By Katherine Rivlin, MD, MSc
Associate Professor, Obstetrics and Gynecology, The Ohio State University Medical Center, Columbus
In this prospective national study among people searching for abortion care online, 28% of respondents reported attempting self-managed abortion. Respondents living farther from an abortion facility and facing barriers to care were more likely to attempt self-managed abortion.
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 2021; Sep 21:S0010-7824(21)00385-1. doi: 10.1016/j.contraception.2021.09.009. [Online ahead of print].
As barriers to abortion access increase in the United States, a person experiencing an unwanted pregnancy may consider a self-managed abortion (SMA) — attempting to end the pregnancy without clinical supervision. Previously described methods of SMA include ordering medications online (including mifepristone and misoprostol, the medications used in medically supervised medication abortion) and ingesting herbs, supplements, or vitamins. Technically, obtaining abortion pills online without medical supervision is illegal in the United States. Prior estimates of SMA, ranging from 2% to 7%, have come from patients seeking care in abortion clinics.1,2 Because these estimates exclude patients who do not reach the abortion clinic, they likely are underestimates. By recruiting from among people who searched for abortion services online, this study may reach those who will never make it to an abortion clinic. In addition, given the associated stigma of SMA, online surveys may allow for more comfort and privacy around discussing SMA, which could reduce both recall and social desirability bias.
This analysis comes from the Google Ads Abortion Access Study, a prospective cohort study among women in the United States searching online for an abortion from 2017 to 2018.3 Using advertisements in Google search results, the study recruited individuals who used search terms, such as “abortion clinic near me.” Ads were targeted by state to generate a sample that included all 50 states. Individuals who clicked the ad then completed an eligibility screener. To be included, respondents had to be pregnant currently and considering an abortion. Eligible respondents then completed demographic and pregnancy characteristic information. They were contacted four weeks later with a follow-up survey about pregnancy outcomes, barriers to accessing care, and SMA.
This study focuses on SMA attempts. Specifically, participants were asked about using abortion pills obtained online, trying to end the pregnancy without medical help, using emergency contraception (EC) after already pregnant, inflicting self-harm, or taking other medications or herbs to end the pregnancy. Of note, these data were collected before medically supervised telemedicine abortion services were available. The study team measured state-level policy environments based on the number of laws restricting abortion in the participant’s state as well as distance to the nearest abortion facility. The team also asked about logistical and financial barriers to obtaining an abortion.
Of all respondents who met eligibility criteria and provided complete SMA data, 28% (95% confidence interval [CI], 25% to 31%) attempted at least one method of SMA and 7% reported more than one. The most commonly reported SMA methods were taking herbs, supplements, or vitamins. Commonly reported substances were vitamin C, blue or black cohosh, unspecified herbs or teas, cinnamon, parsley, and fruits, such as pineapple, papaya, pomegranate, and dong quai. About 19% of respondents attempting SMA reported taking EC after confirming pregnancy; 18% took mifepristone and/or misoprostol on their own (although not through online services); 18% inflicted harm on themselves; 10% used smoking, alcohol, or other substances; and 7% took other prescription or over-the-counter medications. While the survey did not ask specifically about subsequent morbidity or mortality related to SMA, participants were able to write in methods of SMA not captured in the survey. Per the authors, the most extreme method reported was “attempting to penetrate the cervix with a hook.”
Although most respondents reported at least one barrier to abortion care, a higher proportion of those who attempted SMA reported at least one barrier to care, as compared to those who did not attempt SMA (98% vs. 94%, P = 0.03). Respondents with difficulty meeting basic needs, with no or undetermined health insurance, and those living farther from an abortion facility were more likely to attempt SMA. Those who attempted SMA were more likely to be pregnant and seeking abortion at follow-up than those who did not (39% vs. 30%, P < 0.001). However, those who ordered abortion pills online all reported successfully ending the pregnancy. Barriers to care and distance to the nearest abortion facility also were significantly associated with SMA attempts. Specifically, respondents who had to keep their abortion secret, who feared for their well-being, and who needed to gather money to travel or for the abortion had higher odds of attempting SMA (adjusted odds ratio [aOR], 2.00; 95% CI, 1.36-2.94). Respondents living 50 to 100 miles (aOR, 1.77; 95% CI, 1.01-3.10) and 100 or more miles (aOR, 2.31; 95% CI, 1.18-4.50) from the nearest abortion facility had significantly higher odds of SMA than those living less than five miles from a facility, a much shorter distance.
COMMENTARY
SMA is an understudied aspect of abortion care. By recruiting participants online from outside abortion clinics, this study provides a higher estimate of SMA than those reported previously in the literature (28% compared to 2% to 7%).1,2,4 This study also expands our understanding of how patients attempt SMA, since it allowed patients to list SMA methods in a private and non-stigmatizing way. Although most of the reported SMA methods are unlikely to cause harm, they are either ineffective for inducing abortion or are much less effective than taking mifepristone and misoprostol. SMA has been reported to delay accessing abortion care since patients may not realize that SMA methods were unsuccessful, which itself could lead to worse clinical outcomes.5 Although rare, this study documents harmful SMA techniques, including inflicting physical harm on oneself. The documentation of such methods is concerning and requires attention, given the potential for maternal morbidity or mortality.
Although this study occurred before telemedicine medication abortion services under medical supervision were available, it documents an interest in these services, since many respondents ordered abortion medications online. It joins mounting evidence that telemedicine abortion is not only safe but patient-centered.3 Yet, instead of expanding these services, currently 19 states have effectively banned telemedicine abortion, as has the U.S. Food and Drug Administration by prohibiting medication dispensing without in-clinic visits.6 Although state policy environment was not associated directly with SMA attempts, the need to obtain money to pay for the abortion or associated costs and the need to travel long distances were. Time and again, we find that patients seeking abortion are resilient and can overcome specific restrictions intended to dissuade them from seeking this care. But restrictions that worsen structural barriers to care, that increase costs (such as a lack of health insurance or Medicaid coverage for abortion), and that increase travel distances to the nearest clinic (such as targeted restrictions on abortion providers that lead to clinic closures) are much harder to overcome. These barriers particularly affect people of color, people with low incomes, and other historically marginalized groups who are disproportionally affected by abortion restrictions.
Better understanding the associations between structural barriers and SMA becomes particularly relevant as patients face mounting abortion restrictions throughout the United States.7 Senate Bill 8, a near total ban on abortion enacted in the state of Texas in September 2021, has led to a 14-fold increase in driving distance to get an abortion among women of reproductive age within Texas counties.8 With one in 10 women in the United States living in Texas, Senate Bill 8 and others like it are creating a public health crisis that studies, such as this one, only begin to describe.
REFERENCES
- Fuentes L, Baum S, Keefe-Oates B, et al. Texas women’s decisions and experiences regarding self-managed abortion. BMC Womens Health 2020;20:6.
- Ralph L, Foster DG, Raifman S, et al. Prevalence of self-managed abortion among women of reproductive age in the United States. JAMA Netw Open 2020;3:e2029245.
- Upadhyay UD, Koenig LR, Meckstroth KR. Safety and efficacy of telehealth medication abortions in the US during the COVID-19 pandemic. JAMA Netw Open 2021;4:e2122320.
- Moseson H, Herold S, Filippa S, et al. Self-managed abortion: A systematic scoping review. Best Pract Res Clin Obstet Gynaecol 2020;63:87-110.
- Grossman D, Holt K, Pena M, et al. Self-induction of abortion among women in the United States. Reprod Health Matters 2010;18:136-146.
- Mello K, Smith MH, Hill BJ, et al. Federal, state, and institutional barriers to the expansion of medication and telemedicine abortion services in Ohio, Kentucky, and West Virginia during the COVID-19 pandemic. Contraception 2021;104:111-116.
- Cartwright AF, Karunaratne M, Barr-Walker J, et al. Identifying national availability of abortion care and distance from major US cities: Systematic online search. J Med Internet Res 2018;20:e186.
- Nash E, Bearak J, Li N, Cross L. Impact of Texas’ abortion ban: A 14-fold increase in driving distance to get an abortion. Guttmacher Institute. Updated Sept. 15, 2021. https://www.guttmacher.org/article/2021/08/impact-texas-abortion-ban-14-fold-increase-driving-distance-get-abortion
