PRB

Medication abortion, sometimes called “abortion with pills,” is a critical component of abortion access that has allowed many individuals to end a pregnancy at home. Following the June 2022 Dobbs Supreme Court decision, which ended the constitutional right to choose abortion, access to medication abortion depends on state laws.

As of June 2024, 14 states have a near-total ban on abortion.¹ Among the states that have not banned abortion, 11 require individuals to make at least one in-person trip to the clinic, effectively prohibiting the use of telehealth for medication abortions and requiring many, particularly those who live in rural communities, to travel long distances to access abortion services.²

A patchwork of state policies means people in some states can easily access medication abortion through in-person or virtual visits with health clinics, depending on their preference. Others must have at least one in-person appointment at the health clinic. Still others must go outside the formal health care setting—to online sources or community networks—under the threat of legal consequences.

Here, we examine what recent evidence shows about the safety, effectiveness, and barriers/facilitators to self-managed medication abortion accessed through online telehealth services.

Restrictive Policies Linked to Higher Preference for Medication Abortion, More Obtained Outside Formal Health Care Setting

When medication abortion is easier to access, people seeking an abortion are more likely to prefer and use it, according to a study out of Texas.

Sarah Baum, a researcher at Ibis Reproductive Health, and colleagues at the University of Texas at Austin analyzed surveys of abortion patients at 10 clinics in Texas following two policy changes: A 2013 state law restricting medication abortion and a 2016 FDA label change for mifepristone that nullified some of the state restrictions.

In 2014—when restrictions were in place—41% of the surveyed patients said they preferred medication abortion. By 2018, when some restrictions were lifted, 55% said they preferred medication abortion. Respondents were also more than twice as likely to obtain or plan to obtain a medication abortion in 2018 (84%) than in 2014 (31%).⁸

Understanding these dynamics is important, Baum and colleagues write, because “In states, such as Texas, where abortion services are no longer available due to a complete abortion ban, people will continue to seek abortion care and continue to have preferences in method and model of care.”

A separate study using data from across the United States found that an estimated 26,000 additional self-managed medication abortions were obtained outside the formal health care system in the six months following Dobbs.

Abigail Aiken at the University of Texas at Austin and colleagues looked at the provision of medications for self-managed medication abortion provided by online telemedicine organizations, community networks, and online vendors from July to December 2022. They compared the total number of such abortions to what would have been expected if the Dobbs decision hadn’t occurred.⁹

“Our findings suggest that even though fewer people accessed abortion care within the formal health care setting in the 6 months after Dobbs, a substantial number were able to access abortion medications outside the formal health care setting, despite state-level bans and restrictions,” Aiken and team wrote.

Cost and Privacy Drive Desire to Self-Manage Abortions

In a separate survey of nearly 20,000 patients at 49 abortion clinics in 29 states, 32% of respondents said they experienced barriers to clinic access, most commonly the cost of care and the inability to miss work or school. The cost of in-clinic care was the most common motivation for considering self-managed medication abortion, followed by a preference for the privacy of using pills at home.¹⁰

Aiken and colleagues found that considering self-managed medication abortion was common before getting care at a clinic, particularly for people who face more barriers to clinic access or who prefer getting their care at home.¹¹

Another study found that the cost of clinic-based care, logistical issues, privacy, and convenience were motivators for people who completed a self-managed medication abortion using online telemedicine. Melissa Madera, also of the University of Texas at Austin, and colleagues conducted in-depth interviews with 80 people who sought abortion medication through Aid Access, an organization that operated outside of the formal health care setting until June 2023 (see note).¹² Participants said they preferred care at home for several reasons, including to limit perceived judgment from others (including clinic staff) and their belief that in-clinic care was financially or logistically out of reach.¹³

“Our findings demonstrate that Aid Access fills a critical gap in abortion access in the U.S. by providing a supported method of self-managed medication abortion in lieu of costly in-clinic care and the ineffective or unsafe methods that participants in our study sometimes resorted to,” said Madera.

People Know About Self-Managed Medication Abortion, but They Don’t Know Where—or How—to Get Pills

In their survey of patients at abortion clinics, Aiken and colleagues found that one in three respondents (34%) knew that they could self-manage an abortion with pills. However, specific knowledge about exactly which pills and where they might get them was low.¹⁴

Echoing this finding, Madera and colleagues found that respondents reported a time-consuming and stressful online search for a reputable source of abortion pills. Some said they encountered misinformation online on ineffective or unsafe ways to self-induce an abortion, including through herbs, teas, supplements and vitamins, and other methods—and some reported trying to end a pregnancy with such methods. Other participants worried that Aid Access was not a legitimate provider.¹⁵

Knowledge and awareness of self-managed medication abortion may have increased following the Dobbs decision due to greater need.

Self-Managed Medication Abortion Can Create Unique Sources of Stress and Anxiety

While some concerns could be a part of any abortion experience—not knowing what to expect physically and emotionally, feeling as though they lacked information about the process, and worry about others finding out they had an abortion—other stressors were specific to self-managing, Madera and colleagues reported. For example, participants frequently worried that they would be forced to seek follow-up care from a health care provider within the formal health care setting due to medical complications or the pills not working and were unsure how to navigate these interactions.¹⁶

Not having a connection to a physical clinic or local health care provider also meant not having someone to answer questions during the abortion or provide follow-up care to assure them that the abortion was complete.¹⁷ Participants also worried about shipping delays and the possibility of their package being intercepted by a government agency, such as the police or post office.¹⁸

Medication Abortion by Telehealth Is Medically Safe, Effective, and Preferred by Many Patients

Aiken and colleagues examined records of the outcomes of medication abortions (using both misoprostol and mifepristone) provided via online telehealth by Aid Access.^{19 20} Ninety-six percent of patients were able to end their pregnancies without surgical intervention from a clinical provider, a rate comparable with medication abortions carried out in clinics. Treatment for serious adverse events was uncommon, with 1% receiving a blood transfusion or intravenous antibiotics, and no deaths reported. Among the 2,268 people who provided information about their experience, 98% said they were satisfied and 96% said it was the right choice for them based on their circumstances.²¹

Similarly, Madera and colleagues found that self-managed medication abortion (using both misoprostol and mifepristone) obtained through Aid Access was effective, acceptable to users, and had a very low rate of serious adverse outcomes. Of 80 participants, 78 reported successfully ending their pregnancies after taking the medication, two sought additional care at the clinic, and none reported serious complications.²² Participants reported that the service met their needs for privacy, convenience, affordability, safety, comfort, discretion, and having a support system at home, and that they would recommend it to others.²³

What happens when patients use misoprostol alone? Dana Johnson of the University of Texas at Austin and colleagues reviewed records from Aid Access on self-managed medication abortions using just misoprostol.²⁴ They found that nearly 9 out of 10 of participants (88%) successfully terminated their pregnancies, and very few experienced adverse events or symptoms of a potential complication.²⁵ This study adds to a growing body of evidence that misoprostol alone is safe and effective for self-managed medication abortion, including when obtained through online telehealth.²⁶

Misoprostol alone is not currently offered as a routine part of the Aid Access model (and the combined drug regimen is the only registered product in the United States). But the finding that misoprostol alone is a safe medication abortion option that can be used outside of the formal health care setting is important at a time where the nationwide status of mifepristone is uncertain—including in states that protect abortion access—due to ongoing legal challenges to the FDA’s approval of the drug for medication abortion.²⁷

Access and Accurate Information About Self-Managed Medication Abortion Can Expand Options for People Facing Barriers to Abortion Care

In the current context, self-managed medication abortion obtained through online telehealth is a critical option, especially for people living in states where abortion is legally restricted, the researchers said.

“In the context of abortion bans, self-managed medication abortion provides a safe, effective, and accessible option for many,” said Aiken.

But the road to equitable access to this abortion method is long, they note. In addition to legislative and systemic barriers, misinformation, stigma, the threat of prosecution, and the need for support from health care providers for people who want to self-manage an abortion or who need post-abortion care are persistent challenges. What could help? More efforts to provide accurate information about abortion laws by state and how to safely self-source abortion pills and manage abortion at home could help more people make informed health decisions and achieve reproductive autonomy, the researchers suggest.^{28 29 30}