more than half increasing their gestational age limits and introducing telemedicine for follow-up of a medication abortion. Interview analysis suggested that physicians were more supportive of self-sourced medication abortion in response to changing clinic protocols that decreased in-clinic assessment and evaluation for medication abortion, and as a result of physicians' altered assessments of risk in the context of COVID-19. Having evidence already in place that supported these practice changes made the implementation of new protocols more efficient, while working in a state with restrictive abortion policies thwarted the flexibility of clinics to adapt to changes in standards of care.

CONCLUSION

This exploratory study reveals that the COVID-19 pandemic has altered clinical assessment of risk and has shifted practice towards a less medicalized model. Further work to facilitate person-centered abortion information and care can build on initial modifications in response to the pandemic.

IMPLICATIONS

COVID-19 has shifted clinician perception of risk and has catalyzed a change in clinical protocols for medication abortion. However, state laws and policies that regulate medication abortion limit physician ability to respond to changes in risk assessment.

Perspectives on self-managed abortion among providers in hospitals along the Texas-Mexico border

BACKGROUND

Following self-managed abortion (SMA), or a pregnancy termination attempt outside of the formal health system, some patients may seek care in an emergency department. Information about provider experiences treating these patients in hospital settings on the Texas-Mexico border is lacking.

METHODS

The study team conducted semi-structured interviews with physicians, advanced practice clinicians, and nurses who had experience with patients presenting with early pregnancy complications in emergency and/or labor and delivery departments in five hospitals near the Texas-Mexico border. Interview questions focused on respondents' roles at the hospital, knowledge of abortion services and laws, perspectives on SMA trends, experiences treating patients presenting after SMA, and potential gaps in training related to abortion. Researchers conducted interviews in person between October 2017 and January 2018, and analyzed transcripts using a thematic analysis approach.

RESULTS

Most of the 54 participants interviewed said that the care provided to SMA patients was, and should be, the same as for patients presenting after miscarriage. The majority had treated a patient they suspected or confirmed had attempted SMA; typically, these cases required only expectant management and confirmation of pregnancy termination, or treatment for incomplete abortion. In rare cases, further clinical intervention was required. Many providers lacked clinical and legal knowledge about abortion, including local resources available.

CONCLUSIONS

Treatment provided to SMA patients is similar to that provided to patients presenting after early pregnancy loss. Lack of provider knowledge about abortion and SMA, despite their involvement with SMA patients, highlights a need for improved training.

Characterizing community-level abortion stigma in the United States

OBJECTIVE

Estimate community-level abortion stigma among U.S. adults and characterize factors associated with high stigma and less favorable opinions toward policies supportive of abortion care.

STUDY DESIGN

We recruited respondents (U.S. adults, English-speaking) from a nationally representative, probability-based online panel in December 2018. We used multivariable logistic regression to identify factors associated with high abortion stigma using the Community Attitudes Abortion Scale (CAAS), a Reproductive Events and Experiences Scale (REES) subscale, and a Community Level Abortion Stigma Scale (CLASS) subscale. We measured favorability toward policies supportive of abortion care using widely used polling questions.

RESULTS

Of 1800 eligible individuals contacted, 984 opened the invitation (54.6%) and 886 (90%) completed the survey. The majority demonstrated midrange stigma scores on all three scales. Increased likelihood of high stigma measured by CAAS was demonstrated among individuals reporting Catholic (OR 2.97, 95%CI 1.49-5.91) and Evangelical or Protestant religion (OR 4.78, 95%CI 2.53-9.00) compared to no religion, and Republican (OR 11.56, 95%CI 6.21-21.52) and Independent political affiliation (5.80, 95%CI, 3.17-10.60) compared to Democratic. Similar trends were seen with REES. Measured by CLASS, we found high stigma in Catholics compared to those with no religion (OR 1.91, 95%CI 1.09-3.32) and Blacks compared to Whites (OR 1.66, 95%CI 1.02-2.68). Identifying as Catholic, Evangelical or Protestant, and Republican were associated with holding less favorable opinions toward policies supportive of abortion care. Identifying as Catholic was the only characteristic associated with high stigma across all measures.

CONCLUSIONS

Across multiple measurement tools, factors associated with high stigma and less favorable opinions toward policies supportive of abortion care include Catholic, Evangelical or Protestant religion and Republican political affiliation.

IMPLICATIONS

Multiple measures are needed to fully understand the extent of and characteristics associated with community-level abortion stigma. Religion and political identity are frequently associated with high stigma. Understanding these relationships may aid in developing interventions to decrease stigma and in turn reduce barriers to abortion care.

Prevalence of Self-Managed Abortion Among Women of Reproductive Age in the United States

IMPORTANCE

Increasing evidence indicates that people are attempting their own abortions outside the formal health care system. However, population-based estimates of experience with self-managed abortion (SMA) are lacking.

OBJECTIVE

To estimate the prevalence of SMA attempts among the general US population.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study was fielded August 2 to 17, 2017 among English- and Spanish- speaking, self-identified female panel members from the GfK web-based KnowledgePanel. Women ages 18 to 49 years were approached to complete a 1-time survey. Data were analyzed from September 22, 2017, to March 26, 2020.

MAIN OUTCOMES AND MEASURES

SMA was defined as "some women may do something on their own to try to end a pregnancy without medical assistance. For example, they may get information from the internet, a friend, or family member about pills, medicine, or herbs they can take on their own, or they may do something else to try to end the pregnancy." SMA was assessed using the question, "Have you ever taken or used something on your own, without medical assistance, to try to end an unwanted pregnancy?" Participants reporting SMA were asked about methods used, reasons, and outcomes. Factors associated with SMA experience, including age, race/ethnicity, socioeconomic status, nativity, reproductive health history, and geography, were assessed. Projected lifetime SMA prevalence was estimated using discrete-time event history models, adjusting for abortion underreporting.

RESULTS

Among 14 151 participants invited to participate, 7022 women (49.6%) (mean [SE] age, 33.9 [9.0] years) agreed to participate. Among these, 57.4% (95% CI, 55.8%-59.0%) were non-Hispanic White, 20.2% (95% CI, 18.9%-21.5%) were Hispanic, and 13.3% (95% CI, 12.1%-14.5%) were non-Hispanic Black; and 15.1% (95% CI, 14.1%-16.3%) reported living at less than 100% federal poverty level (FPL). A total of 1.4% (95% CI, 1.0%-1.8%) of participants reported a history of attempting SMA while in the US. Projected lifetime prevalence of SMA adjusting for underreporting of abortion was 7.0% (95% CI, 5.5%-8.4%). In bivariable analyses, non-Hispanic Black (prevalence ratio [PR], 3.16; 95% CI, 1.48-6.75) and Hispanic women surveyed in English (PR, 3.74; 95% CI, 1.78-7.87) were more likely than non-Hispanic White women to have attempted SMA. Women living below 100% of the FPL were also more likely to have attempted SMA compared with those at 200% FPL or greater (PR, 3.43; 95% CI, 1.83-6.42). At most recent SMA attempt, 20.0% (95% CI, 10.9%-33.8%) of respondents used misoprostol, 29.2% (95% CI, 17.5%-44.5%) used another medication or drug, 38.4% (95% CI, 25.3%-53.4%) used herbs, and 19.8% (95% CI, 10.0%-35.5%) used physical methods. The most common reasons for SMA included that it seemed faster or easier (47.2% [95% CI, 33.0%-61.8%]) and the clinic was too expensive (25.2% [95% CI, 15.7%-37.7%]). Of all attempts, 27.8% (95% CI, 16.6%-42.7%) of respondents reported they were successful; the remainder reported they had subsequent facility-based abortions (33.6% [95% CI, 21.0%-49.0%]), continued the pregnancy (13.4% [95% CI, 7.4%-23.1%]), had a miscarriage (11.4% [95% CI, 4.2%-27.5%]), or were unsure (13.3% [95% CI, 6.8%-24.7%]). A total of 11.0% (95% CI, 5.5%-21.0%) of respondents reported a complication.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that approximately 7% of US women reported having attempted SMA in their lifetime, commonly with ineffective methods. These findings suggest that surveys of SMA experience among patients at abortion clinics may capture only one-third of SMA attempts. People's reasons for attempting SMA indicate that as abortion becomes more restricted, SMA may become more common.

Abortion restrictions in the state of Georgia: Anticipated impact on people seeking abortion

OBJECTIVE

To explore the impact of restrictive abortion policies in the state of Georgia on the lives of people seeking abortion and how they would manage unwanted pregnancies.

STUDY DESIGN

We conducted a cross sectional study of English and Spanish-speaking people seeking abortion from three high-volume outpatient abortion clinics in Atlanta, Georgia from April 2019 through August 2019. Participants completed a multiple-choice questionnaire. We used bivariable and multivariable analysis to explore relationships between demographic characteristics and how people would manage their unwanted pregnancies if abortion were illegal in the state. Two researchers (EC and SC) conducted qualitative analysis on free response answers and coded them by key emotion.

RESULTS

Of the 382 participants, 312 (81.9%) considered at least one way to end their pregnancy if abortion were illegal in Georgia: 252 (66.1%) by traveling to another state, 85 (22.3%) by self-management with medications and/or herbs, and 32 (8.4%) considered self-harm behaviors. When asked how they would feel about not being able to have a desired abortion, 94% reported negative emotions, ranging from "scared" to "enslaved."

CONCLUSIONS

Limiting access to legal abortion in Georgia would negatively impact the lives of people seeking abortion and has the potential to drive individuals to seek more costly and risky alternatives to end their pregnancy.

IMPLICATIONS

Restricting abortion in Georgia may cause medically unnecessary delays in care, increased travel time, cost and negative emotional responses to people seeking abortion. Mitigating strategies include legislative challenges to restrictive laws as well as harm reduction education.

Exploring potential interest in missed period pills in two US states

OBJECTIVE

Missed period pills (MPP) are uterine evacuation medications used for treatment of delayed menses without prior pregnancy confirmation. This study explores potential interest in missed period pills in two US states.

STUDY DESIGN

We enrolled people seeking pregnancy test services at nine health centers in two US states between June 2015 and October 2017. Participants completed an anonymous questionnaire containing closed- and open-ended questions about background characteristics, reproductive practices, pregnancy feelings and intentions, abortion attitudes, and MPP interest. We used ordered logistic regression to identify factors associated with MPP interest and inductive content analysis to identify recurring qualitative themes related to MPP interest or disinterest.

RESULTS

In all, 678 people completed the survey and 286/678 (42%) indicated interest in missed period pills. Interest was greatest (129/185 or 70%) among those who would be unhappy if pregnant. Variables associated with interest in the multivariate analyses were age ≥ 35, nulliparity, prior abortion and contraceptive use, recent use of emergency contraception, pregnancy feelings and intentions, and abortion attitudes (p < .05). Variables not associated with interest included state of residence, educational attainment, ethnicity, religious affiliation, and frequency of religious attendance. Key reasons for interest were to prevent, avoid or terminate pregnancy; and psychological or emotional benefits, including management of abortion stigma. Reasons for non-interest included concerns about safety or side effects, desire to be pregnant or have a baby, and not wanting to abort or hurt the fetus/baby.

CONCLUSION

If missed period pills were available in the United States, demand might be substantial and wide-ranging across demographic groups.

IMPLICATIONS

Our findings suggest that some people with missed periods do not desire pregnancy confirmation before taking medications that might disrupt a pregnancy. As a result, provision of missed period pills in the United States would expand reproductive service options and could improve the delivery of patient-centered care.

Knowledge, interest, and motivations surrounding self-managed medication abortion among patients at three Texas clinics

BACKGROUND

A rapid increase in restrictive abortion legislation in the United States has sparked renewed interest in self-managed abortion as a response to clinic access barriers. Yet little is known about knowledge of, interest in, and experiences of self-managed medication abortion among patients who obtain abortion care in a clinic.

OBJECTIVES

We examined patients' knowledge of, interest in, and experience with self-managed medication abortion before presenting to the clinic. We characterized the clinic- and person-level factors associated with these measures. Finally, we examined the reasons why patients express an interest in or consider self-management before attending the clinic.

MATERIALS AND METHODS

We surveyed 1502 abortion patients at 3 Texas clinics in McAllen, San Antonio, and Fort Worth. All individuals seeking abortion care who could complete the survey in English or Spanish were invited to participate in an anonymous survey conducted using iPads. The overall response rate was 90%. We examined the prevalence of 4 outcome variables, both overall and separately by site: (1) knowledge of self-managed medication abortion; (2) having considered self-managing using medications before attending the clinic; (3) interest in medication self-management as an alternative to accessing care at the clinic; and (4) having sought or tried any method of self-management before attending the clinic. We used binary logistic regression models to explore the clinic- and patient-level factors associated with these outcome variables. Finally, we analyzed the reasons reported by those who had considered medication self-management before attending the clinic, as well as the reasons reported by those who would be interested in medication self-management as an alternative to in-clinic care.

RESULTS

Among all respondents, 30% knew about abortion medications available outside the clinic setting (37% in Fort Worth, 33% in McAllen, 19% in San Antonio, P < .001), and among those with prior knowledge, 28% had considered using this option before coming to the clinic (36% in McAllen, 25% in Fort Worth, 21% in San Antonio, P = .028). Among those without prior knowledge of self-management, 39% expressed interest in this option instead of coming to the clinic (54% in San Antonio, 30% in McAllen, 29% in Fort Worth, P < .001). Overall, 13% had sought out or tried any method of self-management before presenting to the clinic (16% in McAllen and 15% in Fort Worth vs 9% in San Antonio, P < .001). Experiencing barriers to clinic access was associated with having considered medication self-management (odds ratio, 2.2; 95% confidence interval, 1.7-3.0) and with seeking or trying any method of self-management before attending the clinic (odds ratio, 1.9; 95% confidence interval, 1.3-2.7). Difficulty affording the cost of in-clinic care was the most commonly cited reason for having considering medication self-management before attending the clinic. Reasons for interest in medication self-management as an alternative to clinic care included both access barriers and preferences for the privacy and comfort of home.

CONCLUSION

Considering or attempting self-managed abortion may be part of the pathway to seeking in-clinic care, particularly among those experiencing access barriers. However, considerable interest in medication self-management as an alternative to the clinic also suggests a demand for more autonomous abortion care options.

Abortion Reporting in the United States: An Assessment of Three National Fertility Surveys

Despite its frequency, abortion remains a highly sensitive, stigmatized, and difficult-to-measure behavior. We present estimates of abortion underreporting for three of the most commonly used national fertility surveys in the United States: the National Survey of Family Growth, the National Longitudinal Survey of Youth 1997, and the National Longitudinal Study of Adolescent to Adult Health. Numbers of abortions reported in each survey were compared with external abortion counts obtained from a census of all U.S. abortion providers, with adjustments for comparable respondent ages and periods of each data source. We examined the influence of survey design factors, including survey mode, sampling frame, and length of recall, on abortion underreporting. We used Monte Carlo simulations to estimate potential measurement biases in relationships between abortion and other variables. Underreporting of abortion in the United States compromises the ability to study abortion-and, consequently, almost any pregnancy-related experience-using national fertility surveys.

Prevalence, attitudes and knowledge of misoprostol for self-induction of abortion in women presenting for abortion at Midwestern reproductive health clinics

In the setting of increasing restrictions to legal abortion in the United States, reports have emerged of self-induced termination of pregnancies with misoprostol, obtained without a prescription or provider. This study seeks to describe the prevalence of women seeking or employing misoprostol for self-induced abortion, and how they access information. In a cross-sectional study of women immediately following their abortion at three reproductive health clinics in the Midwestern United States, an anonymous survey queried gestational age, barriers, online investigation about self-induction and opinions concerning the availability of medical abortion. From June to September 2016, 276 women participated out of 437 presenting to the clinics during the study period. One hundred and ninety-one (74.6%) women had investigated abortion options online, and of those, 58 (30.9%) investigated misoprostol online, for home use. Women who investigated online options were less likely to have had a prior abortion than those who did not investigate online (29.3% vs. 63.1%, p < .01). They were also more likely to report prior home attempts to end this pregnancy (8.6% vs. 0%, p = .05). Overall, four (1.6%) of the respondents purchased misoprostol and three (1.2%) used it. A majority of women seeking an abortion sought online information prior to their clinic appointment, and almost a third of those had investigated misoprostol for home use. Women are accessing information regarding misoprostol for self-induction of abortion on the Internet. As barriers to legal abortion increase, women may be more likely to self-induce abortion.

Texas women's decisions and experiences regarding self-managed abortion

BACKGROUND

Prior research has shown that a small proportion of U.S. women attempt to self-manage their abortion. The objective of this study is to describe Texas women's motivations for and experiences with attempts to self-manage an abortion. The objective of this study is to describe Texas women's motivations for and experiences with attempts to self-manage an abortion.

METHODS

We report results from two data sources: two waves of surveys with women seeking abortion services at Texas facilities in 2012 and 2014 and qualitative interviews with women who reported attempting to self-manage their abortion while living in Texas at some time between 2009 and 2014. We report the prevalence of attempted self-managed abortion for the current pregnancy among survey respondents, and describe interview participants' decision-making and experiences with abortion self-management.

RESULTS

6.9% (95% CI 5.2-9.0%) of abortion clients (n = 721) reported they had tried to end their current pregnancy on their own before coming to the clinic for an abortion. Interview participants (n = 18) described multiple reasons for their decision to attempt to self-manage abortion. No single reason was enough for any participant to consider self-managing their abortion; however, poverty intersected with and layered upon other obstacles to leave them feeling they had no other option. Ten interview participants reported having a complete abortion after taking medications, most of which was identified as misoprostol. None of the six women who used home remedies alone reported having a successful abortion; many described using these methods for several days or weeks which ultimately did not work, resulting in delays for some, greater distress, and higher costs.

CONCLUSION

These findings point to a need to ensure that women who may consider self-managed abortion have accurate information about effective methods, what to expect in the process, and where to go for questions and follow-up care. There is increasing evidence that given accurate information and access to clinical consultation, self-managed abortion is as safe as clinic-based abortion care and that many women find it acceptable, while others may prefer to use clinic-based abortion care.

Demand for Self-Managed Medication Abortion Through an Online Telemedicine Service in the United States

Objectives. To examine demand for abortion medications through an online telemedicine service in the United States.Methods. We examined requests from US residents to the online telemedicine abortion service Women on Web (WoW) between October 15, 2017, and August 15, 2018. We calculated the population-adjusted rate of requests by state and examined the demographics, clinical characteristics, and motivations of those seeking services, comparing those in states with hostile versus supportive abortion policy climates.Results. Over 10 months, WoW received 6022 requests from US residents; 76% from hostile states. Mississippi had the highest rate of requests (24.9 per 100 000 women of reproductive age). In both hostile and supportive states, a majority (60%) reported a combination of barriers to clinic access and preferences for self-management. Cost was the most common barrier (71% in hostile states; 63% in supportive states; P < .001). Privacy was the most common preference (49% in both hostile and supportive states; P = .66).Conclusions. Demand for self-managed medication abortion through online telemedicine is prevalent in the United States. There is a public health justification to make these abortions as safe, effective, and supported as possible.

Reducing underreporting of stigmatized pregnancy outcomes: results from a mixed-methods study of self-managed abortion in Texas using the list-experiment method

BACKGROUND

Accurately measuring stigmatized experiences is a challenge across reproductive health research. In this study, we tested a novel method - the list experiment - that aims to reduce underreporting of sensitive events by asking participants to report how many of a list of experiences they have had, not which ones. We applied the list experiment to measure "self-managed abortion" - any attempt by a person to end a pregnancy on one's own, outside of a clinical setting - a phenomenon that may be underreported in surveys due to a desire to avoid judgement.

METHODS

We administered a double list experiment on self-managed abortion to a Texas-wide representative sample of 790 women of reproductive age in 2015. Participants were asked how many of a list of health experiences they had experienced; self-managed abortion was randomly added as an item to half of the lists. A difference in the average number of items reported by participants between lists with and without self-managed abortion provided a population level estimate of self-managed abortion. In 2017, we conducted cognitive interviews with women of reproductive age in four states to understand how women (1) interpreted the list experiment question format, and (2) interpreted the list item on prior experiences attempting to self-manage an abortion.

RESULTS

Results from this list experiment estimated that 8% of women of reproductive age in Texas have ever self-managed an abortion. This number was higher than expected, thus, the researchers conducted cognitive interviews to better understand how people interpreted the list experiment on self-managed abortion. Some women interpreted "on your own" to mean "without the knowledge of friends or family", as opposed to "without medical assistance", as intended.

CONCLUSION

The list experiment may have reduced under-reporting of self-managed abortion; however, the specific phrasing of the list item may also have unintentionally increased reporting of abortion experiences not considered "self-managed." High participation in and comprehension of the list experiment, however, suggests that this method is worthy of further exploration as tool for measuring stigmatized experiences.

Self-managed abortion: A systematic scoping review

Self-managed abortion, when a person performs their own abortion without clinical supervision, is a model of abortion care used across a range of settings. To provide a comprehensive synthesis of the available literature on self-managed abortion, we conducted a systematic search for peer-reviewed research in April 2019 in PubMed, Embase, Web of Science, Popline, PsycINFO, Google Scholar, Scielo, and Redalyc. We included studies that had a research question focused on self-managed abortion; and were published in English or Spanish. The combined search returned 7167 studies; after screening, 99 studies were included in the analysis. Included studies reported on methods, procurement, characteristics of those who self-managed, effectiveness, safety, reasons for self-managed abortion, and emotional and physical experiences. Numerous abortion methods were reported, most frequently abortion with pills and herbs. Studies reporting on self-managed medication abortion reported high-levels of effectiveness. We identify gaps in the research, and make recommendations to address those gaps.

Experiences of women who travel for abortion: A mixed methods systematic review

OBJECTIVE

To systematically review the literature on women's experiences traveling for abortion and assess how this concept has been explored and operationalized, with a focus on travel distance, cost, delays, and other barriers to receiving services.

BACKGROUND

Increasing limitations on abortion providers and access to care have increased the necessity of travel for abortion services around the world. No systematic examination of women's experiences traveling for abortion has been conducted; this mixed-methods review provides a summary of the qualitative and quantitative literature on this topic.

METHODS

A systematic search was conducted using PubMed, Embase, Web of Science, Popline, and Google Scholar in July 2016 and updated in March 2017 (PROSPERO registration # CRD42016046007). We included original research studies that described women's experiences traveling for abortion. Two reviewers independently performed article screening, data extraction and determination of final inclusion for analysis. Critical appraisal was conducted using CASP, STROBE, and MMAT checklists.

RESULTS

We included 59 publications: 46 quantitative studies, 12 qualitative studies, and 1 mixed-methods study. Most studies were published in the last five years, relied on data from the US, and discussed travel as a secondary outcome of interest. In quantitative studies, travel was primarily conceptualized and measured as road or straight-line distance to abortion provider, though some studies also incorporated measures of burdens related to travel, such as financial cost, childcare needs, and unwanted disclosure of their abortion status to others. Qualitative studies explored regional disparities in access to abortion care, with a focus on the burdens related to travel, the impact of travel on abortion method choice, and women's reasons for travel. Studies generally were of high quality, though many studies lacked information on participant recruitment or consideration of potential biases.

CONCLUSIONS

Standardized measurements of travel, including burdens associated with travel and more nuanced considerations of travel costs, should be implemented in order to facilitate comparison across studies. More research is needed to explore and accurately capture different dimensions of the burden of travel for abortion services on women's lives.

Why do they take the risk? A systematic review of the qualitative literature on informal sector abortions in settings where abortion is legal

BACKGROUND

Restrictive abortion laws are the single most important determinant of unsafe abortion, a major, yet preventable, global health issue. While reviews have been conducted on the extent of the phenomenon, no study has so far analysed the evidence of why women turn to informal sector providers when legal alternatives are available. This work provides a systematic review of the qualitative literature on informal sector abortion in setting where abortion is legal.

METHODS

We used the PRISMA guidelines to search Pubmed, Web of Science, Sciencedirect and Google Scholar databases between January and February 2018. 2794 documents in English and French were screened for eligibility against pre-determined inclusion and exclusion criteria. Articles investigating women's reasons for aborting in the informal sector in settings where abortion is legal were included. In total, sixteen articles were identified as eligible for this review. Findings were reported following the PRISMA guidelines.

RESULTS

The review highlights the diverse reasons women turn to the informal sector, as abortions outside of legal health facilities were reported to be a widespread and normalised practice in countries where legal abortion is provided. Women cited a range of reasons for aborting in the informal sector; these included fear of mistreatment by staff, long waiting lists, high costs, inability to fulfil regulations, privacy concerns and lack of awareness about the legality of abortion or where to procure a safe and legal abortion. Not only was unsafe abortion spoken of in terms of medical and physical safety, but also in terms of social and economic security.

CONCLUSION

The use of informal sector abortions (ISAs) is a widespread and normalised practice in many countries despite the liberalisation of abortion laws. Although ISAs are not inherently unsafe, the practice in a setting where it is illegal will increase the likelihood that women will not be given the necessary information, or that they will be punished. This study brings to the fore the diverse reasons why women opt to abort outside formal healthcare settings and their issues with provision of abortion services in legal contexts, providing an evidence base for future research and policies.

Motivations and Experiences of People Seeking Medication Abortion Online in the United States

CONTEXT

State legislation restricting access to abortion in the clinic setting raises the possibility that an increasing number of individuals in the United States will self-manage their abortion at home. Medications sourced online represent a potential pathway to abortion self-management. Yet, very little is known about the reasons U.S. residents may seek abortion online or their experiences finding medications and information.

METHODS

In January-June 2017, anonymous in-depth interviews were conducted with 32 people from 20 states who sought abortion medications online (30 women and two men seeking medications for their partners). Participants were asked about their (or their partners') motivations for considering self-managed abortion, the sources of medications they identified and any other methods they considered. Transcripts were coded and analyzed according to the principles of grounded theory.

RESULTS

The analysis revealed four key themes: Seeking abortion medications online can be a response to clinic access barriers both in states with and in ones without restrictive abortion laws; self-managed abortion can be a preference over clinical care; online options offer either information or medications, but not both; and the lack of trusted online options can delay care and lead to consideration of ineffective or unsafe alternatives.

CONCLUSION

Current online options for abortion medications leave many important needs unmet, particularly for women who encounter barriers to obtaining clinic-based abortion services. There is a public health justification to reduce clinic access barriers and to make medication abortion that is sourced online and managed at home as safe and supported as possible.

Support for and interest in alternative models of medication abortion provision among a national probability sample of U.S. women

OBJECTIVE

The objective was to assess women's personal interest in and support for three alternative models of medication abortion (MA) provision.

STUDY DESIGN

Using an online survey of a U.S. national, probability-based representative sample of women ages 18-49, we gauged personal interest in and general support for three alternative models for accessing abortion pills: (1) in advance from a doctor for future use, (2) over-the-counter (OTC) from a drugstore and (3) online without a prescription. We conducted multivariable analyses to identify characteristics associated with support for these provision models.

RESULTS

Fifty percent (n=7022) of eligible women invited completed the survey. Nearly half (49%) supported and 30% were personally interested in one or more of the three access models; 44% supported advance provision, 37% supported OTC access, and 29% supported online access. Common advantages reported for advance provision, OTC and online access included privacy (49%, 29% and 46%, respectively), convenience (38%, 44% and 38%) and being able to end the pregnancy earlier (48%, 40% and 29%). Common disadvantages included concern that women might take the pills incorrectly (55%, 53% and 57%), not seeing a clinician before the abortion (52%, 54% and 53%) and safety (42%, 43% and 60%). History of abortion and experiencing barriers accessing reproductive health services were associated with greater support for the alternative models.

CONCLUSION

Women are interested in and support alternative models of MA provision, in particular, advance provision. However, they also reported concerns about incorrect pill use and not seeing a clinician beforehand.

IMPLICATIONS

Offering women more choices in how they access medication abortion, including options where they can safely self-manage their own care, has the potential to expand access to care.

What are people looking for when they Google "self-abortion"?

OBJECTIVE

To examine the motivations and circumstances of individuals seeking information about self-abortion on the Internet.

STUDY DESIGN

We identified 26 terms that we anticipated someone might use to find information about self-abortion on the internet. Users who entered these terms into the Google search engine were provided with a link to our survey via Google AdWords. We fielded the survey over a 32-day period; users were eligible if accessing the survey from a US-based device. We examined demographic characteristics of the sample, reasons for searching for information on self-abortion, knowledge of the legality of abortion and of nearby providers, and top performing keywords.

RESULTS

Our Google AdWords campaign containing the survey link was shown approximately 210,000 times, and clicked 9,800 times; 1,235 respondents completed the survey. The vast majority of the sample was female (96%), and 41% were minors. Almost three-quarters (73%) indicated that they were searching for information because they were pregnant and did not or may not want to be. Eleven percent had ever attempted to self-abort. One-third of respondents did not know if abortion was legal in their state of residence, and knowledge of legality did not differ by age.

CONCLUSIONS

There is interest in learning more about self-abortion on the Internet. Our findings suggest that, among those who participated in our survey, online searches for information on self-abortion may be driven by adolescents and young adults facing an unintended pregnancy.

IMPLICATIONS

Young women, in particular, may have an unmet need for information about safe and accessible abortion options.

Use of modern contraceptive methods and its association with QOL among Nepalese female migrants living in Japan

Introduction

Modern contraceptive use among migrants may be limited due to factors such as language barriers, socio-economic condition, and inadequate knowledge. Limited evidence is available on the factors associated with the use of modern contraceptive methods by migrants in Japan. Moreover, evidence remains scarce on the quality of life (QOL) of migrants in relation to contraceptive use. As the Nepalese migrant population in Japan is increasing, this study was conducted to address their sexual and reproductive health issues. Therefore, the objectives of this study were to examine the factors associated with the use of modern contraceptive methods and to explore the association between the use of modern contraceptive methods and QOL among married Nepalese female migrants in Japan.

Methods

This is a cross-sectional study conducted among 189 married Nepalese female migrants residing in five prefectures of Japan from August to October 2016. This study employed snowball sampling to recruit the migrants. Simple and multiple logistic analyses were used to examine the association between independent variables and the use of modern contraceptive methods. Similarly, multiple linear regression analysis was used to examine the association between the use of modern contraceptive methods and quality of life.

Results

Migrants who had higher knowledge of modern contraceptive methods were more likely to use them (Adjusted Odds Ratio [AOR] = 1.31; 95% Confidence Interval [CI]: 1.07, 1.60). The psychological domain scores were higher in those who used modern contraceptive methods (Coefficient [B] = 0.58; 95% CI: 0.05, 1.11).

Conclusion

This study highlights the importance of the knowledge of modern contraceptive methods to increase their use. Also, the use of modern contraceptive methods improves the psychological QOL domain scores of the migrants using them. These results suggest a need for sexual and reproductive health education for migrants, especially pertaining to modern contraceptive use.

Exploring the feasibility of obtaining mifepristone and misoprostol from the internet

OBJECTIVES

We aimed to document the experience of buying abortion pills from online vendors that do not require a prescription and to evaluate the active ingredient content of the pills received.

STUDY DESIGN

We searched the internet to identify a convenience sample of websites that sold mifepristone and misoprostol to purchasers in the United States and attempted to order these products. We documented price, shipping time and other aspects of ordering. We sent the samples received to a testing laboratory that measured the amount of active ingredient in individual tablets.

RESULTS

We identified 18 websites and ordered 22 products: 20 mifepristone-misoprostol combination products and 2 that contained only misoprostol. We received 18 combination products and the 2 misoprostol products from 16 different sites. No site required a prescription or any relevant medical information. The time between order and receipt of the 20 products ranged from 3 to 21 business days (median 9.5 days). The price for the 18 combination products ranged from $110 to $360, including shipping and fees; the products without mifepristone cost less. Chemical assays found that the 18 tablets labeled 200 mg mifepristone contained between 184.3 mg and 204.1 mg mifepristone, while the 20 tablets labeled 200 mcg misoprostol contained between 34.1 mcg and 201.4 mcg of the active ingredient.

CONCLUSIONS

Obtaining abortion medications from online pharmaceutical websites is feasible in the United States. The mifepristone tablets received contained within 8% of the labeled amount of active agent. The misoprostol tablets all contained that compound but usually less than labeled.

IMPLICATIONS STATEMENT

Given our findings, we expect that some people for whom clinic-based abortion is not easily available or acceptable may consider self-sourcing pills from the internet to be a rational option.

Women's experiences seeking informal sector abortion services in Cape Town, South Africa: a descriptive study

Background

In settings where abortion is legally restricted, or permitted but not widely accessible, women face significant barriers to abortion access, sometimes leading them to seek services outside legal facilities. The advent of medication abortion has further increased the prevalence of informal sector abortion. This study investigates the reasons for attempting self-induction, methods used, complications, and sources of information about informal sector abortion, and tests a specific recruitment method which could lead to improved estimates of informal sector abortion prevalence among an at-risk population.

Methods

We recruited women who have sought informal sector abortion services in Cape Town, South Africa using respondent driven sampling (RDS). An initial seed recruiter was responsible for initiating recruitment using a structured coupon system. Participants completed face-to-face questionnaires, which included information about demographics, informal sector abortion seeking, and safe abortion access needs.

Results

We enrolled 42 women, nearly one-third of whom reported they were sex workers. Thirty-four women (81%) reported having had one informal sector abortion within the past 5 years, 14% reported having had two, and 5% reported having had three. These women consumed home remedies, herbal mixtures from traditional healers, or tablets from an unregistered provider. Twelve sought additional care for potential warning signs of complications. Privacy and fear of mistreatment at public sector facilities were among the main reported reasons for attempting informal sector abortion. Most women (67%) cited other community members as their source of information about informal sector abortion; posted signs and fliers in public spaces also served as an important source of information.

Conclusions

Women are attempting informal sector abortion because they seek privacy and fear mistreatment and stigma in health facilities. Some were unaware how or where to seek formal sector services, or believed the cost was too high. Many informal methods are ineffective and unsafe, leading to potential warning signs of complications and continued pregnancy. Sex workers may be at particular risk of unsafe abortion. Based on these results, it is essential that future studies sample women outside of the formal health sector. The use of innovative sampling methods would greatly improve our knowledge about informal sector abortion in South Africa.

Electronic supplementary material

The online version of this article (10.1186/s12905-017-0443-6) contains supplementary material, which is available to authorized users.

A trauma-informed examination of the hardships experienced by abortion fund patients in the United States

Researchers describe hardships experienced by abortion patients, examining administrative health cases from 2010 to 2015 in the United States. All patients received financial assistance from an abortion fund to help pay for abortion. Case data were analyzed to assess types and numbers of hardships experienced by age, race, and geographic origin. Hardships ranged from homelessness to parenting multiple children. Patients from the geographic South experienced the most hardships, followed by those from the Midwest. Hardships experienced by abortion fund patients are like those reported in other samples of abortion patients; hardships potentially cause or exacerbate trauma. Results are discussed in the context of a trauma-informed perspective.

Abortion politics in Cambodia social history, local forms and transnational issues

Cambodia's current abortion rate and ratio could be among the highest in Southeast Asia. In 1997, the Cambodian parliament passed the first law regulating abortions. This law was adopted to contribute to reduce the high maternal mortality ratio, as a significant number of maternal deaths were believed to be related to complications of unsafe abortion. A decade later, the Ministry of Health had not yet established medical protocols for safe abortion access and women often continued to induce their own terminations or seek unsafe services. However, in 2009, the Cambodian authorities approved the importation and distribution of one manufactured abortion pill. In addition, manual vacuum abortions and medical abortion training programmes were implemented at the referral hospital level. How has this situation come about? What do we know about the local agencies of the transnational reproductive health policies related to safe abortion access in this country? This paper aims to analyse how history and intersections between global interventions, state policies, local moralities and individual strategies shape abortion policies, practices and technologies. Finally, our findings raise some issues for public health programming.

Self-management of first trimester medical termination of pregnancy: a qualitative study of women's experiences

OBJECTIVE

To explore the experiences of women in Scotland who return home to complete medical termination of pregnancy (TOP) ≤63 days of gestation, after being administered with mifepristone and misoprostol at an NHS TOP clinic.

DESIGN

Qualitative interview study.

SETTING

One National Health Service health board (administrative) area in Scotland.

POPULATION OR SAMPLE

Women in Scotland who had undergone medical TOP ≤63 days, and self-managed passing the pregnancy at home; recruited from three clinics in one NHS health board area between January and July 2014.

METHODS

In-depth, semi-structured interviews with 44 women in Scotland who had recently undergone TOP ≤63 days of gestation, and who returned home to pass the pregnancy. Data were analysed thematically using an approach informed by the Framework method.

MAIN OUTCOME MEASURES

Women's experiences of self-management of TOP ≤63 days of gestation.

RESULTS

Key themes emerging from the analysis related to self-administration of misoprostol in clinic; reasons for choosing home self-management; facilitation of self-management and expectation-setting; experiences of getting home; self-managing and monitoring treatment progress; support for self-management (in person and remotely); and pregnancy self-testing to confirm completion.

CONCLUSIONS

Participants primarily found self-administration of misoprostol and home self-management to be acceptable and/or preferable, particularly where this was experienced as a decision made jointly with health professionals. The way in which home self-management is presented to women at clinic requires ongoing attention. Women could benefit from the option of home administration of misoprostol.

TWEETABLE ABSTRACT

Women undergoing medical TOP 63 days found home self-management to be acceptable and/or preferable.

"I was close to death!": abortion and medical risk on American television, 2005-2016

OBJECTIVES

To examine the portrayal of complications and long-term health consequences associated with abortion on television, recognizing the impact that fictional stories can have on public beliefs about abortion's safety.

STUDY DESIGN

Using a systematic online search, we identified all instances of abortion on US television from 2005 to 2016. We qualitatively coded these plotlines to identify any occurrences of complications, interventions or long-term health consequences associated with abortion care, with 95% intercoder reliability. We calculated the frequencies and rates of these occurrences in Microsoft Excel.

RESULTS

Our search identified 80 abortion plot lines. A percentage of 37.5 of characters who obtained an abortion experienced complications, interventions and/or negative health consequences. This rate contrasts with the 2.1% of real patients who experience complications or require intervention as a result of their abortions. Most onscreen complications were major events (e.g., hemorrhage), as opposed to real women, whose complications are mostly minor. Major medical interventions (e.g., hysterectomy) were similarly overportrayed, while the most commonly used interventions for real patients (e.g., medication) were not depicted at all. Finally, 22.5% of characters faced a long-term adverse health consequence, including mental illness, infertility or death. The onscreen abortion mortality rate was 5%, about 7000 times the actual mortality rate.

CONCLUSIONS

Overall, television dramatically exaggerates the risk associated with abortion procedures, overportraying medical complications - particularly major and life-threatening complications - and long-term adverse health consequences. This pattern of misrepresentation may be partially attributable to the occurrence of stories about illegal abortions or abortions taking place outside of modern medical contexts.

IMPLICATIONS

Onscreen abortion portrayals may contribute to inaccurate beliefs about abortion's risk that are common among the public, broadly, and abortion patients, specifically. Abortion advocates and providers will be more equipped to respond misinformation if they understand how and to what extent our popular culture portrays abortion as unsafe.

Self-management of medical abortion: a qualitative evidence synthesis

Medical abortion is a method of pregnancy termination that by its nature enables more active involvement of women in the process of managing, and sometimes even administering the medications for, their abortions. This qualitative evidence synthesis reviewed the global evidence on experiences with, preferences for, and concerns about greater self-management of medical abortion with lesser health professional involvement. We focused on qualitative research from multiple perspectives on women's experiences of self-management of first trimester medical abortion (<12weeks gestation). We included research from both legal and legally-restricted contexts whether medical abortion was accessed through formal or informal systems. A review team of four identified 36 studies meeting inclusion criteria, extracted data from these studies, and synthesized review findings. Review findings were organized under the following themes: general perceptions of self-management, preparation for self-management, logistical considerations, issues of choice and control, and meaning and experience. The synthesis highlights that the qualitative evidence base is still small, but that the available evidence points to the overall acceptability of self-administration of medical abortion. We highlight particular considerations when offering self-management options, and identify key areas for future research. Further qualitative research is needed to strengthen this important evidence base.