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Lands M, Dyer RL, Seymour JW. Sampling strategies among studies of barriers to abortion in the United States: A scoping review of abortion access research. Contraception 2024; 131:110342. [PMID: 38012964 DOI: 10.1016/j.contraception.2023.110342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVES Understanding barriers to abortion care is particularly important post-Dobbs. However, many abortion access studies recruit from abortion-providing facilities, which overlook individuals who do not present for clinic-based care. To our knowledge, no studies have reviewed research recruitment strategies in the literature or considered how they might affect our knowledge of abortion barriers. We aimed to identify populations included and sampling methods used in studies of abortion barriers in the United States. STUDY DESIGN We used a scoping review protocol to search five databases for articles examining US-based individuals' experiences accessing abortion. We included English-language articles published between January 2011 and February 2022. For included studies, we identified the sampling strategy and population recruited. RESULTS Our search produced 2763 articles, of which 71 met inclusion criteria. Half of the included papers recruited participants at abortion-providing facilities (n = 35), while the remainder recruited from online sources (n = 14), other health clinics (n = 10), professional organizations (n = 8), abortion funds (n = 2), community organizations (n = 2), key informants (n = 2), and an abortion storytelling project (n = 1). Most articles (n = 61) reported information from people discussing their own abortions; the rest asked nonabortion seekers (e.g., physicians, genetic counselors, attorneys) about barriers to care. CONCLUSIONS Studies of abortion barriers enroll participants from a range of venues, but the majority recruit people who obtained abortions, and half recruit from abortion clinics. IMPLICATIONS As abortion access becomes constrained and criminalized in the post-Roe context, our findings indicate how investigators might recruit study participants from a variety of settings to fully understand the abortion seeking experience.
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Affiliation(s)
- Madison Lands
- University of Wisconsin Collaborative for Reproductive Equity, Madison, WI, United States.
| | - Rachel L Dyer
- University of Wisconsin Collaborative for Reproductive Equity, Madison, WI, United States; University of Wisconsin Department of Counseling Psychology, Madison, WI, United States
| | - Jane W Seymour
- University of Wisconsin Collaborative for Reproductive Equity, Madison, WI, United States
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Herold S, Morris N, Biggs MA, Schroeder R, Kaller S, Sisson G. Abortion pills on TV: An exploratory study of the associations between abortion plotline viewership and beliefs regarding in-clinic and self-managed medication abortion. Contraception 2024:110416. [PMID: 38431259 DOI: 10.1016/j.contraception.2024.110416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVES Entertainment television is an influential source of health information, including about reproductive health. We investigated the association between exposure to television plotlines about medication abortion on audience awareness and beliefs about medication abortion. STUDY DESIGN We administered a national cross-sectional online survey from December 2021 to January 2022 with a probability-based sample of people assigned female at birth. We asked respondents to select plotlines they had seen from a list of seven that portrayed medication abortion. Among the 3425 people who responded to plotline items, 3340 responded to our outcome measures. Using weighed multivariable analyses, we examined adjusted relationships between exposure to specific types of abortion plotlines and awareness of and beliefs about medication abortion medical safety. RESULTS We found that audience exposure to medication abortion plotlines in which the medication abortion was obtained from a clinic and portrayed as safe was associated with greater awareness of medication abortion compared to nonexposure (RR: 1.68; 95% CI: 1.17, 2.40). Exposure to plotlines that portrayed MA or self-managed MA as safe was associated with audience beliefs that medication abortion is safe. CONCLUSIONS This study demonstrates that the content of abortion plotlines and exposure to accurate information may be connected to audience awareness of and beliefs about abortion. IMPLICATIONS In a climate of misinformation about abortion, audience exposure to medically accurate television plotlines about medication abortion may be an effective way to increase awareness of medication abortion and influence beliefs about medication abortion safety.
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Affiliation(s)
- Stephanie Herold
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, Oakland, CA, United States.
| | - Natalie Morris
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, Oakland, CA, United States
| | - M Antonia Biggs
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, Oakland, CA, United States
| | - Rosalyn Schroeder
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, Oakland, CA, United States
| | - Shelly Kaller
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, Oakland, CA, United States
| | - Gretchen Sisson
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, Oakland, CA, United States
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Verma N, Grossman D. Self-Managed Abortion in the United States. Curr Obstet Gynecol Rep 2023; 12:70-75. [PMID: 37305376 PMCID: PMC9989574 DOI: 10.1007/s13669-023-00354-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
Purpose of Review This review aims to provide up-to-date information about self-managed abortion in the USA. Recent Findings Evidence indicates that there is growing demand for self-managed abortion in the USA as obstacles to facility-based care increase, especially since the Supreme Court overturned Roe v. Wade. Self-managed abortion with medications is safe and effective. Summary Based on a nationally representative survey, the lifetime prevalence of self-managed abortion in the USA in 2017 was estimated to be 7%. People experiencing barriers to abortion care, including people of color, people with lower incomes, people in states that have restrictive abortion laws, and those living farther from facilities providing abortion care are more likely to attempt self-managed abortion. While people may use a range of methods to self-manage abortion, there is growing use of safe and effective medications, including mifepristone used together with misoprostol and misoprostol used alone; use of traumatic and dangerous methods is rare. While many people attempt to self-manage their abortion because of barriers to facility-based care, others have a preference for self-care because it is convenient, accessible, and private. While the medical risks of self-managed abortion may be few, the legal risks may be significant. Sixty-one people have been criminally investigated or arrested between 2000 and 2020 for allegedly self-managing their abortion or helping someone else do so. Clinicians play an important role in providing evidence-based information and care to patients considering or attempting self-managed abortion, as well as minimizing legal risks.
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Affiliation(s)
- Nisha Verma
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco (UCSF), 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
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Ralph L, Ehrenreich K, Kaller S, Biggs MA. A cross-sectional study examining consideration of self-managed abortion among people seeking facility-based care in the United States. Reprod Health 2022; 19:176. [PMID: 35962384 PMCID: PMC9375262 DOI: 10.1186/s12978-022-01486-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/22/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction With increasing restrictions on abortion across the United States, we sought to understand whether people seeking abortion would consider ending their pregnancy on their own if unable to access a facility-based abortion. Methods From January to June 2019, we surveyed patients seeking abortion at 4 facilities in 3 US states. We explored consideration of self-managed abortion (SMA) using responses to the question: “Would you consider ending this pregnancy on your own if you are unable to obtain care at a health care facility?” We used multivariable Poisson regression to assess associations between individual sociodemographic, pregnancy and care-seeking characteristics and prevalence of considering SMA. In bivariate Poisson models, we also explored whether consideration of SMA differed by specific obstacles to abortion care. Results One-third (34%) of 741 participants indicated they would definitely or probably consider ending the pregnancy on their own if unable to obtain care at a facility. Consideration of SMA was higher among those who reported no health insurance (adjusted prevalence ratio [aPR] = 1.66; 95% Confidence Interval [CI] 1.12–2.44), described the pregnancy as unintended (aPR = 1.53; 95% CI 1.08–2.16), were seeking abortion due to concerns about their own physical or mental health (aPR = 1.50, 95% CI 1.02, 2.20), or experienced obstacles that delayed their abortion care seeking (aPR = 2.26, 95% CI 1.49, 3.40). Compared to those who would not consider SMA, participants who would consider SMA expressed higher difficulty finding an abortion facility (35 vs. 27%, p = 0.019), figuring out how to get to the clinic (29 vs 21%, p = 0.021) and needing multiple clinic visits (23 vs 17%, p = 0.044). Conclusions. One in three people seeking facility-based abortion would consider SMA if unable to obtain abortion care at a facility. As abortion access becomes increasingly restricted in the US, SMA may become more common. Future research should continue to monitor people’s consideration and use of SMA and ensure that they have access to safe and effective methods.
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Affiliation(s)
- Lauren Ralph
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA.
| | - Katherine Ehrenreich
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
| | - Shelly Kaller
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
| | - M Antonia Biggs
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
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Gordon MR, Coverdale J, Chervenak FA, McCullough LB. Undue burdens created by the Texas Abortion Law for vulnerable pregnant women. Am J Obstet Gynecol 2022; 226:529-534. [PMID: 34954218 DOI: 10.1016/j.ajog.2021.12.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 12/09/2021] [Accepted: 12/17/2021] [Indexed: 11/25/2022]
Abstract
The new Texas abortion law requires the physician to determine whether a fetal heartbeat is present and prohibits abortion after a heartbeat has been documented. An exception is allowed when a "medical emergency necessitated the abortion." These and other provisions of the statute are to be enforced through "civil actions" brought by private citizens. This article identifies 3 populations of vulnerable women who will experience undue burdens created by the Texas abortion law. We begin with an account of the concept of undue burden in the jurisprudence of abortion, as expressed in the 1992 US Supreme Court case, Planned Parenthood v. Casey of Southeastern Pennsylvania. We then provide an evidence-based account of the predictable, undue burdens for 3 populations of vulnerable women: pregnant women with decreased freedom of movement; pregnant minors; and pregnant women with major mental disorders and cognitive disabilities. The Texas law creates an undue burden on these 3 populations of vulnerable women by reducing or even eliminating access to abortion services outside of Texas. The Texas law also creates an undue burden by preventably increasing the risks of morbidity, including loss of fertility, and mortality for these 3 populations of vulnerable women. For these women, it is indisputable that the Texas law will create undue burdens and is therefore not compatible with the jurisprudence of abortion as set forth in Planned Parenthood v. Casey because a "significant number of women will likely be prevented from obtaining an abortion." Federal courts should therefore strike down this law.
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Baldwin A, Johnson DM, Broussard K, Tello-Pérez LA, Madera M, Ze-Noah C, Padron E, Aiken ARA. U.S. Abortion Care Providers' Perspectives on Self-Managed Abortion. Qual Health Res 2022; 32:788-799. [PMID: 35322703 PMCID: PMC9152602 DOI: 10.1177/10497323221077296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
State-level restrictions on abortion access may prompt greater numbers of people to self-manage their abortion. The few studies exploring perspectives of providers towards self-managed abortion are focused on physicians and advanced practice clinicians. Little is known about the wider spectrum of abortion care providers who encounter self-managed abortion in their clinic-based work. To gain a deeper understanding of this issue and inform future care delivery, we conducted in-depth interviews with 46 individuals working in a range of positions in 46 abortion clinics across 29 states. Our interpretative analysis resulted in themes shaped by beliefs about safety and autonomy, and a tension between the two: that self-managed abortion is too great a risk, that people are capable of self-managing an abortion, and that people have a right to a self-managed abortion. Our findings highlight the importance of increasing knowledge and clarifying values among all abortion care providers, including clinic staff.
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Affiliation(s)
- Aleta Baldwin
- Department of Public Health, California State University
Sacramento, USA
| | - Dana M. Johnson
- Lyndon B Johnson School of Public Affairs, The University of Texas at Austin, USA
| | | | | | - Melissa Madera
- Lyndon B Johnson School of Public Affairs, The University of Texas at Austin, USA
| | - Carol Ze-Noah
- Department of Political Science, University of California Berkeley, USA
| | | | - Abigail R. A. Aiken
- Lyndon B Johnson School of Public Affairs, The University of Texas at Austin, USA
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Ferguson L, Narasimhan M, Gutierrez J, Jardell W, Gruskin S. Law, human rights and gender in practice: an analysis of lessons from implementation of self-care interventions for sexual and reproductive health. Sex Reprod Health Matters 2022; 29:2105284. [PMID: 35975874 PMCID: PMC9387312 DOI: 10.1080/26410397.2022.2105284] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Self-care interventions for health are becoming increasingly available, and among the preferred options, including during the COVID-19 pandemic. This research assessed the extent of attention to laws and policies, human rights and gender in the implementation of self-care interventions for sexual and reproductive health (SRH), to identify where additional efforts to ensure an enabling environment for their use and uptake will be useful. A literature review of relevant studies published between 2010 and 2020 was conducted using PubMed, Scopus and Web of Science. Relevant data were systematically abstracted from 61 articles. In March–April 2021, semi-structured interviews were conducted with 10 key informants, selected for their experience implementing self-care interventions for SRH, and thematically analysed. Laws and policies, rights and gender are not being systematically addressed in the implementation of self-care interventions for SRH. Within countries, there is varied attention to the enabling environment including the acceptability of interventions, privacy, informed consent and gender concerns as they impact both access and use of specific self-care interventions, while other legal considerations appear to have been under-prioritised. Operational guidance is needed to develop and implement supportive laws and policies, as well as to ensure the incorporation of rights and gender concerns in implementing self-care interventions for SRH.
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Affiliation(s)
- Laura Ferguson
- Associate Professor of Population and Public Health Sciences, Director of Research, USC Institute on Inequalities in Global Health, University of Southern California, Los Angeles, CA, USA. Correspondence:
| | - Manjulaa Narasimhan
- Scientist, Department of Sexual and Reproductive Health and Research, World Health Organization, includes the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction – HRP, Geneva, Switzerland
| | - Jose Gutierrez
- Student, University of Southern California, Los Angeles, CA, USA
| | - William Jardell
- Project Specialist, USC Institute on Inequalities in Global Health, University of Southern California, Los Angeles, CA, USA
| | - Sofia Gruskin
- Professor of Population and Public Health Sciences and Law, Director, USC Institute on Inequalities in Global Health, University of Southern California, Los Angeles, CA, USA
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Johnson DM, Madera M, Gomperts R, Aiken AR. The economic context of pursuing online medication abortion in the United States. SSM - Qualitative Research in Health 2021; 1. [PMID: 35368445 PMCID: PMC8976452 DOI: 10.1016/j.ssmqr.2021.100003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Access to in-clinic abortion has become increasingly restricted in the U.S. and for many, the high cost of care is a significant barrier. However, little is known about how financial circumstances shape the alternate pathways to abortion care people seek when the clinic is out of reach. In a unique sample of people who used medication abortion pills from Aid Access, a non-profit telemedicine service, we examine the impact of economic circumstances on abortion care pathway decision-making and experiences seeking care. Between June and August 2019, we conducted 80 anonymous, semi-structured in-depth interviews with U.S. residents who self-managed their own abortions using medication abortion pills from Aid Access. Participants were asked about their experiences seeking abortion, and their motivations for using the service. We coded interviews using an iteratively developed coding guide and performed thematic analyses to identify key themes. The unaffordable cost of in-clinic abortion was a key reason why participants sought care using online telemedicine. Experiences of personal financial hardship exacerbated by restrictive policies impacted participants’ ability to access the clinic. For participants with children, their financial decisions were further guided by the concerns of providing economic stability for their family. Although telemedicine was considered more affordable than in-clinic care, for some, the suggested donation of $90 still posed a financial burden and accessing pills at no cost or a reduced cost was necessary. The availability of affordable telemedicine and policy interventions addressing Medicaid and insurance coverage for abortion would democratize abortion access for populations with low incomes.
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Affiliation(s)
- Dana M. Johnson
- The University of Texas at Austin, USA
- Corresponding author. (D.M. Johnson)
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Holten L, de Goeij E, Kleiverda G. Permeability of abortion care in the Netherlands: a qualitative analysis of women's experiences, health professional perspectives, and the internet resource of Women on Web. Sex Reprod Health Matters 2021; 29:1917042. [PMID: 33975533 PMCID: PMC8118432 DOI: 10.1080/26410397.2021.1917042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Despite a relatively permissive abortion law, women in the Netherlands encounter difficulties in accessing abortion care. Little is known about their experiences. This study explores women's experiences with (online) abortion services and relevant health professionals' experiences delivering care, with the goal of identifying key barriers encountered by abortion-seekers in the Netherlands. An exploratory qualitative research design with a constructivist approach and an abbreviated grounded theory method was used. Interviews with 20 women who had had an abortion and 14 health professionals who provide abortion care, and 200 emails of women seeking abortion care through the non-governmental organisation Women on Web, were coded inductively and deductively (using the Candidacy Framework) thereby generating themes. Abortion-seekers faced barriers including: (i) burden of taboo, (ii) vulnerability (emotional, financial, and social), (iii) health professional evaluation and (iv) disempowerment and distress. The overarching theme was women's lack of autonomy in access to abortion care. The key barriers to abortion access in the Netherlands are the institutionalisation of taboo in abortion law and care, complex candidacy regulations, lack of permeability for certain marginalised groups, and women's inability to speak openly about abortion. To increase the permeability of abortion care, and thereby women's autonomy, legislators and policy-makers must trust women to make their own reproductive decisions and avoid actions that stigmatise abortion and hinder access to care, while actively developing systemic support for vulnerable groups.
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Affiliation(s)
- Lianne Holten
- Researcher, Women on Waves, Amsterdam, the Netherlands
| | - Eva de Goeij
- Independent scholar, Dutch Humanist Association (Humanistich Verbond), Amsterdam, the Netherlands
| | - Gunilla Kleiverda
- Consultant Obstetrician and Gynaecologist, Flevoziekenhuis, Almere, the Netherlands
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Raifman S, Ralph L, Biggs MA, Grossman D. "I'll just deal with this on my own": a qualitative exploration of experiences with self-managed abortion in the United States. Reprod Health 2021; 18:91. [PMID: 33947413 PMCID: PMC8093912 DOI: 10.1186/s12978-021-01142-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/17/2021] [Indexed: 11/25/2022] Open
Abstract
Background A growing body of evidence indicates that some people seek options to terminate a pregnancy without medical assistance, but experiences doing so have largely been documented only among people accessing a clinic-based abortion. We aim to describe self-managed abortion (SMA) experiences of people recruited outside of clinics, including their motivations for SMA, pregnancy confirmation and decision-making processes, method choices, and clinical outcomes. Methods In 2017, we conducted 14 in-depth interviews with self-identified females of reproductive age who recently reported in an online survey administered to Ipsos’ KnowledgePanel that, since 2000, they had attempted SMA while living in the United States. We asked participants about their reproductive histories, experiences seeking reproductive health care, and SMA experiences. We used an iterative process to develop codes and analyzed transcripts using thematic content analysis methods. Results Motivations and perceptions of effectiveness varied by whether participants had confirmed the pregnancy prior to SMA. Participants who confirmed their pregnancies chose SMA because it was convenient, accessible, and private. Those who did not test for pregnancy were motivated by a preference for autonomy and felt empowered by the ability to try something on their own before seeking facility-based care. Participants prioritized methods that were safe and available, though not always effective. Most used herbs or over-the-counter medications; none used self-sourced abortion medications, mifepristone and/or misoprostol. Five participants obtained facility-based abortions and one participant decided to continue the pregnancy after attempting SMA. The remaining eight reported being no longer pregnant after SMA. None of the participants sought care for SMA complications; one participant saw a provider to confirm abortion completion. Conclusions There are many types of SMA experiences. In addition to those who pursue SMA as a last resort (after facing barriers to facility-based care) or as a first resort (because they prefer homeopathic remedies), our findings show that some individuals view SMA as a potential interim step worth trying after suspecting pregnancy and before accessing facility-based care. These people in particular would benefit from a medication abortion product available over the counter, online, or in the form of a missed-period pill. Some people in the United States (US) attempt to end a pregnancy on their own without medical supervision. What we know about this experience comes from studies focused on people who go to clinics. In this study, we conducted 14 interviews with self-identified women ages 18–49 who recently reported attempting to end a pregnancy on their own and who were recruited outside of the clinic setting. We asked participants about their fertility histories, experiences seeking reproductive health care, and experiences ending a pregnancy without medical assistance. Those who took a pregnancy test and then chose to end the pregnancy on their own did so because it was convenient, accessible, and private. Those who did not test for pregnancy felt empowered by the ability to try something on their own before seeking facility-based care. All participants prioritized methods that were safe and available, though not always effective. After they attempted to end the pregnancy on their own, five participants accessed abortion care in facilities, one decided to continue the pregnancy, and eight were no longer pregnant. Our findings show that, in addition to people who end a pregnancy on their own as a last resort (after facing barriers to facility-based care) or as a first resort (because of preferences for homeopathic methods), a third group values having an interim step to try after suspecting pregnancy and before accessing facility-based care. These people would particularly benefit from a medication abortion product available over the counter, online, or in the form of a missed-period pill.
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Affiliation(s)
- Sarah Raifman
- Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA.
| | - Lauren Ralph
- Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
| | - M Antonia Biggs
- Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
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11
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Abstract
IMPORTANCE People in the US have been seeking self-managed abortions outside the formal health care system using medications obtained through online telemedicine. However, little is known about this practice, including potential motivating factors. OBJECTIVE To examine individual reasons for accessing medication abortion through an online telemedicine service as well as associations between state- and county-level factors and the rate of requests. DESIGN, SETTING, AND PARTICIPANTS This population-based cross-sectional study examined all requests for self-managed medication abortion through an online consultation form available from Aid Access, a telemedicine service in the US, between March 20, 2018, and March 20, 2020. MAIN OUTCOMES AND MEASURES Individual-level reasons for accessing the telemedicine service were examined as well as the rate of requests per 100 000 women of reproductive age by state. Zip code data provided by individuals making requests were used to examine county-level factors hypothesized to be associated with increased demand for self-managed abortion: distance to a clinic (calculated using location data for US abortion clinics) and the population proportion identifying as a member of a racial/ethnic minority group, living below the federal poverty level, and having broadband internet access (calculated using census data). RESULTS During the 2-year study period, 57 506 individuals in 2458 counties in 50 states requested self-managed medication abortion; 52.1% were aged 20 to 29 years (mean [SD] age, 25.9 [6.7] years), 50.0% had children, and 99.9% were 10 weeks' pregnant or less. The most common reasons cited by individuals making requests were the inability to afford in-clinic care (73.5%), privacy (49.3%), and clinic distance (40.4%). States with the highest rate of requests were Louisiana (202.7 per 100 000 women) and Mississippi (199.9 per 100 000 women). At the county level, an increase of 1 SD (47 miles) in distance to the nearest clinic was significantly associated with a 41% increase in requests (incidence rate ratio, 1.41; 95% CI, 1.31-1.51; P < .001), and a 10% increase in the population living below the federal poverty level was significantly associated with a 20% increase in requests (incidence rate ratio, 1.20; 95% CI, 1.13-1.28; P < .001). CONCLUSIONS AND RELEVANCE In this cross-sectional study, clinic access barriers were the most commonly cited reason for requesting self-managed medication abortion using an online telemedicine service. At the county level, distance to an abortion clinic and living below the federal poverty level were associated with a higher rate of requests. State and federal legislation could address these access barriers.
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Affiliation(s)
- Abigail R. A. Aiken
- LBJ School of Public Affairs, The University of Texas at Austin
- Population Research Center, The University of Texas at Austin
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12
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Raifman S, Baum SE, White K, Hopkins K, Ogburn T, Grossman D. Perspectives on self-managed abortion among providers in hospitals along the Texas-Mexico border. BMC Womens Health 2021; 21:132. [PMID: 33784993 PMCID: PMC8008213 DOI: 10.1186/s12905-021-01281-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/12/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Following self-managed abortion (SMA), or a pregnancy termination attempt outside of the formal health system, some patients may seek care in an emergency department. Information about provider experiences treating these patients in hospital settings on the Texas-Mexico border is lacking. METHODS The study team conducted semi-structured interviews with physicians, advanced practice clinicians, and nurses who had experience with patients presenting with early pregnancy complications in emergency and/or labor and delivery departments in five hospitals near the Texas-Mexico border. Interview questions focused on respondents' roles at the hospital, knowledge of abortion services and laws, perspectives on SMA trends, experiences treating patients presenting after SMA, and potential gaps in training related to abortion. Researchers conducted interviews in person between October 2017 and January 2018, and analyzed transcripts using a thematic analysis approach. RESULTS Most of the 54 participants interviewed said that the care provided to SMA patients was, and should be, the same as for patients presenting after miscarriage. The majority had treated a patient they suspected or confirmed had attempted SMA; typically, these cases required only expectant management and confirmation of pregnancy termination, or treatment for incomplete abortion. In rare cases, further clinical intervention was required. Many providers lacked clinical and legal knowledge about abortion, including local resources available. CONCLUSIONS Treatment provided to SMA patients is similar to that provided to patients presenting after early pregnancy loss. Lack of provider knowledge about abortion and SMA, despite their involvement with SMA patients, highlights a need for improved training.
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Affiliation(s)
- Sarah Raifman
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA.
| | - Sarah E Baum
- Ibis Reproductive Health, 1736 Franklin St, Suite 600, Oakland, CA, 94612, USA
| | - Kari White
- Steve Hicks School of Social Work, The University of Texas at Austin, 1925 San Jacinto Blvd, Stop D3500, TX, 78712, Austin, USA
| | - Kristine Hopkins
- Population Research Center, The University of Texas at Austin, 305 E. 23rd St. Stop G1800, Austin, TX, 78712-1699, USA
| | - Tony Ogburn
- University of Texas Rio Grande Valley, 2102 Treasure Hill Blvd, Harlingen, TX, 78550, USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA, 94612, USA
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Ralph L, Foster DG, Raifman S, Biggs MA, Samari G, Upadhyay U, Gerdts C, Grossman D. Prevalence of Self-Managed Abortion Among Women of Reproductive Age in the United States. JAMA Netw Open 2020; 3:e2029245. [PMID: 33337493 PMCID: PMC7749440 DOI: 10.1001/jamanetworkopen.2020.29245] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Increasing evidence indicates that people are attempting their own abortions outside the formal health care system. However, population-based estimates of experience with self-managed abortion (SMA) are lacking. OBJECTIVE To estimate the prevalence of SMA attempts among the general US population. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional survey study was fielded August 2 to 17, 2017 among English- and Spanish- speaking, self-identified female panel members from the GfK web-based KnowledgePanel. Women ages 18 to 49 years were approached to complete a 1-time survey. Data were analyzed from September 22, 2017, to March 26, 2020. MAIN OUTCOMES AND MEASURES SMA was defined as "some women may do something on their own to try to end a pregnancy without medical assistance. For example, they may get information from the internet, a friend, or family member about pills, medicine, or herbs they can take on their own, or they may do something else to try to end the pregnancy." SMA was assessed using the question, "Have you ever taken or used something on your own, without medical assistance, to try to end an unwanted pregnancy?" Participants reporting SMA were asked about methods used, reasons, and outcomes. Factors associated with SMA experience, including age, race/ethnicity, socioeconomic status, nativity, reproductive health history, and geography, were assessed. Projected lifetime SMA prevalence was estimated using discrete-time event history models, adjusting for abortion underreporting. RESULTS Among 14 151 participants invited to participate, 7022 women (49.6%) (mean [SE] age, 33.9 [9.0] years) agreed to participate. Among these, 57.4% (95% CI, 55.8%-59.0%) were non-Hispanic White, 20.2% (95% CI, 18.9%-21.5%) were Hispanic, and 13.3% (95% CI, 12.1%-14.5%) were non-Hispanic Black; and 15.1% (95% CI, 14.1%-16.3%) reported living at less than 100% federal poverty level (FPL). A total of 1.4% (95% CI, 1.0%-1.8%) of participants reported a history of attempting SMA while in the US. Projected lifetime prevalence of SMA adjusting for underreporting of abortion was 7.0% (95% CI, 5.5%-8.4%). In bivariable analyses, non-Hispanic Black (prevalence ratio [PR], 3.16; 95% CI, 1.48-6.75) and Hispanic women surveyed in English (PR, 3.74; 95% CI, 1.78-7.87) were more likely than non-Hispanic White women to have attempted SMA. Women living below 100% of the FPL were also more likely to have attempted SMA compared with those at 200% FPL or greater (PR, 3.43; 95% CI, 1.83-6.42). At most recent SMA attempt, 20.0% (95% CI, 10.9%-33.8%) of respondents used misoprostol, 29.2% (95% CI, 17.5%-44.5%) used another medication or drug, 38.4% (95% CI, 25.3%-53.4%) used herbs, and 19.8% (95% CI, 10.0%-35.5%) used physical methods. The most common reasons for SMA included that it seemed faster or easier (47.2% [95% CI, 33.0%-61.8%]) and the clinic was too expensive (25.2% [95% CI, 15.7%-37.7%]). Of all attempts, 27.8% (95% CI, 16.6%-42.7%) of respondents reported they were successful; the remainder reported they had subsequent facility-based abortions (33.6% [95% CI, 21.0%-49.0%]), continued the pregnancy (13.4% [95% CI, 7.4%-23.1%]), had a miscarriage (11.4% [95% CI, 4.2%-27.5%]), or were unsure (13.3% [95% CI, 6.8%-24.7%]). A total of 11.0% (95% CI, 5.5%-21.0%) of respondents reported a complication. CONCLUSIONS AND RELEVANCE This cross-sectional study found that approximately 7% of US women reported having attempted SMA in their lifetime, commonly with ineffective methods. These findings suggest that surveys of SMA experience among patients at abortion clinics may capture only one-third of SMA attempts. People's reasons for attempting SMA indicate that as abortion becomes more restricted, SMA may become more common.
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Affiliation(s)
- Lauren Ralph
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Diana G. Foster
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Sarah Raifman
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - M. Antonia Biggs
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Goleen Samari
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, New York
| | - Ushma Upadhyay
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | - Caitlin Gerdts
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, New York
- Ibis Reproductive Health, Oakland, California
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
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