Provision of Medications for Self-Managed Abortion Before and After the Dobbs v Jackson Women's Health Organization Decision

Importance

The Supreme Court decision in Dobbs v Jackson Women's Health Organization overturned the right to choose abortion in the US, with at least 16 states subsequently implementing abortion bans or 6-week gestational limits. Prior research indicates that in the 6 months following Dobbs, approximately 32 360 fewer abortions were provided within the US formal health care setting. However, trends in the provision of medications for self-managed abortion outside the formal health care setting have not been studied.

Objective

To determine whether the provision of medications for self-managed abortion outside the formal health care setting increased in the 6 months after Dobbs.

Design, Setting, and Participants

Cross-sectional study using data from sources that provided abortion medications outside the formal health care setting to people in the US between March 1 and December 31, 2022, including online telemedicine organizations, community networks, and online vendors. Using a hierarchical bayesian model, we imputed missing values from sources not providing data. We estimated the change in provision of medications for self-managed abortion after the Dobbs decision. We then estimated actual use of these medications by accounting for the possibility that not all provided medications are used by recipients.

Exposure

Abortion restrictions following the Dobbs decision.

Main Outcomes and Measures

Provision and use of medications for a self-managed abortion.

Results

In the 6-month post-Dobbs period (July 1 to December 31, 2022), the total number of provisions of medications for self-managed abortion increased by 27 838 (95% credible interval [CrI], 26 374-29 175) vs what would have been expected based on pre-Dobbs levels. Excluding imputed data changes the results only slightly (27 145; 95% CrI, 25 747-28 246). Accounting for nonuse of medications, actual self-managed medication abortions increased by an estimated 26 055 (95% CrI, 24 739-27 245) vs what would have been expected had the Dobbs decision not occurred.

Conclusions and Relevance

Provision of medications for self-managed abortions increased in the 6 months following the Dobbs decision. Results suggest that a substantial number of abortion seekers accessed services despite the implementation of state-level bans and restrictions.

Experiences with misoprostol-only used for self-managed abortion and acquired from an online or retail pharmacy in the United States

OBJECTIVES

This study aimed to understand individual experiences with medication abortion using misoprostol-only among people living in the United States.

STUDY DESIGN

We conducted 31 semistructured anonymous in-depth interviews with individuals who used misoprostol-only for self-managed medication abortion. Participants were recruited from Aid Access, an online telemedicine organization that provided prescriptions for misoprostol to eligible people in all 50 states in May and June 2020 when a combined mifepristone and misoprostol regimen was unavailable. We coded transcripts with a flexible coding approach and focused on perceptions and experiences with use.

RESULTS

Participants were knowledgeable about misoprostol. Previous abortion experiences shaped perceptions of misoprostol-only by allowing comparison to the mifepristone and misoprostol regimen. Most participants expressed an unwavering desire for an effective abortion method, regardless of the medications or regimen. Individual physical experiences with misoprostol, including bleeding, cramping, nausea, and diarrhea, varied in intensity and duration. Participants proactively managed symptoms with self-care strategies and drew extensively from their prior experiences with menstruation, miscarriage, abortion, and childbirth. Clear instructions and information on potential complications and what to expect throughout the abortion fostered a sense of preparedness, and personalized interactions with an online help desk brought comfort.

CONCLUSIONS

Misoprostol offered an essential abortion method for study participants. This regimen was physically challenging for some, and there is potentially a greater need for communication and support for individuals using misoprostol-only regimens. Prior reproductive experiences informed participant's knowledge, preparedness, pain management, and ability to both recognize and manage potential complications.

IMPLICATIONS

As restrictions on mifepristone continue, more people may use misoprostol-only regimens. All regimens can be supported with detailed instructions, clear expectations, information on signs of potential complications, and personalized support. To achieve reproductive autonomy, people must have access to a range of abortion care options that meet their needs.

Advance Provision of Mifepristone and Misoprostol via Online Telemedicine in the US

This cross-sectional study examines trends in the demand and characteristics and motivations of individuals who requested advance provision of abortion medications.

Preabortion ultrasound - a patient perspective

PURPOSE

To explore women's perception of the need for an ultrasound scan before medical abortion provided by telemedicine services.

METHODS

We have analysed women's requests for medical abortion through the website www.womenonweb.org from the 1st of January 2019 to the 5th of October 2020. Before receiving abortion drugs for self-managed medical abortion, women received online counselling and were asked to complete an online survey on pre-abortion ultrasound scan and the reasons for having or not having one. The initial dataset included 62641 entries from 207 countries. Each entry corresponded to a person's request for medical abortion. Women reported only one or multiple reasons for not having a pre-abortion ultrasound scan.

RESULTS

Among 59648 women requesting a medical abortion, 45653 (76,54%) did not have any pre-abortion ultrasound scan and specified a reason for that. The countries with the highest rates of women not having a pre-abortion ultrasound scan were Thailand, Poland, Northern Ireland, Mexico, South Korea, Japan, Chile, Indonesia, Germany, and Brazil. The main reasons for not having a pre-abortion ultrasound scan were being confident regarding pregnancy length; and thus, no need for a scan stated by 10910/34390 women (31.7%), lack of resources stated by 10589/34390 women (30.8%), and privacy issues stated by 6472/34390 women (18.8%).

CONCLUSION

Most women opting for medical abortion through telemedicine did not undergo a pre-abortion ultrasound scan. The main reason stated was that women did not find it necessary, lack of resources and privacy issues.

Accessing abortion in a highly restrictive legal regime: characteristics of women and pregnant people in Malta self-managing their abortion through online telemedicine

OBJECTIVE

To examine the numbers and characteristics of women and pregnant people in Malta seeking at-home medical abortion using online telemedicine from 2017 to 2021.

DESIGN

Population-based study.

SETTING

Republic of Malta PARTICIPANTS: Between 1 January 2017 and 31 December 2021, 1090 women and pregnant people requested at-home medical abortion through one online telemedicine provider (Women on Web). Mifepristone and misoprostol were shipped to 658 women (60.4% of requests).

MAIN OUTCOME MEASURES

The numbers and demographics of persons to which abortion pills were shipped, their reasons for accessing abortion, and reasons for requesting medical abortion via telemedicine between January 2017 and December 2021 were analysed. Selected data were compared across different groups.

RESULTS

The number of people in Malta to whom medical abortion pills were shipped increased significantly in the 5 years analysed. Women and pregnant people requesting medical abortion were diverse with respect to age, pregnancy circumstances and reasons for seeking an abortion. More than half had existing children and over 90% reached out to Women on Web at <7 weeks. Among those completing a medical abortion, 63% did not use contraception, and in 30% there was contraception failure. The most common reasons for ordering medical abortion pills online were difficulty accessing abortion because of legal restrictions (73%) and abortion pills not being available (45%) in the country.

CONCLUSIONS

Despite a complete ban on abortion, the number of women and pregnant people residing in Malta completing at-home medical abortions is considerable and has been steadily increasing.

"In some clinics, they said it's elective, and then they would refuse": A Mixed-Methods Study on the impact of the COVID-19 pandemic on access to abortion services in Germany

OBJECTIVE

The World Health Organization recognizes abortion as essential health care and has encouraged governments to ensure access to abortion services throughout the COVID-19 pandemic. However, the threat of infection combined with government responses to COVID-19 have impacted access to abortion services globally. This study explores access to abortion in Germany during the pandemic.

METHODS

This study used a mixed-methods design. An analysis of data collected by Women on Web (WoW) was carried out to assess women's reasons for choosing telemedicine abortion outside the formal health system in Germany during the pandemic. Descriptive statistics were generated for 2057 requests for telemedicine abortion received by WoW between March 2020-March 2021. Semi-structured interviews were conducted with eight healthcare professionals involved in the provision of abortion services to explore how they perceive of women's access to abortion services in Germany during the pandemic.

RESULTS

The quantitative analysis found that preferences and needs for privacy (47.3%), secrecy (44.4%) and comfort (43.9%) were the most common reasons for choosing telemedicine abortion. COVID-19 was another important reason (38.8%). The thematic analysis of the interviews was organized into two overarching themes: service provision, and axes of difference.

CONCLUSIONS

The pandemic affected the provision of abortion services as well as the circumstances of women seeking abortion. The main barriers to access were financial constraints, privacy issues, and lack of abortion providers. Throughout the pandemic, accessing abortion services was more difficult for many women in Germany, especially women experiencing multiple and overlapping forms of discrimination.

Why women choose self-managed telemedicine abortion in the Netherlands during the COVID-19 pandemic: a national mixed methods study

BACKGROUND

The COVID-19 pandemic has imposed strict lockdown restrictions that have introduced barriers to in-person abortion clinic visits in the Netherlands. Women on Web (WoW) is a global medical abortion telemedicine service operating outside the formal health sector.

AIM

To understand the motivations and perceived barriers women faced when choosing telemedicine abortion outside the formal health sector, and how this was affected by the pandemic.

METHODS

178 women who completed an online consultation on the Dutch WoW website during the period 6 March 2020 to 5 March 2021 were included in this cross-sectional cohort study and exploratory qualitative study. Patient characteristics and motivations were analysed and associated with the severity of COVID-19 restrictions. Email exchanges in which women could further describe their requests were also examined for recurrent clarification of motivations.

RESULTS

Women experienced barriers to regular abortion care due to COVID-19 restrictions and had the preference to (1) self-manage their abortion, (2) stay in the comfort of their own home, and (3) keep their abortion private. In particular, women who did not live in the cities where abortion clinics were located experienced barriers to abortion services. As COVID-19 restrictions tightened, it was more frequently mentioned that women sought help from WoW because COVID-19 restrictions and abortion care were not accessible to them in the Netherlands. In the qualitative analysis of email exchanges, the reasons of COVID-19, privacy concerns, and domestic violence were particularly evident.

CONCLUSIONS

In the Netherlands, barriers to receiving adequate abortion care were exacerbated for women in vulnerable positions such as being geographically farther away from an abortion clinic, being in a deprived socioeconomic position, or being in an unsafe home situation. Similar to other medical care, abortion care should be deliverable online.

Self-managed medication abortion in South Korea: A retrospective records review of the uptake of medication abortion through online telemedicine prior to decriminalization

OBJECTIVES

To examine the uptake of medication abortion through online telemedicine in South Korea prior to decriminalization of abortion beginning in 2019.

STUDY DESIGN

We conducted a descriptive cross-sectional analysis of medication abortion consultations submitted to Women on Web, an online telemedicine service, from South Korea between 2013 and 2019.

RESULTS

The uptake of medication abortion through Women on Web increased every year between 2013 and 2019, adding up to 12,115 consultations across 7 years. The median age was 25 and the median gestational age was 37 days. Individuals reported financial constraints (66.2%) as the most common reason for wanting an abortion. This was followed by not wanting a child at this point (64.7%) and wanting to finish school (34.6%).

CONCLUSIONS

This study illustrates the uptake of medication abortions via Women on Web between 2013 and 2019, prior to decriminalization of abortion in South Korea.

IMPLICATIONS

This study attests to the use of online telemedicine for medication abortion, despite the legal restrictions prior to decriminalization of abortion in South Korea.

Safety and effectiveness of self-managed abortion using misoprostol alone acquired from an online telemedicine service in the United States

OBJECTIVES

To evaluate self-reported outcomes and serious adverse events following self-managed medication abortion using misoprostol alone provided from an online service.

STUDY DESIGN

We conducted a retrospective record review of self-managed abortion outcomes using misoprostol obtained from Aid Access, an online telemedicine organization serving United States (US) residents, between June 1, 2020, and June 30, 2020. The main outcomes were the proportion of people who reported ending their pregnancy without instrumentation intervention and the proportion who received treatment for serious adverse events.

RESULTS

During the study period, 1016 people received prescriptions for misoprostol. We obtained follow-up information for 610 (60%) of whom 568 confirmed use of the medication and 42 confirmed non-use. When taking the medication, 96% were at or less than 10 weeks' gestation and 4% were more than 10 weeks. Overall, 88% (95% CI: 84.6-90.2) reported successfully ending their pregnancy without instrumentation intervention. Of the 568 who took the misoprostol, 12 (2%) reported experiencing one or more serious adverse events and 20 (4%) reported experiencing a symptom of a potential complication.

CONCLUSIONS

Self-managed medication abortion using misoprostol provided by an online telemedicine service has a high rate of effectiveness and a low rate of serious adverse events. Outcomes compare favorably to other service delivery models using a similar regimen. As mifepristone continues to be over-regulated and the 2022 US Supreme Court ruling allows states to severely restrict access to in-clinic abortion care, this regimen is a promising option for self-managed abortion in the US.

Experiences seeking, sourcing, and using abortion pills at home in the United States through an online telemedicine service

A growing number of people in the United States seek to self-manage their abortions by self-sourcing abortion medications online. Prior research focuses on people's motivations for seeking self-management of abortion and experiences trying to obtain medications. However, little is known about the experiences of people in the U.S. who actually complete a self-managed abortion using medications they self-sourced online. We conducted anonymous in-depth interviews with 80 individuals who sought abortion medications through Aid Access, the only online telemedicine service that provides abortion medications in all 50 U.S. states. Through grounded theory analysis we identified five key themes: 1) participants viewed Aid Access as a "godsend"; 2) Fears of scams, shipping delays, and surveillance made ordering pills online a "nerve-racking" experience; 3) a "personal touch" calmed fears and fostered trust in Aid Access; 4) participants were worried about the "what ifs" of the self-managed abortion experience; and 5) overall, participants felt that online telemedicine met their important needs. Our findings demonstrate that online telemedicine provided by Aid Access not only provided a critical service, but also offered care that participants deemed legitimate and trustworthy.

Requests for Self-managed Medication Abortion Provided Using Online Telemedicine in 30 US States Before and After the Dobbs v Jackson Women's Health Organization Decision

This study assesses changes in online telemedicine requests to self-manage abortions with medications before vs after the Dobbs v Jackson Women’s Health Organization Supreme Court decision overturning Roe v Wade.

Telemedicine as an alternative way to access abortion in Italy and characteristics of requests during the COVID-19 pandemic

INTRODUCTION

Induced abortion is legal in Italy but with restrictions. The online abortion provider Women on Web (WoW) serves as an alternative way to access abortion. The COVID-19 pandemic has affected sexual and reproductive health worldwide. Italy was one of the first countries hit by the pandemic and imposed strict lockdown measures. We aimed to understand why women requested WoW abortion in Italy and how this was affected by the pandemic.

METHODS

We conducted an observational study analysing requests made to WoW before and during the pandemic. We analysed 778 requests for medical abortion from Italy between 1 March 2019 to 30 November 2020 and compared the characteristics of requests submitted before and during the pandemic. We also performed subgroup analysis on teenagers and COVID-19-specific requests.

RESULTS

There was an increase in requests during the COVID-19 pandemic compared with the previous year (12% in the first 9 months). The most common reasons for requesting a telemedicine abortion through WoW were privacy-related (40.9%); however, this shifted to COVID-19-specific (50.3%) reasons during the pandemic. Requests from teenagers (n=61) were more frequently made at later gestational stages (p=0.003), had a higher prevalence of rape (p=0.003) as the cause of unwanted pregnancies, and exhibited less access to healthcare services compared with adult women.

CONCLUSIONS

There was an increase in total demand for self-managed abortion during the pandemic and reasons for requesting an abortion changed, shifting from privacy-related to COVID-19-specific reasons. This study also highlighted the uniquely vulnerable situation of teenagers with unwanted pregnancies seeking self-managed abortion.

Seeking online telemedicine abortion outside the jurisdiction from Ireland following implementation of telemedicine provision locally

BACKGROUND

Abortion was legalised in Ireland in 2019 and telemedicine provision introduced in April 2020. We examined patterns in and reasons for seeking and receiving online telemedicine abortion outside the jurisdiction following legalisation and introduction of telemedicine abortion.

METHODS

Quantitative analysis compared frequency of contact, completed requests, service user characteristics and reasons for contacting Women on Web (WoW). Statistical analyses assessed if COVID-19 restrictions and the implementation of telemedicine abortion locally impacted on WoW contact patterns. Thematic analysis of email correspondence analysed reasons for seeking online telemedicine abortion.

RESULTS

There were 764 requests from Ireland to WoW in 2019-2020, with 225 (29.5%) completed. Requests declined by 90 (21%) between 2019 and 2020, and proportion of completed requests declined by 11.3% (n=70). During COVID-19 restrictions, the proportion of completed requests decreased even more (25%, n=24). Legal restrictions and cost declined as reasons for seeking online telemedicine and childcare, work/study commitments and being with partner/friend increased. During COVID-19 an abusive partner increased as the cited reason. Barriers cited in email correspondence included lack of proximate provider, not qualifying due to legal status and difficulty participating in consultations due to an abusive partner.

CONCLUSIONS

Online telemedicine abortion seeking from WoW outside the jurisdiction reduced in the second year of legalisation. Local introduction of telemedicine abortion addressed reasons cited for seeking online telemedicine, other than abusive partner. Increasing awareness of abortion provision, particularly access pathways, free cost and confidentiality, promoting normalisation and retaining local telemedicine can reduce reliance on online telemedicine. Extending the format of local telemedicine abortion to include text-based contact could alleviate how an abusive partner impedes access.

A telemedicine model for abortion in South Africa: a randomised, controlled, non-inferiority trial

BACKGROUND

Telemedicine for medical abortion increases access to safe abortion but its use has not been described in a controlled trial. We aimed to investigate the effectiveness, adherence, safety, and acceptability of a modified telemedicine protocol for abortion compared with standard care in a low-resource setting.

METHODS

In this randomised, controlled, non-inferiority trial we recruited women seeking medical abortion at or before 9 gestational weeks at four public health clinics in South Africa. Participants were randomly allocated (1:1) by computer-generated blocks of varying sizes to telemedicine or standard care. The telemedicine group received asynchronous online abortion consultation and instruction, self-assessed gestational duration, and had a uterine palpation as a safety measure. Participants in this group took 200 mg mifepristone and 800 μg misoprostol at home. The standard care group received in-person consultation and instruction together with an ultrasound, took 200 mg mifepristone in clinic and 800 μg misoprostol at home. Our primary outcome was complete abortion after initial treatment, assessed at a 6-week interview. Our non-inferiority margin was 4%. Group differences were assessed by modified intention-to-treat (mITT) analysis and per protocol. The trial is registered at ClinicalTrials.gov, NCT04336358, and the Pan African Clinical Trials Registry, PACTR202004661941593.

FINDINGS

Between Feb 28, 2020, and Oct 5, 2021, we enrolled 900 women, 153 (17·0%) of whom were discontinued before the abortion and were not included in the analysis. By mITT analysis, 355 (95·4%) of 372 women in the telemedicine group had a complete abortion compared with 338 (96·6%) of 350 in the standard care group (odds ratio 0·74 [95% CI 0·35 to 1·57]). The risk difference was -1·1% (-4·0 to 1·7). Among women who completed treatment as allocated (per protocol), 327 (95·6%) of 342 women in telemedicine group had complete abortion, compared with 338 (96·6%) of 350 in the standard care group (0·77 [0·36 to 1·68]), with a risk difference of -1·0% (-3·8 to 1·9). One participant (in the telemedicine group) had a ruptured ectopic pregnancy, and a further four participants were admitted to hospital (two in each group), of whom two had blood transfusions (one in each group).

INTERPRETATION

Asynchronous online consultation and instruction for medical abortion and home self-medication, with uterine palpation as the only in-person component, was non-inferior to standard care with respect to rates of complete abortion, and did not affect safety, adherence, or satisfaction.

FUNDING

Grand Challenges Canada and the Swedish Research Council.

A trans-national examination of the impact of the COVID-19 pandemic on abortion requests through a telemedicine service

BACKGROUND

The COVID-19 pandemic is limiting access to reproductive healthcare worldwide. Substantial research gaps remain regarding the impact of the pandemic on access to abortion care.

METHODS

We performed a cohort analysis of abortion requests made through the telemedicine abortion service Women on Web (WoW) between 18 March 2020 and 4 May 2020. We used binary logistic regression analyses to test the association between COVID-19 as a reason for the help request and reporting having had an ultrasound to determine gestation and/or use of contraception. A subanalysis of Italy, Argentina, Malaysia and the United Arab Emirates (UAE) was executed to explore differences between countries.

RESULTS

Of requests made during the study period, 43.5% (n=1972) were COVID-19-related. A negative association was found with having had an ultrasound to determine gestation length and COVID-19-related requests. Italy had the highest percentage (66.5%, n=117) of COVID-19-related requests in the subanalysis, followed by Argentina (55.3%, n=68), Malaysia (51.9%, n=41) and the UAE (44.4%, n=75).

CONCLUSIONS

Almost half the women and pregnant people having an abortion through WoW reported experiencing obstacles to abortion care because of COVID-19. Abortion guidelines should be updated to permit abortion services via telemedicine. This is especially urgent during the ongoing pandemic.

Safety and effectiveness of self-managed medication abortion provided using online telemedicine in the United States: A population based study

Background

As access to clinical abortion care becomes increasingly restricted in the United States, the need for self-managed abortions (i.e. abortions taking place outside of the formal healthcare setting) may increase. We examine the safety, effectiveness, and acceptability of self-managed medication abortion provided using online telemedicine.

Methods

We retrospectively examined records of the outcomes of abortions provided by the sole online telemedicine service providing self-managed medication abortion in the U.S. We calculated the prevalence of successful medication abortion (the proportion who ended their pregnancy without surgical intervention); the prevalence of serious adverse events (the proportions who received intravenous antibiotics and blood transfusion); and assessed whether any deaths were reported to the service. We also examined the proportions who were satisfied and felt self-management was the right choice.

Findings

Between March 20th 2018 and March 20th 2019, abortion medications were mailed to 4,584 people and 3,186 (70%) provided follow-up information. Among these, 2,797 (88%) confirmed use of the medications and provided outcome information, while 389 (12%) confirmed non-use. Overall, 96.4% (95% CI 95.7% to 97.1%) of those who used the medications reported successfully ending their pregnancy without surgical intervention and 1.0% (CI 0.7%–1.5%) reported treatment for any serious adverse event. Among these, 0.6% (CI 0.4% to 1.0%) reported receiving a blood transfusion, and 0.5% (CI 0.3% to 0.9%) reported receiving intravenous antibiotics. No deaths were reported to the service by family, friends, the authorities, or the media. Among 2,268 who provided information about their experience, 98.4% were satisfied and 95.5% felt self-management was the right choice.

Interpretation

Self-managed medication abortion provided using online telemedicine can be highly effective with low rates of serious adverse events. In light of increasingly restricted access to in-clinic abortion in the U.S., it may offer a safe and effective option for those who cannot access clinical care.

Funding

The Society of Family Planning and The National Institutes of Health.

Dutch GPs' views on prescribing mifepristone and misoprostol: a mixed-methods study

BACKGROUND

The World Health Organization has indicated that GPs can safely and effectively provide mifepristone and misoprostol for medical termination of pregnancy (TOP). Dutch GPs are allowed to treat miscarriages with mifepristone and misoprostol, but few do so. Current Dutch abortion law prohibits GPs from prescribing these medications for medical TOP. Medical TOP is limited to the specialised settings of abortion clinics and hospitals. Recently, the House of Representatives debated shifting abortion to the domain of primary care, following the example of France and the Republic of Ireland. This would improve access to sexual and reproductive health care, and increase choices for women. Nevertheless, little is known about GPs' willingness to provide medical TOP and miscarriage management.

AIM

To gain insight into Dutch GPs' willingness to prescribe mifepristone and misoprostol for medical TOP and miscarriages, as well as the anticipated barriers.

DESIGN AND SETTING

Mixed-methods study among Dutch GPs.

METHOD

A questionnaire provided quantitative data that were analysed using descriptive methods. Thematic analyses were performed on qualitative data collected through in-depth interviews.

RESULTS

The questionnaire was sent to 575 GPs; the response rate was 22.1% (n = 127). Of the responders, 84.3% (n = 107) were willing to prescribe mifepristone and misoprostol, with 58.3% (n = 74) willing to provide this medication for both medical TOP and miscarriage management. A total of 57.5% (n = 73) of participants indicated a need for training. The main barriers influencing participants' willingness to provide medical TOP and miscarriage management were lack of experience, lack of knowledge, time constraints, and a restrictive abortion law.

CONCLUSION

Over 80.0% of responders were willing to prescribe mifepristone and misoprostol for medical TOP or miscarriages. Training, (online) education, and a revision of the abortion law are recommended.

Association of Texas Senate Bill 8 With Requests for Self-managed Medication Abortion

This cross-sectional study examines whether the passage of Texas Senate Bill 8 was associated with an increase in requests for self-managed medication abortion.

Why women choose abortion through telemedicine outside the formal health sector in Germany: a mixed-methods study

INTRODUCTION

Women on Web (WoW) is a global medical abortion telemedicine service operating outside the formal health sector. In April 2019 they opened their helpdesk to Germany. Our aim was to understand the motivations, and perceived barriers to access, for women who choose telemedicine abortion outside the formal health sector in Germany.

METHODS

We conducted a parallel convergent mixed-methods study among 1090 women consulting WoW from Germany between 1 January and 31 December 2019. We performed a cross-sectional study of data contained in online consultations and a content analysis of 108 email texts. Analysis was done until saturation; results were merged and triangulation used to validate results.

RESULTS

The quantitative analysis found that the need for secrecy (n=502, 48%) and the wish for privacy (n=500, 48%) were frequent reasons for choosing telemedicine abortion. Adolescents were more likely to report secrecy, cost, stigma and legal restrictions as reasons for using telemedicine abortion compared with older women. The content analysis developed two main themes and seven subsidiary categories, (1) internal motivations for seeking telemedicine abortion encompassing (i) autonomy, (ii) perception of external threat and (iii) shame and stigma, and (2) external barriers to formal abortion care encompassing (iv) financial stress, (v) logistic barriers to access, (vi) provider attitudes and (vii) vulnerability of foreigners.

CONCLUSIONS

Women in Germany who choose telemedicine abortion outside the formal health sector do so both from a place of empowerment and a place of disempowerment. Numerous barriers to abortion access exist in the formal sector which are of special relevance to vulnerable groups such as adolescents and undocumented immigrants.

The economic context of pursuing online medication abortion in the United States

Access to in-clinic abortion has become increasingly restricted in the U.S. and for many, the high cost of care is a significant barrier. However, little is known about how financial circumstances shape the alternate pathways to abortion care people seek when the clinic is out of reach. In a unique sample of people who used medication abortion pills from Aid Access, a non-profit telemedicine service, we examine the impact of economic circumstances on abortion care pathway decision-making and experiences seeking care. Between June and August 2019, we conducted 80 anonymous, semi-structured in-depth interviews with U.S. residents who self-managed their own abortions using medication abortion pills from Aid Access. Participants were asked about their experiences seeking abortion, and their motivations for using the service. We coded interviews using an iteratively developed coding guide and performed thematic analyses to identify key themes. The unaffordable cost of in-clinic abortion was a key reason why participants sought care using online telemedicine. Experiences of personal financial hardship exacerbated by restrictive policies impacted participants’ ability to access the clinic. For participants with children, their financial decisions were further guided by the concerns of providing economic stability for their family. Although telemedicine was considered more affordable than in-clinic care, for some, the suggested donation of $90 still posed a financial burden and accessing pills at no cost or a reduced cost was necessary. The availability of affordable telemedicine and policy interventions addressing Medicaid and insurance coverage for abortion would democratize abortion access for populations with low incomes.

Why women choose at-home abortion via teleconsultation in France: drivers of telemedicine abortion during and beyond the COVID-19 pandemic

OBJECTIVES

In an attempt to understand the demand and main drivers of telemedicine abortion, we analysed the requests that Women on Web (WoW), an online telemedicine abortion service operating worldwide, received from France throughout 2020.

METHODS

We conducted a parallel, convergent, mixed-methods study among 809 consultations received from France at WoW between 1 January and 31 December 2020. We performed a cross-sectional study of data obtained from the WoW consultation survey and a manifest content analysis of anonymised email correspondence of 140 women consulting with the WoW helpdesk from France.

FINDINGS

We found that women encounter macro-level, individual-level and provider-level constraints while trying to access abortion in France. The preferences and needs over secrecy (n=356, 46.2%), privacy (n=295, 38.3%) and comfort (n=269, 34.9%) are among the most frequent reasons for women from France to choose telemedicine abortion through WoW. The COVID-19 pandemic seems to be an important driver for resorting to telemedicine (n=236, 30.6%). The lockdowns had a significant impact on the number of consultations received at WoW from France, increasing from 60 in March to 128 in April during the first lockdown and from 54 in October to 80 in November during the second lockdown.

CONCLUSIONS

The demand for at-home medical abortion via teleconsultation increased in France during the lockdowns. However, drivers of telemedicine abortion are multidimensional and go beyond the conditions unique to the pandemic.

Demand for self-managed online telemedicine abortion in eight European countries during the COVID-19 pandemic: a regression discontinuity analysis

OBJECTIVES

In most European countries, patients seeking medication abortion during the COVID-19 pandemic are still required to attend healthcare settings in person. We assessed whether demand for self-managed medication abortion provided by online telemedicine increased following the emergence of COVID-19.

METHODS

We examined 3915 requests for self-managed abortion to online telemedicine service Women on Web (WoW) between 1 January 2019 and 1 June 2020. We used regression discontinuity to compare request rates in eight European countries before and after they implemented lockdown measures to slow COVID-19 transmission. We examined the prevalence of COVID-19 infection, the degree of government-provided economic support, the severity of lockdown travel restrictions and the medication abortion service provision model in countries with and without significant changes in requests.

RESULTS

Five countries showed significant increases in requests to WoW, ranging from 28% in Northern Ireland (97 requests vs 75.8 expected requests, p=0.001) to 139% in Portugal (34 requests vs 14.2 expected requests, p<0.001). Two countries showed no significant change in requests, and one country, Great Britain, showed an 88% decrease in requests (1 request vs 8.1 expected requests, p<0.001). Among countries with significant increases in requests, abortion services are provided mainly in person in hospitals or abortion is unavailable and international travel was prohibited during lockdown. By contrast, Great Britain implemented a fully remote no-test telemedicine service.

CONCLUSION

These marked changes in requests for self-managed medication abortion during the COVID-19 pandemic demonstrate demand for remote models of care, which could be fulfilled by expanding access to medication abortion by telemedicine.

Accessing abortion outside jurisdiction following legalisation of abortion in the Republic of Ireland

BACKGROUND

After having one of the most restrictive abortion laws worldwide, Ireland legalised abortion in January 2019. We examine how legalisation impacted on demand for online telemedicine outside the jurisdiction.

METHODS

We analysed anonymised data from 534 people from Ireland seeking online telemedicine abortion prior to legalisation (January-March and October-December 2018) and in the first 3 months following legalisation (January-March 2019). Numbers, characteristics and reasons for seeking the service before and after legalisation were compared. Content analysis of emails from people seeking the service following legalisation explored reasons for seeking care.

RESULTS

Half as many people contacted Women on Web in the 3 months immediately after legalisation as compared with contacts 12 months prior (103 vs 221). Of these, the proportion receiving the service reduced, from 72% prior to legalisation to 26% after legalisation (p≤0.001). After legalisation, access related reasons for seeking online telemedicine featured less while reasons relating to privacy, stigma and avoiding protestors featured more.

CONCLUSIONS

People continued to seek abortion through online telemedicine after legalisation, though the number of contacts reduced by half and the proportion receiving the service decreased considerably. To address access issues, policy measures should promote normalisation of abortion, legislate for safe zones around providers, and consider access in situations of coercive control or abuse including the role of telemedicine in the local model of care. Abortion provided through online telemedicine continues to be an important part of providing safe, accessible abortion even after legalisation.

10-year evaluation of the use of medical abortion through telemedicine: a retrospective cohort study

OBJECTIVE

To provide a descriptive overview and evaluate changes in the use and outcome of abortions provided worldwide by telemedicine in the past 10 years.

DESIGN

Retrospective cohort study.

SETTING

Multi-country.

POPULATION/SAMPLE

30 344 women who completed the follow-up survey of the telemedical abortion service Women on Web from January 2009 till January 2020.

METHODS

Analyses of follow-up surveys, binary logistic regressions to test the association between year and outcomes.

MAIN OUTCOME MEASURES

Rate of complete abortions, surgical interventions, ongoing pregnancies, blood transfusions per year, socio-economic situation, knowledge on medical abortion, acceptability of receiving service, appropriateness of method and the likelihood of recommending the service to a friend.

RESULTS

Medical abortions were provided to 81 683 women, of whom 30 344 (37.2%) completed the follow-up survey. In total, 26 076 women reported doing the medical abortion, of whom 1.5% reported an ongoing pregnancy, 10.2% a surgical intervention and 0.6% a blood transfusion. Acceptability of the service was 99%, and 59.2% of the users reported previous knowledge of medical abortion. We found a significant increase in complete abortions in 2019 (odds ratio 1.92; 95% CI 1.59-2.31) and decrease in surgical interventions (odds ratio 0.49; 95% CI 0.40-0.60) compared with 2009.

CONCLUSION

Low follow-up rates present a limitation in analysing trends in telemedical abortion usage. However, our findings suggest that it is a highly acceptable method around the world and that there has been an increase in complete abortions by telemedical abortions and a decrease in surgical interventions in the last 10 years.

TWEETABLE ABSTRACT

In the last 10 years, there has been an increase in complete abortions and decrease in surgical interventions of telemedical abortion.

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.

Medical abortion at 13 or more weeks gestation provided through telemedicine: A retrospective review of services

Objectives

To evaluate medical abortion effectiveness and safety in women at 13 or more weeks gestation provided care through Women on Web's telemedicine service.

Study Design

We conducted a retrospective case study of abortions at 13 or more weeks gestation provided by Women on Web between 2016 and 2019. Women received mifepristone and misoprostol or misoprostol alone for abortion. We extracted demographic characteristics and outcome data for cases with pregnancy continuation outcomes.

Results

We identified 144 women who used medical abortion at 13 or more weeks; 131 (91%) provided abortion outcome data. Almost all, 118 (90%) received mifepristone and misoprostol. The population had an average age of 26 ± 5.8 years, 102 (78%) reported a gestational age of 13 to 15 weeks, 114 (87%) had experienced prior pregnancy, and represented all world regions. Overall, 13 (10%) women reported a continuing pregnancy, with 5 (5%) among women 13 to 15 weeks and 8 (28%) among those ≥16 weeks (p = 0.001); 38 (29%) reported adverse events (heavy bleeding, fever), 53 (43%) sought additional care from a health provider, and 18% of all cases received treatment with D&C/aspiration.

Conclusions

Efficacy of self-administered medical abortion decreases as gestational age increases, risking continuation of pregnancy. Provision through telemedicine at 13 to 15 weeks appears safe and effective.

Implications

Limited data suggest that medical abortion through telemedicine services may be a safe option through 15 weeks gestation in settings where there is ready access to the formal health system. More research with adequate sample sizes and high rates of follow-up is needed to inform on the safety of telemedicine for pregnancies 13 weeks and greater.

Abortion Need among U.S. Servicewomen: Evidence from an Internet Service

INTRODUCTION

U.S. servicewomen have high rates of unintended pregnancy, but federal policy prohibits abortion provision at military treatment facilities and military insurance coverage of abortion, except in cases of rape, incest, or a life-endangering pregnancy. Such restrictions pose challenges to abortion access for servicemembers, particularly during deployment. We aimed to explore the experiences of U.S. servicewomen when accessing abortion during overseas tours and deployment.

METHODS

We reviewed de-identified data from email inquiries and online consultation forms from U.S. servicewomen or military spouses seeking medication abortion from the telemedicine service Women on Web between January 2010 and December 2017. We used descriptive statistics and inductively coded textual responses to describe client characteristics, circumstances of pregnancy, reasons for abortion, and barriers to abortion care.

RESULTS

Our sample included data for 323 individuals. Reasons for abortion related to military service included disruption of deployment, fear of military reprimand, and potential career impacts. Additionally, servicemembers faced barriers to abortion access related to overseas military deployment or tour, including a lack of legal abortion in-country, limited financial resources, language barriers, travel restrictions, and a lack of confidentiality.

CONCLUSIONS

U.S. military servicewomen stationed in countries where safe, legal abortion is restricted or unavailable face deployment-related barriers to abortion care, which compound those barriers they may face regardless of deployment status. Removal of federal bans on the provision and coverage of abortion care and improved education about existing regulations could improve access to timely abortion care and in some cases allow servicewomen who wish to obtain abortion care to remain deployed.

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.

Telemedicine for medical abortion: a systematic review

Background

Telemedicine is increasingly being used to access abortion services.

Objective

To assess the success rate, safety, and acceptability for women and providers of medical abortion using telemedicine.

Search strategy

We searched PubMed, EMBASE, ClinicalTrials.gov, and Web of Science up until 10 November 2017.

Study criteria

We selected studies where telemedicine was used for comprehensive medical abortion services, i.e. assessment/counselling, treatment, and follow up, reporting on success rate (continuing pregnancy, complete abortion, and surgical evacuation), safety (rate of blood transfusion and hospitalisation) or acceptability (satisfaction, dissatisfaction, and recommendation of the service).

Data collection and analysis

Quantitative outcomes were summarised as a range of median rates. Qualitative data were summarised in a narrative synthesis.

Main results

Rates relevant to success rate, safety, and acceptability outcomes for women ≤10⁺⁰ weeks’ gestation (GW) ranged from 0 to 1.9% for continuing pregnancy, 93.8 to 96.4% for complete abortion, 0.9 to 19.3% for surgical evacuation, 0 to 0.7% for blood transfusion, 0.07 to 2.8% for hospitalisation, 64 to 100% for satisfaction, 0.2 to 2.3% for dissatisfaction, and 90 to 98% for recommendation of the service. Rates in studies also including women >10⁺⁰GW ranged from 1.3 to 2.3% for continuing pregnancy, 8.5 to 20.9% for surgical evacuation, and 90 to 100% for satisfaction. Qualitative studies on acceptability showed no negative impacts for women or providers.

Conclusion

Based on a synthesis of mainly self‐reported data, medical abortion through telemedicine seems to be highly acceptable to women and providers, success rate and safety outcomes are similar to those reported in literature for in‐person abortion care, and surgical evacuation rates are higher.

Tweetable abstract

A systematic review of medical abortion through telemedicine shows outcome rates similar to in‐person care.

A systematic review of medical abortion through telemedicine shows outcome rates similar to in‐person care.

Barriers to accessing abortion services and perspectives on using mifepristone and misoprostol at home in Great Britain

OBJECTIVE

To examine reasons for seeking abortion services outside the formal healthcare system in Great Britain, where abortion is legally available.

STUDY DESIGN

We conducted a mixed-methods study among women resident in England, Scotland, and Wales who requested at-home medication abortion through online telemedicine initiative Women on Web (WoW) between November 22, 2016, and March 22, 2017. We examined the demographics and circumstances of all women requesting early medication abortion and conducted a content analysis of a sample of their anonymized emails to the service to explore their reasons for seeking help.

RESULTS

Over a 4-month period, 519 women contacted WoW seeking medication abortion. These women were diverse with respect to age, parity, and circumstance. One hundred eighty women reported 209 reasons for seeking abortion outside the formal healthcare setting. Among all reasons, 49% were access barriers, including long waiting times, distance to clinic, work or childcare commitments, lack of eligibility for free NHS services, and prior negative experiences of abortion care; 30% were privacy concerns, including lack of confidentiality of services, perceived or experienced stigma, and preferring the privacy and comfort of using pills at home; and 18% were controlling circumstances, including partner violence and partner/family control.

CONCLUSION

Despite the presence of abortion services in Great Britain, a diverse group of women still experiences logistical and personal barriers to accessing care through the formal healthcare system, or prefer the privacy of conducting their abortions in their own homes. Health services commissioning bodies could address existing barriers if supported by policy frameworks.

IMPLICATIONS

The presence of multiple barriers to accessing abortion care in Great Britain highlights the need for future guidelines to recommend a more woman-centered approach to service provision. Reducing the number of clinic visits and designing services to meet the needs of those living in controlling circumstances are particularly important goals.

Experiences and characteristics of women seeking and completing at-home medical termination of pregnancy through online telemedicine in Ireland and Northern Ireland: a population-based analysis

OBJECTIVE

To examine the characteristics and experiences of women in Ireland and Northern Ireland seeking at-home medical termination of pregnancy (TOP) using online telemedicine.

DESIGN

Population-based study.

SETTING

Ireland and Northern Ireland.

POPULATION

Between 1 January 2010 and 31 December 2015, 5650 women requested at-home medical TOP through online telemedicine initiative Women on Web.

METHODS

We examined the demographics and circumstances of women requesting medical TOP and examined the experiences of the 1023 women who completed TOP between January 2010 and December 2012. We conducted a content analysis of women's evaluations and used logistic regression to examine factors associated with lack of emotional support during and after TOP MAIN OUTCOME MEASURES: Satisfaction with TOP; feelings before and after TOP; emotional support during TOP.

RESULTS

Women requesting TOP were diverse with respect to age, pregnancy circumstances and reasons for seeking TOP. Among those completing TOP, 97% felt they made the right choice and 98% would recommend it to others in a similar situation. Women commonly reported serious mental stress caused by their pregnancies and their inability to afford travel abroad to access TOP. The feelings women most commonly reported after completing TOP were 'relieved' (70%) and 'satisfied' (36%). Women with financial hardship had twice the risk of lacking emotional support (odds ratio = 2.0, P < 0.001).

CONCLUSIONS

The vast majority of women who completed at-home medical TOP through Women on Web had a positive experience. These demonstrated benefits to health and wellbeing contribute new evidence to the debate surrounding abortion laws in Ireland and Northern Ireland.

TWEETABLE ABSTRACT

Irish and Northern Irish women completing at-home medical TOP report benefits for health, wellbeing and autonomy.

Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland

Objectives To assess self reported outcomes and adverse events after self sourced medical abortion through online telemedicine.Design Population based study.Setting Republic of Ireland and Northern Ireland, where abortion is unavailable through the formal healthcare system except in a few restricted circumstances.Population 1000 women who underwent self sourced medical abortion through Women on Web (WoW), an online telemedicine service, between 1 January 2010 and 31 December 2012.Main outcome measures Successful medical abortion: the proportion of women who reported ending their pregnancy without surgical intervention. Rates of adverse events: the proportion who reported treatment for adverse events, including receipt of antibiotics and blood transfusion, and deaths reported by family members, friends, or the authorities. Care seeking for symptoms of potential complications: the frequency with which women reported experiencing symptoms of a potentially serious complication and the proportion who reported seeking medical attention as advised.Results In 2010-12, abortion medications (mifepristone and misoprostol) were sent to 1636 women and follow-up information was obtained for 1158 (71%). Among these, 1023 women confirmed use of the medications, and follow-up information was available for 1000. At the time women requested help from WoW, 781 (78%) were <7 weeks pregnant and 219 (22%) were 7-9 weeks pregnant. Overall, 94.7% (95% confidence interval 93.1% to 96.0%) reported successfully ending their pregnancy without surgical intervention. Seven women (0.7%, 0.3% to 1.5%) reported receiving a blood transfusion, and 26 (2.6%, 1.7% to 3.8%) reported receiving antibiotics (route of administration (IV or oral) could not be determined). No deaths resulting from the intervention were reported by family, friends, the authorities, or the media. Ninety three women (9.3%, 7.6% to 11.3%) reported experiencing any symptom for which they were advised to seek medical advice, and, of these, 87 (95%, 87.8% to 98.2%) sought attention. None of the five women who did not seek medical attention reported experiencing an adverse outcome.Conclusions Self sourced medical abortion using online telemedicine can be highly effective, and outcomes compare favourably with in clinic protocols. Reported rates of adverse events are low. Women are able to self identify the symptoms of potentially serious complications, and most report seeking medical attention when advised. Results have important implications for women worldwide living in areas where access to abortion is restricted.

Regional differences in surgical intervention following medical termination of pregnancy provided by telemedicine

OBJECTIVE

Analysis of factors influencing surgical intervention rate after home medical termination of pregnancy (TOP) by women in countries without access to safe services using the telemedical service 'Women on Web'.

DESIGN

Cohort study.

SETTING

Women with an unwanted pregnancy less than nine weeks pregnant who used the telemedicine service of Women on Web between February 2007 and September 2008 and provided follow-up information.

SAMPLE

Women who used medical TOP with a known follow up.

METHODS

Information from the online consultation, follow-up form and emails was used to analyze the outcome of the TOP.

MAIN OUTCOME MEASURES

Ongoing pregnancy, reason for surgical intervention, perceived complications and satisfaction.

RESULTS

Of the 2 323 women who did the medical TOP and had no ongoing pregnancy, 289 (12.4%) received a surgical intervention. High rates were found in Eastern Europe (14.8%), Latin America (14.4%) and Asia/Oceania (11.0%) and low rates in Western Europe (5.8%), the Middle East (4.7%) and Africa (6.1%; p=0.000). More interventions occurred with longer gestational age (p=0.000). Women without a surgical intervention more frequently reported satisfaction with the treatment (p=0.000).

CONCLUSIONS

The large regional differences in the rates of reported surgical interventions after medical TOP provided by telemedicine cannot be explained by demographic factors or differences in gestational length. It is likely that these differences reflect different clinical practice and local guidelines on (incomplete) abortion rather than complications that genuinely needed surgical intervention. Surgical interventions significantly influenced womens' views on the acceptability of the TOP.

Women on waves: where next for the abortion boat?

Women on Waves was founded to contribute to the prevention of unwanted pregnancy and unsafe abortions throughout the world by direct action. Because national penal laws, including those governing abortion, generally extend only as far as territorial waters (12 miles), Women on Waves made plans to provide reproductive health services on a ship with a mobile clinic, including abortions, outside the territorial waters of countries where abortion is illegal. We went to Ireland first because it was nearby and there was a dedicated pro-choice community with immediate interest in and commitment to the project. Although we encountered problems that meant we could not do abortions, we were contacted by more than 300 women in five days and provided reproductive health information, contraception, workshops and information on where to obtain legal abortions in Europe. In many parts of the world an anti-abortion backlash is taking place. To safeguard our reproductive rights in the face of anti-abortion activities, it is crucial to recapture a pro-active, pro-choice role. Women on Waves helped to make visible the need for legal abortion services in Ireland, and the extensive class and other differences between women able to access abortions abroad and those who could not. We are currently attempting to resolve our status under Dutch law, but until women everywhere have the right to reproductive freedom, we will continue to make waves.