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In May 2018, the Iowa legislature passed the so-called “heartbeat bill” which prohibits abortion once a fetal heartbeat can be detected, typically around six weeks of gestation. This is the most restrictive U.S. abortion law to date – in a period witnessing a tidal wave of restrictions across many U.S. states. What next? In countries like Northern Ireland, Poland, and Brazil that severely limit access to abortion, studies show that women often turn to options outside the formal healthcare system. Today, ordering abortion medication online for home use is one such option; and beginning in 2006, such online care became available when a group of doctors and advocates began to serve women in countries where safe abortions are not available.
In light of increasing abortion restrictions, women in the United States may also be seeking these services – yet researchers know little about the motivations and needs of these would-be users. In 2017 our research team conducted anonymous, in-depth interviews with 32 people living in 20 states who sought abortion medications online. We recruited participants from two non-profit organizations – called “Women on Web” and “Safe2Choose” – that provide early medication abortion through online telemedicine. Although neither of these organizations provides services in the United States, they nevertheless receive requests from U.S. residents every year.
We asked participants who made such requests about their reasons for considering medication abortion outside of clinics and also about the options they encountered. Our analysis reveals many reasons women consider self-managed medication abortions. And it suggests paths toward legal, well-supported self-care for those who want this option.
Barriers to Clinic Access are Not Just a Red State Issue
Although abortion is still legal in all 50 states, the range of access to clinical services varies dramatically depending on state laws and the local environment. Participants in our study described significant barriers to obtaining abortion care – including high costs, difficulty finding nearby providers, transportation and childcare issues, and fear of harassment by anti-abortion protestors. Notably, while barriers of cost and distance were particularly severe for individuals living in states with highly restrictive laws, other barriers presented challenges for women in all states. Our sample of those who sought abortion medication included women from Louisiana and Texas, where the policy environment is hostile, and also women from California and New York, where there are fewer legal restrictions for providing and receiving abortion care.
Women May Prefer Self-Managed Medication Abortion
Although many participants in our study sought abortion medication online as a second-choice option because of the difficulties they faced getting care in clinics, others described the use of pills at home as a preferred method for ending their pregnancies. Some women spoke about their desire to proceed in the comfort of their own homes; in some cases, this setting would have allowed them to remain with their families, close to their own beds and bathrooms. One woman echoed the feelings of others when she said she preferred using pills at home because it would be “private, convenient, and personal.” Others believed a self-managed abortion would give them autonomy, allowing them to undergo the procedure independently and on their own timeline.
Current Online Access
Most of our study participants who sought to self-manage a medication abortion had little difficulty finding and contacting the telemedicine organizations online, and they spoke highly of the information they received, including instructions about the safe and effective use of the medications mifepristone and misoprostol. Participants also appreciated the online testimonials and stories shared by previous users of the telemedicine service in other countries. However, because neither of the organizations with which we worked provides abortion medication to the United States, respondents in our sample were frustrated that they could not obtain pills from a safe and reliable source.
Some participants found online pharmacy sites selling pills. But they worried that these sites might steal their money, send fake pills, or even provide an unsafe or dangerous product. Others thought that the price of pills from online pharmacies was too high, or learned that the billing process was complicated. Although some online pharmacies do ship medications to the United States, they lacked detailed information about usage, side effects, and complications, and did not provide support comparable to that provided by Women on Web and Safe2Choose.
Ultimately, difficulties with obtaining abortion medication online led some women to consider less effective or unsafe methods. Some tried herbs, supplements, and botanicals, but none were able to end their pregnancies using these methods. In some cases, attempts to find alternative methods led to further delays in obtaining clinic services. Sadly, others reported feeling desperate enough to consider unsafe methods such as strenuous exercise, physical trauma, the use of sharp objects, or the ingestion of alcohol or household cleaning substances.
Care That Supports Women’s Needs
Previous studies indicate that misoprostol and mifepristone can be used at home just as effectively as under clinical supervision. The WHO also classifies medication abortions using online telemedicine as safe abortions. Our conversations with people who sought abortion medications online suggest that, beyond state restrictions, a range of non-legal barriers prompt many women to want convenient options for self-managed abortions. And in addition to convenience, some women expressed an explicit desire to use abortion medication in the comfort of their own home, where they felt they had more privacy, control, and autonomy throughout the process. Those who sought abortion medicine online needed a source that would both ship medications to the United States and provide adequate and reassuring information, advice, and support.
By collecting and analyzing personal narratives to probe the needs, motivations, and experiences of people in the United States who seek abortion medication online, our study provides clinicians, public health practitioners, and policymakers with a deeper understanding of the needs of this population. With this knowledge, policymakers and healthcare leaders should begin building new pathways of efficient and private access for American women who need or want safe, self-managed abortion care. Many would welcome this option.
Read more in Abigail R. A. Aiken, Kathleen Broussard, Dana Johnson, and Elisa Padron, “” Perspectives on Sexual and Reproductive Health 50, no. 4 (2018).