People are turning to at-home abortion as state lawmakers attack reproductive rights and restrict clinic access across the United States, according to new research published in the American Journal of Public Health on Thursday.
The findings are the result of a 10-month study of Women on Web, a website that prescribes and sells abortion pills abroad—not in the United States. But despite that caveat, the Netherlands-based doctor who runs the site, Rebecca Gomperts, says she has received requests from American women since she began operations in 2006.
The study is based on women who inadvertently went to Women on Web rather than Aid Access, the site Gomperts later launched in March 2018 to prescribe abortion pills to women in the U.S.
After examining the 6,022 requests Women on Web received from U.S. residents between October 2017 and August 2018, a team of University of Texas researchers determined that 76 percent of them came from people living in states that are hostile to abortion. Researchers used a 2017 state policy analysis from Guttmacher Institute to determine which states were “hostile” and which were “supportive.”
The highest rate of requests came from Mississippi, where people seeking abortions must undergo state-sponsored counseling, receive an ultrasound, and wait 24 hours before a doctor can perform the procedure. Abortion is banned past the 20-week mark, save for instances when the pregnant person’s life or well-being is severely threatened, or if there are fetal anomalies. Dilation and evacuation—a common second-trimester procedure—is only permitted under similar circumstances.
Mississippi is also a state with just one remaining abortion clinic.
“The likelihood that Roe v. Wade will be overturned or severely diminished has increased with the current composition of the Supreme Court,” the paper reads. “Among the least advantaged, however, it is already clear that lack of access has compromised the right to choose to the extent that some are already seeking self-managed alternatives.”
And that includes those living in states with fewer restrictions: Americans from all 50 states have reached out to Women on Web for help ending unintended pregnancies, according to AJPH paper. What’s more, researchers found that no matter what state requests came from—a more restrictive one, like Mississippi, or a less restrictive one, like New York—people seeking out Gomperts’ services cited the same motivations: barriers to clinic access and a preference for self-managed abortion.
Experts say these findings challenge common ideas about the ease with which people in progressive states can access abortion, and prompt us to imagine new models of abortion care.
“This shows us that just because a state hasn’t made abortion hard to get doesn’t necessarily mean it’s easy to access,” said Abigail Aiken, a lead author of the study. “Even if there’s a clinic right around the corner, someone still might not be able to take time off from work, find childcare, or afford the cost of the procedure. So even in more supportive state-policy environments, there is a need for this telemedicine model.”
Previous studies have hinted at the growing interest in self-managed abortion. A February 2018 study from Guttmacher Institute found that during the month-long period between May and June 2017, shortly after President Donald Trump took office, people in the U.S. ran more than 200,000 Google searches for information related to self-managed abortion. Twenty-seven percent of them reported that information pertaining to the search term “abortion pill” was most relevant to their search. And last month, in a report about abortion rates in the U.S., Guttmacher found that the number of non-hospital facilities that reported seeing people after a self-managed abortion increased by 50 percent between 2014 and 2017. The report suggests that the decline in reported abortions could owe in part to self-managed abortions.
These findings, combined with Aiken’s research, reflect a broader cultural shift around self-managed abortion that has only occurred over the last few years. Whereas people once equated abortion outside of a traditional clinic setting with coat hangers and dangerous “back-alley” procedures, now it’s more closely associated with buying pills online and taking them at home.
There are a few reasons for the shift, Aiken said. She believes there’s a greater awareness that medication abortion is overwhelmingly safe and effective, even outside of the clinic setting, which has made self-managed abortion less stigmatized. Plus, the larger phenomenon of self-care has also normalized the practice of addressing physical and mental well-being outside of the healthcare system, as has the proliferation of telemedicine in general, which allows people to receive consultation and medication remotely.
And to anti-choice lawmakers’ chagrin, Aiken said the vast number of restrictions on abortion might be making people more open-minded about the different ways they can access the procedure. “I think a lot of hostile state laws have had a paradoxical effect: They’re intended to restrict abortion, but they’ve actually opened up a lot of different avenues for people.”
Amy Merrill, the cofounder of Plan C, a site that rates online retailers of abortion pills, sees the evolving attitudes toward self-managed abortion as an opportunity to keep chipping away at stigma, and change the narrative around the practice.
“We can start to reimagine all of these social norms around abortion methods,” Merrill said. “For so long, self-managed abortion been perceived as a risky and dangerous last resort. But over the last couple of years, we’ve reframed self-managed abortion as an empowered individual act.”
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But that doesn’t mean government officials and policymakers have caught up. Selling abortion pills online remains highly contested by the Food and Drug Administration, whose long-standing restrictions on mifepristone—one of the drugs used in medication abortion—require healthcare providers to administer the drug in person, at a clinic or hospital. Gomperts is suing the FDA for the right to continue her U.S.-based abortion pill service, Aid Access, which the agency ordered her to shut down earlier this year.
Gomperts told VICE she’s simply meeting a need: In the first year Aid Access was live, she received more than 21,000 requests from women in the U.S. In a previous study, Aiken determined that more than three-quarters of those who received abortion pills from Gomperts resided in states with restrictive abortion policies as well.
"I sincerely believe there is a human right here to be defended,” Gomperts said. “What I’m doing is in accordance with all the human rights agreements that exist, as well as the U.S. Constitution.”
Gomperts’ battle with the FDA coincides with escalating calls from physicians and reproductive health advocates, who are demanding that the agency lift the restrictions on mifepristone in order to reflect scientific consensus around the safety of the drug, and to expand abortion access.
Aiken says her team’s newest findings only make those arguments stronger. Until recently, she said, no one knew for sure how often self-managed abortion was happening, or if it was happening at all. Now there’s a growing body of evidence that shows definitively that people are self-managing their own abortions, and might even prefer it to other forms of abortion care because of the privacy, convenience, and comfort it can offer.
Aiken and her colleagues argue that the only reasonable response to their findings is to make self-managed abortion as “safe, effective, and supported as possible.”
“More people are seeking out self-managed abortion as a first choice,” she said. "There’s more than one model of ideal care for people now: Some people to have their abortion in a clinic, some prefer to do it at home. We need to meet people where they are.”
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