Barriers to abortion care and incidence of attempted self-managed abortion among individuals searching Google for abortion care: A national prospective study

Abstract

Objective: Studies on self-managed abortion conducted at abortion clinics may exclude those facing the greatest barriers to care. We aimed to assess association of attempted self-managed abortion with reported barriers to abortion care. Study Design: We used data from the Google Ads Abortion Access Study, a prospective cohort study that recruited people searching for abortion care on Google between August 2017 and April 2018. We used a stratified sampling design recruiting by state to ensure representation from all 50 states. Participants completed an online baseline survey and follow-up 4 weeks later. We modeled the adjusted odds of attempting self-managed abortion using multivariable logistic regression, with random effects for state of residence. We assessed attempted self-managed abortion at follow-up by asking: "Did you take or try to do any of the following to try to end this pregnancy?" with a closed-ended list of methods. Results: Among 856 participants with follow-up data, 28% (95% confidence interval [95% CI]: 25%-31%) reported attempting self-managed abortion. Most common methods used were: herbs, supplements, or vitamins (52%); emergency contraception or many contraceptive pills (19%); mifepristone and/or misoprostol (18%); and abdominal or other physical trauma (18%). Participants still seeking abortion at 4 weeks were more likely to attempt self-management (33%) than those planning to carry to term (20%, p < 0.001). Reporting having to keep the abortion a secret, fearing for one's safety/well-being, needing to gather money for travel or the abortion, or living further from an abortion facility as barriers were associated with higher odds of attempts. Conclusions: Attempted self-managed abortion is higher among people facing barriers to abortion care. Implications: Reducing financial and distance barriers, such as by removing legal restrictions on abortion, could help reduce attempted self-managed abortion. Additionally, removing restrictions on telehealth for abortion could reduce attempted self-managed abortion. Efforts are needed to permanently remove United States Food and Drug Administration (FDA) regulations and state policies prohibiting telehealth for medication abortion, thereby allowing individuals to end their pregnancies without a clinic visit.

A cross-sectional study examining consideration of self-managed abortion among people seeking facility-based care in the United States

“…In this sample of 741 abortion patients, we find that as many as one in three (34%) indicate that they would consider doing something to end their pregnancy on their own if unable to obtain care at a health care facility. This figure is somewhat higher yet consistent with prior research that finds that 28% of pregnant people searching online for abortion care attempted self-managed abortion during their care seeking process [5]. Thus, our findings reinforce that a hypothetical question asking people what they might do if unable to get care at a health care facility is largely consistent with pregnant people's actual…”

“…Research has estimated that with the reversal of federal protections on [16]. Echoing prior research, we find that being uninsured, having difficulty paying for abortion, and facing one or more logistical or practical obstacles that delayed access to abortion care are associated with elevated likelihood of considering SMA [4][5][6]17]. Evidence that consideration of SMA is consistently higher for those who report obstacles related to finding or getting to a clinic or paying for care provide indication of what might happen as facility-based care becomes harder to access, and as people are forced to travel further and incur more costs for this care.…”

“…To identify covariates, we reviewed the literature to identify factors associated with considering self-managed abortion [3][4][5]. We included questions on sociodemographic characteristics, including age, race/ethnicity, health insurance status, and state of residence, specifically whether the participant had traveled from a different state to access abortion care.…”

“…In Texas, a state with many different types of restrictions on abortion, this proportion was higher, at 7% of abortion patients in 2012 and 2014 [ 3 ]. Beyond the clinic setting, research indicates that 28% of pregnant people looking for information online about where to access an abortion attempt to self-manage without medical assistance at some point during their care-seeking, and that 7% of US women of reproductive age will attempt to self-manage an abortion outside the formal health care system at some point in their lifetime [ 4 , 5 ].…”

“…Prior research offers insight into some of the factors that contribute to people’s decision to self-manage their abortion. Logistical and practical obstacles, including distance to a clinic, the need for multiple visits, and the cost of abortion and travel, figure prominently [ 1 , 4 , 5 ]. Moreover, interpersonal factors including a desire for privacy; fear of violence, threats, or negative reactions that would affect their wellbeing; and preference for a more natural experience also play a role [ 6 ].…”