Interest in advance provision of abortion medication was high even before the U.S. Supreme Court overturned Roe v. Wade, according to recent research. Many of those interested in advance provision were more likely to be highly motivated to prevent pregnancy. They had been using highly effective contraceptives, were well-educated, had private insurance, and were not poor.1
“Our question focused on advance provision provided by a clinician, so people need to be plugged into some kind of healthcare system,” says Klaira Lerma, MPH, research director of the Green Inequality Lab in the department of OB/GYN at the University of Wisconsin-Madison.
Lerma and co-investigator Paul D. Blumenthal, MD, MPH, explored interest in advance provision when access to abortion was limited. This was particularly true in Texas, where legislators passed Senate Bill 8 (SB 8), a six-week abortion ban that allowed any person to sue someone who helped a woman obtain an abortion. That decision was upheld by the Supreme Court in 2021.
“Inequities of access to abortion existed since Roe, so we looked at advance provision at a time when some people could access abortion — like in California — but there were challenges where it was difficult to gain access,” Lerma says. “We saw advance provision as a strategy for people who live in states supportive [of abortion care].”
People interested in advance provision may be drawn to this method because of the convenience of obtaining the medication without having to visit a clinic and going through the abortion in the privacy of their home. “It’s hard to get a doctor’s appointment in time,” Lerma adds.
Advance provision may appeal to people who want to avoid the stigma and the abortion clinic protestors. They believe advance provision is more confidential, Lerma notes. “I believe this is a huge motivator for why people are interested in this,” she adds. “Abortion is healthcare, and people responded as consumers to this survey.”
Participants’ responses to why they were interested in advance provision include:
- “I would be able to take care of the issue confidentially and in a safe way.”
- “I live in Texas, where abortion is essentially banned, so I would definitely love to have access to this within my own home, without risk of someone punishing me for seeking a clinic abortion.”
- “Many clinics that offer [abortions] in the South have protestors outside often, so there wouldn’t be the fear of needing to get past them.”
- “You could use them whenever is convenient rather than going through the hassle of making an appointment.”1
After SB 8, some states were inundated with Texans seeking an abortion. This meant that people who lived in states that still allowed abortion care were going to see longer wait times before they could get on the schedule at an abortion clinic. If more people had obtained advance provision through their community providers, this could help ease the congestion. “No one strategy will save us all,” Lerma says. “We need a number of strategies, and advance provision is one of those tools.”
The online survey study examined interest in advance provision — not people obtaining advance provision of mifepristone and misoprostol.
The authors of a more recent research letter studied advance provision using data from Aid Access, an international online telemedicine service that began offering this service in September 2021. The researchers explored what has happened since the Supreme Court decision to overturn Roe was leaked in May 2022, and after the decision was published in June 2022.2
“In that [paper], they saw that those requesting pills for advance provision vs. those with immediate need were older, more likely to be white, more likely to have no children, lived in urban areas, and they lived in areas where poverty rates were lower,” Lerma says. “That’s not who we know face the most barriers to access, and they’re not the folks most likely to have abortions in our country. What stood out to me is that these are folks willing to spend $150 on something they don’t know if they’ll need.”
The willingness and ability to pay a significant sum for advance provision of pills highlights the barrier to improving abortion access for the most vulnerable people in states with abortion bans.
The authors of the Aid Access study highlighted that those accessing the pill wanted to maintain their reproductive autonomy, Lerma says. People who are most in need of advance provision also might be people for whom paying $150 for advance access is not feasible. “We see huge barriers due to cost,” she notes.
The researchers studied residents of all U.S. states and Washington, DC, who requested advance provision from Sept. 1, 2021, to April 30, 2023. This period was compared with the mean daily request rate across periods before the Dobbs v. Jackson Women’s Health Organization decision, after the Supreme Court decision was leaked from May 2, 2022, to June 23, 2022, and after the Dobbs decision was formally announced. The fourth period compared was from April 7-30, 2023, when there were conflicting judicial rulings on the FDA’s approval for mifepristone and whether it should remain available to Americans. The researchers found the greatest peaks in requests for advance provision abortion medications after the Dobbs leak and during the period when courts were issuing opinions on the FDA’s approval of mifepristone and whether the medication could remain available in the United States.2
Other findings include:
- At baseline in September 2021, the mean number of daily requests was 24.8. After the Dobbs leak, this jumped to 247.
- At the time of the Dobbs decision, the mean number of daily requests was 89.
- When opposing rulings were made about mifepristone remaining legal in the United States, the mean number of daily requests spiked to 172.
Researchers observed that states considering abortion bans reported the highest rates of advance provision requests. Other findings were that 12.3% of advance provision requests came from youth younger than age 20 years. This same cohort accounted for 18.2% of those requesting abortion medication for self-managed abortions.
Pregnancy-capable people in their 20s were the group with the highest proportion of advance provision requests, as well as ordering abortion pills online for a self-managed abortion. This age group accounted for 53.6% of advance provision requests and 54.7% of those needing the pills for a current pregnancy.
People in their 30s accounted for 26.5% of those seeking advance provision and 23.9% of those needing abortion medication for a current pregnancy. Those in their 40s and older accounted for 7.5% for advance provision and 3.1% for current pregnancy.
Sixty-six percent of the people calling for advance provision were white, 12.9% were Hispanic, and 7.1% were Black. Also, most asking for advance provision were childless and lived in urban areas.
Lerma and Blumenthal’s study revealed that 65% of those surveyed were interested in advance provision. They also found these characteristics among people interested in advance provision:
- They were mostly white, non-Hispanic (53.3%), followed by Asian American or Asian (17.4%).
- They mostly identified as women (96.1%).
- They were mostly straight (61.8%) or bisexual (24.5%).
- They were well-educated and held a bachelor’s degree or higher (53.4%).
- They had private insurance (77%).
- They lived in the South and Midwest (37.2% and 25.2%, respectively).
- They did not live in a household below the poverty guidelines (69.9%).
- They previously had sex that could result in pregnancy (85.1%).
- Many had a previous pregnancy (34.2%).
Neither study examines other ways women are obtaining abortion medication in abortion-ban states.
“We know there are people in communities who are distributing pills to create a safety network,” Lerma explains. “A lot of my work on advance provision was inspired by work done with emergency contraception and advance provision of that. People do keep emergency contraception on hand and do share it with friends and family.”
Future research could study the legal risks of advance provision of abortion medication. Fear of arrest or civil action is a major barrier to accessing abortion medication. “Along with cost, there is the unknown risk due to increasing criminalization of people who have abortion — and the people most likely to be criminalized are people of color,” Lerma says. “I highlight in the article that we have not explored enough the legal implications of this.”
Some abortion-rights states have shield laws for providers, but these have not been tested. “Shield laws allow providers in states without legal restrictions to mail pills to people who are in states where it’s restricted,” Lerma adds. “Those participating in shield law states have lawyers who have done a lot of work to protect providers.”
However, individual pregnant people may be at legal risk if they obtain advance provision abortion pills. “The resources exist, but it’s hard to protect people with legal help should they need it,” Lerma says. “It’s a huge risk for some people.”
REFERENCES
- Lerma K, Blumenthal PD. Interest in advance provision of abortion pills: A national survey of potential users in the USA. BMJ Sex Reprod Health 2023;49:183-191.
- Aiken ARA, Starling JE, van Blitterswijk DC, et al. Advance provision of mifepristone and misoprostol via online telemedicine in the US. JAMA Intern Med 2024;184:220-223.
Interest in advance provision of abortion medication was high even before the U.S. Supreme Court overturned Roe v. Wade, according to recent research. Many of those interested in advance provision were more likely to be highly motivated to prevent pregnancy. They had been using highly effective contraceptives, were well-educated, had private insurance, and were not poor.
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