The nature of self-managed abortion means that, for decades, little has been known about how it’s practiced in the United States, or if it’s practiced at all. The method usually involves sourcing pills on the internet, and taking them at home, outside of a traditional clinic or hospital setting that would otherwise be able to give us an idea of how many people are receiving their healthcare services.
But that’s starting to change. New research published in the journal BMC Women’s Health shows that women in Texas—one of the states with the most restrictions on abortion—attempted to self-manage abortions because an in-clinic procedure was out of reach for them. Their reasons were many, but largely centered on cost, which was prohibitive for these patients, and the distance to the nearest clinic.
These are common barriers to abortion care, but for patients in Texas they were made worse by House Bill 2, an unconstitutional state law that went into effect in 2013, shuttering more than half of Texas clinics before it was struck down in 2016. Researchers interviewed 18 women who attempted to self-manage their abortions in Texas between 2012 and 2014, nine of whom attempted to do so after HB2 was enacted.
While the findings don’t establish a clear correlation between HB2 and the rate of self-managed abortion in the state at the time, researchers say it’s clear that increased obstacles to abortion care can inform patients’ decisions about attempting an abortion on their own.
“Whether or not a patient’s clinic closed in response to HB2, [our findings] tell us that when clinics close, the distance to the nearest clinic increases, and it exacerbates the constraints people feel when they can’t access clinic care,” said Liza Fuentes, a senior research scientist at Guttmacher Institute, and one of the lead authors of the BMC paper. “Health insurance companies also don’t cover abortion in Texas, so a patient’s ability to decide where to have an abortion depends on how much money they make.”
The patterns Fuentes and her colleagues uncovered in their research aren’t specific to Texas. In October, Abigail Aiken, an assistant professor at the University of Texas at Austin, found that the rate of requests for abortion pills to Women on the Web—a website that prescribes and sells abortion pills—was highest in Mississippi, a state with just one remaining abortion clinic.
“These findings add further weight to the evidence provided by my study that self-managed abortion is partly a response to clinic access barriers,” Aiken said on Friday, referring to Fuentes’s research. “When clinical care is put out of reach due to cost, distance and other factors, it makes sense that people will look for ways to take care of their abortion themselves.”
Where Aiken’s findings diverged from Fuentes’s, however, is when it came to the matter of preference. While Aiken similarly found that some people were driven to self-managed abortion by hostile restrictions, she also reported that some people had a preference for managing their abortions on their own—despite the legal risks—even if clinic care was an option available to them. Ending a pregnancy on one’s own can mean convenience, privacy, or being surrounded by family or friends who can offer comfort and support, according to reproductive health advocates.
“For so long, self-managed abortion has been perceived as a risky and dangerous last resort,” Amy Merrill, the cofounder of Plan C, a site that rates online abortion pill retailers, told VICE at the time. “But over the last couple of years, we’ve reframed self-managed abortion as an empowered individual act.”
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That’s not to say the stigma and misinformation around self-managed abortion has been completely squashed: Some patients told Fuentes and her colleagues that they were worried the procedure wouldn’t be safe or effective in ending their pregnancy, even though research has shown medication abortion is both safe and effective.
And though some used the abortion drug misoprostol to self-terminate—one of two drugs doctors prescribe for medication abortion—others tried to manage their abortions using herbs, vitamins, or birth control pills. Patients who tried these latter methods weren’t successful in ending their pregnancies, and ended up seeking out the clinic care that was out of reach for them to begin with; only this time they were further along in pregnancy, resulting in higher costs and greater distress after trying to self-manage for days or even weeks.
While sites like Safe2Choose and Aid Access provide people with instructions on how to self-manage abortion, Fuentes said there’s still a dearth of information on the method that can affect the way people seek care. One of the study’s biggest takeaways is that people who choose self-managed abortion should have the resources and support to do so. But just as important, for Fuentes, is that people be able to choose the method that’s right for them—not the one they’re forced to choose for lack of other options.
“No one should have to choose a method because they can’t afford the method of abortion they would like,” she said, “and they shouldn’t have to choose a method when they fear what it could mean for their health, or fear it won’t be effective.”
Correction 1/13/2020: A previous version of this story stated that some patients Fuentes interviewed decided not to pursue self-managed abortion because they were worried it wouldn't be safe or effective. In fact, these patients still attempted self-managed abortion.
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