Reproductive Health

This has been the worst legislative year for U.S. abortion rights on record. More restrictions have been passed in 2021 than in any year since Roe v. Wade. In the most extreme case, Texas banned abortions after six weeks of pregnancy. The Supreme Court may be poised to overturn Roe. Yet despite moves by some states to make abortions harder to obtain from a clinic, an increasing number of people are using abortion pills at home. Medication abortion, which involves two pills taken 24 hours apart to terminate pregnancies up to 10 weeks, is one of the simplest and safest procedures in all of medicine. The pills cause bleeding and cramping. Afterward, a simple pregnancy test can confirm that the pills have worked. But for many in the United States, accessing these pills is an obstacle course, thanks to a rash of state-level restrictions blocking clinic access. With no federal and little state funding available, the price tag of $300 to $800 often falls on the individual. 

Key Points Question: What factors are associated with use of an online telemedicine service for accessing self-managed medication abortion in the U.S.? Findings: In this cross-sectional study of 57 506 individuals in 2458 counties, the cost of in-clinic care was the most commonly cited reason for accessing self-managed abortion using online telemedicine. At the county level, a 47-mile increase in distance to the nearest clinic was significantly associated with a 41% increase in requests, and a 10% increase in the population living below the federal poverty level was significantly associated with a 20% increase in requests. Meaning: In this study, clinic access barriers were the most common reason for accessing self-managed medication abortion, and both distance to an abortion clinic and living below the federal poverty level were associated with higher demand for self-management. Abstract Importance: People in the U.S. 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 U.S., 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 U.S. 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 two-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.

Objective: To compare outcomes before and after implementation of medical abortion (termination of pregnancy) without ultrasound via telemedicine. Design: Cohort analysis. Setting: The three main abortion providers. Population or sample: Medical abortions at home at ≤69 days' gestation in two cohorts: traditional model (in-person with ultrasound, n = 22 158) from January to March 2020 versus telemedicine-hybrid model (either in person or via telemedicine without ultrasound, n = 29 984, of whom 18 435 had no-test telemedicine) between April and June 2020. Sample (n = 52 142) comprises 85% of all medical abortions provided nationally. Methods: Data from electronic records and incident databases were used to compare outcomes between cohorts, adjusted for baseline differences. Main outcome measures: Treatment success, serious adverse events, waiting times, gestation at treatment, acceptability. Results: Mean waiting time from referral to treatment was 4.2 days shorter in the telemedicine-hybrid model and more abortions were provided at ≤6 weeks' gestation (40% versus 25%, P < 0.001). Treatment success (98.8% versus 98.2%, P > 0.999), serious adverse events (0.02% versus 0.04%, P = 0.557) and incidence of ectopic pregnancy (0.2% versus 0.2%, P = 0.796) were not different between models. In the telemedicine-hybrid model, 0.04% were estimated to be over 10 weeks' gestation at the time of the abortion; all were completed safely at home. Within the telemedicine-hybrid model, effectiveness was higher with telemedicine than in-person care (99.2% versus 98.1%, P < 0.001). Acceptability of telemedicine was high (96% satisfied) and 80% reported a future preference for telemedicine. Conclusions: A telemedicine-hybrid model for medical abortion that includes no-test telemedicine and treatment without an ultrasound is effective, safe, acceptable and improves access to care. Tweetable abstract: Compelling evidence from 52 142 women shows no-test telemedicine abortion is safe, effective and improves care.

For many in the United States, abortion care is already difficult to access, and the coronavirus disease 2019 (COVID-19) pandemic has created yet more potential barriers—including infection risk at clinics and state policies limiting in-clinic services. The severity of these state policies varies, but, in the most extreme case, Texas effectively suspended all abortions for approximately four weeks. As a result, people may increasingly be seeking self-managed abortion outside the formal health care system. Using data from Aid Access, the sole online abortion telemedicine service in the United States, we assessed whether demand for self-managed medication abortion increased as in-clinic access became more challenging.

Objectives: To examine demand for abortion medications through an online telemedicine service in the United States. Methods: We examined requests from U.S. residents to the online telemedicine abortion service Women on Web (WoW) between Oct. 15, 2017, and Aug. 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 U.S. 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. A rapid increase in legislation restricting access to abortion in the clinic setting coupled with a decline in the U.S. abortion rate to its lowest level in the post-Roe era, has sparked renewed interest in abortions that are self-managed outside the formal health care setting. The 334 abortion restrictions enacted by state legislatures between January 2011 and mid-July 2016 account for one third of all restrictions passed since 1973. Moreover, the likelihood that Roe v. Wade will be overturned or severely diminished has increased with the current composition of the Supreme Court. Among the least advantaged, however, it is already clear that lack of access has compromised the right to choose to the extent that some are already seeking self-managed alternatives. Contemporary reports of self-management in the United States focus not on sharp objects or back-alley providers but on the abortion medications mifepristone and misoprostol. The development of modern medication abortion protocols using misoprostol with or without mifepristone, coupled with the role of the Internet as a go-to source for information and services, has changed the concept of what a self-managed abortion might look like. A 2014 sample of abortion clinic patients weighted to be representative of all U.S. abortion patients suggested that 1.2% had ever attempted to self-manage using misoprostol, whereas a study of Dominican women recruited from three obstetrics–gynecology clinics in New York in 2000 found that 5% reported misoprostol self-use. A study conducted in 2015 in Texas, a state with some of the most burdensome barriers to clinic access in the country, found that an estimated 100 000 women had ever attempted to self-induce their own abortion. Additionally, in-depth interviews conducted in 2015 with women living in the Texas Rio Grande Valley found that a prevalent route to self-induction was misoprostol purchased from pharmacies across the border in Mexico. More recently, studies have shown that people frequently seek information about "self-abortion" online through Google, and that mifepristone and misoprostol are available for purchase in the United States through online pharmacy sites. In the United States, mifepristone and misoprostol typically require a prescription from a medical provider, but many of these online pharmacy sites will provide the medications without such a prescription. Beyond barriers to access, people in the United States may also seek self-managed medication abortion because of a preference for self-care. Preliminary evidence from a qualitative study of people in 20 states who sought abortion medications online indicates that some preferred the convenience and privacy of self-managing an abortion at home, whereas others found accessing clinical care impossible because of state policy restrictions. However, regardless of whether their motivations were underpinned by barriers or preferences, those seeking to self-manage using medications obtained online were sensitive to the difference between online pharmacy sites that simply sell medications and online telemedicine services that are set up to provide physician oversight, instructions, and support, in addition to genuine medications in the correct dose. This distinction is important, because although very little is known about experience of those who use online pharmacy sites, online telemedicine abortion services have demonstrated high levels of safety, effectiveness, and acceptability in other settings where they are widely used because of legal restrictions on abortion. Findings from Ireland and Northern Ireland, where women have used online telemedicine to self-manage for more than a decade, indicate rates of effectiveness on par with medication abortion provided in the clinic setting, as well as very low rates of adverse events. Until very recently, no such online telemedicine service has been available in the United States. Given the potential for further restrictions on abortion clinic access at both the state and national levels combined with the ability to self-care using online services, our objectives in this study are to (1) assess demand and geographical variation in demand for medication abortion through an online telemedicine service in the United States, and (2) examine motivations for seeking this service and how types of motivation for doing so vary by state abortion policy context.