Self-Managed Abortions Becoming More Important as Post-Roe Era Looms
Advance provision of abortion pills is one option
More states are passing highly restrictive anti-abortion legislation that will lead more people to seek abortions out of state or that are self-managed.
- Advance provision of medication abortion pills is one way to empower women to make their own decisions in the privacy of their homes.
- When people attempt abortion self-management, they try to end their pregnancies with methods that will not succeed — and, sometimes, with methods that could be dangerous.
- It is up to clinicians to provide patients with information about how to safely and effectively obtain a self-managed abortion.
Anti-abortion state legislation grows bolder and broader as both sides of the debate over safe and legal abortions predict an end in 2022 to national protection of abortion rights.
Missouri legislators introduced a bill that would have sent people to jail for decades for delivering, prescribing, or dispensing anything used for an abortion. It later was changed to not criminalize ending ectopic pregnancies.1
In March, the governor of Idaho signed an anti-abortion law modeled after Texas’ six-week abortion ban, allowing close relatives of patients to file civil lawsuits against abortion providers. The bill even allows rapists’ relatives and others to sue abortion providers for a minimum $20,000 in damages.2
As reproductive health providers and advocates survey the potential landscape post-Roe v. Wade, the map looks stark for millions of people of reproductive age in most states in the South, Midwest, Great Plains, and Southwest. There will be fewer states to which women could travel to obtain a safe and legal abortion, and there will be multiple obstacles to overcome, including travel costs, child care, time off work, and noninsured abortion care costs.
Advance Provision an Option
Researchers and reproductive health leaders increasingly mention self-managed abortions as a way to make abortion care access a little less difficult in coming years. One method of helping women obtain self-managed abortion is to prescribe advance provision of mifepristone and misoprostol — a backup option, just in case.
“I think it’s something some providers have been doing for a long time,” says Daniel Grossman, MD, FACOG, a professor and director of Advancing New Standards in Reproductive Health at the University of California, San Francisco (UCSF). “If they had a patient who was going somewhere with very limited access to abortion care, like someone going into the Peace Corps, they’d talk about contraception, emergency contraception, and abortion medication if those first two failed. Now, we’re in a situation in the U.S. where abortion care is becoming restricted in many states and is likely to get even worse with the Supreme Court decision that will be coming out later this year. So many people will be in a situation with very limited access. If they could get these pills in advance, it would help them better manage their reproductive healthcare.”
Because of the escalating legislative assault on abortion rights, many women have limited access to abortion care.
“There have been an increasing number of state-level restrictions over the past decade — particularly over the past few years,” says Ushma D. Upadhyay, PhD, MPH, associate professor with Advancing New Standards in Reproductive Health of UCSF.
Patients Need Safe Self-Management
Upadhyay, Grossman, and colleagues studied barriers to abortion care and what happened when people attempted self-managed abortion.3
“We wanted to understand how these state-level restrictions were impacting people who were getting an abortion,” Upadhyay says. “Most [studies] looked at national-level data, or looked at rates, or interviewed people at clinics about barriers they faced. We were frustrated by that because these were people who had already made it to the clinic.”
The investigators decided to contact people earlier in the abortion-seeking process by enrolling people who had searched online for services.(For more information, see story on abortion searches online in this issue.) They found 28% of participants tried to end their pregnancy via self-managed abortion. The most commonly reported method was taking herbs, vitamins, and supplements, such as those listed on the internet as having abortifacient properties.
“People were trying to avoid having to go get an abortion because of all the barriers, so they said things like, ‘Starving myself and not eating for a few days,’” Upadhyay says. “There were a lot of mentions of drinking a lot of alcohol or taking a lot of drugs.”
Slightly more than half the people attempting a self-managed abortion were unsuccessful, she adds.
One of the challenges for reproductive health providers, particularly in states with abortion bans and severe restrictions, will be to provide patients with information about safely and effectively obtaining a self-managed abortion.
The method of advance provision of medication abortion pills holds promise and should be studied further, according to the authors of a recent paper.4 Grossman and colleagues outlined a protocol to screen patients for advance provision of mifepristone and misoprostol and for patients to self-assess their need for the medication. The prescreening criteria include:
- The patient does not report any risk factors for ectopic pregnancy, such as prior ectopic pregnancy, prior tubal surgery, or an intrauterine device;
- The patient does not report a history of hemorrhage or currently taking anticoagulants, chronic adrenal failure, inherited porphyria, allergy to the abortion medications, and currently taking long-term corticosteroid therapy.
“I think lots of people who live where access to abortion is restricted, if they could get the pills ahead of time, that’s one population that might be well served by this service delivery model,” Grossman says. “We found that people who had a prior medication abortion were twice as likely to support advance provision of medication abortion pills compared to those who had never had an abortion before.”
Generally, mifepristone is labeled for use up to five years after manufacture, but it is possible the pills could last longer, although this has not been studied.
“Misoprostol is sensitive to humidity and expires after two years, so it has a shorter shelf life,” Grossman says. “They don’t have evidence on whether it can last longer in a refrigerator, but that’s an area that should be explored.”
Telemedicine Safe, Effective
Recent research confirmed the safety and efficacy of medication abortions that are secured through telemedicine.5
“It’s possible for people to get abortion pills without a doctor’s visit,” says Elizabeth Raymond, MD, MPH, senior medical associate at Gynuity Health Project in Tacoma, WA. Patients can obtain a prescription via telemedicine.
People also bypass U.S. medication laws by accessing abortion medications from international sources, such as AidAccess. Patients who live in states that prohibit abortions and the mailing of abortion medication still may find ways around these restrictions through international distributors.
“There’s a lot of research going on about that approach,” Raymond notes. “There are websites where you can order pills. We did a study to look at the quality of the pills, and they seem to be good quality. The ones that come from India seem to be legitimate pills.”6
From a socio-behavioral perspective, it is unlikely that many people will try to obtain medication abortion pills before a pregnancy occurs. “A lot of years ago, we did work on emergency contraception, suggesting people have these available in their house. It’s difficult to get people to do that because they don’t expect to need it,” Raymond explains. “Also, these abortion pills are fairly expensive, so they could buy these pills and have them there for years, and then they’re lost [or expire]. It’s not an efficient way of taking care of this problem.”7,8
Exceptions are people traveling into areas where access to safe abortion care is challenging or impossible. “If I was traveling to somewhere, say Africa, or Texas, and would spend a year there, then I might want to have some of those pills in my pocket,” Raymond says. This is especially true if a person is traveling to an area with other dangers and risks, such as refugee camps or war zones.
There are other situations in which advance provision would be a good option, including for people with chronic conditions in which pregnancy could endanger the person’s life.
“But I think a more immediate way of addressing this problem is to look at the self-managed abortion idea,” Raymond says. “History-based screening is safe and effective, as our study showed, and it is not that complicated.” (See the story on history-based screening for medication abortion in this issue.)
“The kinds of questions the doctor asks, the patient could ask herself,” she adds. “She’d need some information to know how to do that, but they’re not complicated questions.”
Discuss Self-Management Options
Reproductive health clinicians in states that ban or restrict abortion access could discuss self-managed abortions with patients, including referring them to websites with accurate information, such as the National Abortion Federation, Plan C Guide to Abortion Pills, and the Ipas Partners for Reproductive Justice.9-11
Telemedicine is another method. People could access telemedicine abortion care in neighboring states in which care remains safe and legal. For instance, a person in Texas could travel across the state line to New Mexico for a telemedicine visit, then pick up a prescription for abortion medication at a pharmacy. Or, they could visit an abortion clinic or mobile van clinic that is located across the state line.
“There are services that provide medication abortion, using online telehealth service, from other countries that operate outside the U.S. regulatory system, like AidAccess,” Grossman adds.
AidAccess, founded by a physician, has an international team of doctors and advocates that provides medication abortion to people worldwide.12
“Then, of course, there is a lot of work that practical support organizations, like abortion funds, are doing to fundraise and support patients to travel to other states where they can attain care,” Grossman says.
While few legal abortion clinics operate in Mexico, there are pharmacies that sell misoprostol, which could be taken in repeated doses to end a pregnancy.
“In states with restrictions or bans, I think it’s going to be really important to be talking to patients about what their options are and what they can do to maintain their reproductive health,” Grossman says.
Robert A. Hatcher, MD, MPH, chairman of the Contraceptive Technology Update editorial board, says, “While advance provision of M&M [mifepristone and misoprostol] would be appropriate in some settings, it would not be the idea way to dispense these medications for all women. In the best of all possible worlds, one would not want to see M&M provided to all women in advance so that should they need them, they have them in their medicine chest. Why not? They are expensive, use involves careful instruction, effectiveness does not remain high forever, and there are some important contraindications to their use.”
- Shorman J. Missouri lawmakers delete ectopic pregnancy provision from abortion bill after uproar. The Kansas City Star. March 23, 2022.
- Ridler K. Idaho governor signs abortion ban modeled on Texas law. Associated Press. March 23, 2022.
- Upadhyay UD, Cartwright AF, Grossman D. Barriers to abortion care and incidence of attempted self-managed abortion among individuals searching Google for abortion care: A national prospective study. Contraception 2022;106:49-56.
- Ehrenreich K, Biggs MA, Grossman D. Making the case for advance provision of mifepristone and misoprostol for abortion in the United States. BMJ Sex Reprod Health 2021;bmjsrh-2021-201321.
- Upadhyay UD, Raymond EG, Koenig LR, et al. Outcomes and safety of history-based screening for medication abortion: A retrospective multicenter cohort study. JAMA Intern Med 2022;Mar 21. doi: 10.1001/jamainternmed.2022.0217. [Online ahead of print].
- Murtagh C, Wells E, Raymond EG, et al. Exploring the feasibility of obtaining mifepristone and misoprostol from the internet. Contraception 2018;97:287-291.
- Trussell J, Raymond E, Stewart FH. Re: Advance supply of emergency contraception. J Pediatr Adolesc Gynecol 2006;19:251.
- Fairhurst K, Ziebland S, Wyke S, et al. Emergency contraception: Why can’t you give it away? Qualitative findings from an evaluation of advance provision of emergency contraception. Contraception 2004;70:25-29.
- Plan C. The Plan C Guide to Abortion Pills. 2022.
- Ipas Partners for Reproductive Justice. How to buy abortion pills that are safe and effective. 2022.
- National Abortion Federation. 2022.
- AidAccess. Online consult for abortion pills by mail. 2022.
More states are passing highly restrictive anti-abortion legislation that will lead more people to seek abortions out of state or that are self-managed. Advance provision of medication abortion pills is one way to empower women to make their own decisions in the privacy of their homes.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.