What Motivates People in the United States to Seek Medication Abortion Pills Outside of the Clinic Setting?

Reprinted from the UT Austin Texas Population Center.

Introduction

For those wanting to end a pregnancy, the cost of in-clinic abortion care can be a significant barrier. The average cost of medication abortion (abortion with pills) in a clinic is $551. The majority of people pay for their abortion out of pocket. Abortion funds help cover some of the in-clinic abortion costs for some people, but they are not able to assist everyone in need of financial help. Many people who struggle to pay for their abortion delay or forgo paying bills such as rent, food, or utilities. The lack of affordable access to abortion care in the United States is linked to ongoing personal financial distress, debt, and poor credit.

Restrictive abortion laws in the U.S. add further economic burdens to people who would like to obtain an abortion in a clinic. At the federal level, the Hyde Amendment bans insurance plans that use federal funds, such as Medicaid, from paying for abortion care. Restrictions at the state level, such as mandatory waiting periods and multiple visit requirements, add costly appointments to the in-clinic experience. Restrictions aimed at abortion facilities, such as requiring that they be fitted out like mini-hospitals, have closed many clinics. These closures have placed additional financial burdens on people seeking in-clinic abortion care by necessitating out-of-pocket costs such as childcare, lodging, transportation, and lost wages.

As abortion has become increasingly restricted, researchers have found evidence that some people in the U.S. forgo the clinic altogether. Instead, they manage their abortion on their own, outside of the formal healthcare setting. While some people have attempted abortion self-management with methods such as herbs, teas, homeopathic remedies, or self-harm, the growth of information-sharing on the internet has brought expanded access to the abortion medications mifepristone and misoprostol.

In 2018, Aid Access became the first service to provide self-managed medication abortion in the U.S. via an online telemedicine service.

This brief reports on a recent study of 80 U.S.-based people who self-managed their abortion using medications obtained from Aid Access. The in-depth interviews, conducted anonymously, sought to understand the role that socioeconomic factors play in an individual’s decision to self-manage an abortion using online telemedicine.

Key Findings

The main reason why participants sought abortion care via online telemedicine was the unaffordable cost of in-clinic abortion.
Restrictive state abortion policies, on top of personal financial hardship, made it impossible for participants to access abortion care in a clinic.
For participants with children, their family’s economic wellbeing motivated the decision both to seek an abortion and to do so via online telemedicine.
Medication abortion provided via online telemedicine offered an affordable alternative to the high costs of in-clinic abortion care. However, for some, accessing pills at no cost or a reduced cost was necessary because the suggested donation of $90 still posed a financial burden. See representative quotes below.

The high costs of in-clinic abortion care, made more difficult by restrictive abortion policies – along with balancing the needs of existing children – motivated people to seek medication abortion via online telemedicine

Note: Quotes have been edited for brevity.

Policy Implications

To improve people’s access to abortion in the United States, particularly for those with low incomes, policymakers can make policy changes to improve the availability and affordability of telemedicine for medication abortion. They can also make policy changes to improve Medicaid and private insurance coverage for clinic-based abortion.

The Food and Drug Administration regulates the abortion medication mifepristone by a Risk Evaluation and Mitigation Strategy (REMS). This regulation requires that providers must register as certified prescribers and that mifepristone be dispensed directly from a healthcare facility, rather than a retail pharmacy. Despite a growing body of evidence demonstrating that the existing restrictions are medically unnecessary and overly burdensome, the REMS remains.

Removing the REMS classification would increase delivery of medication abortion. In the 31 states that do not ban the provision of abortion by telemedicine, providers could implement flexible service delivery models. Providers could conduct the pre-abortion appointment via telemedicine, and partner with mail-order pharmacies to ship the medications directly to the patient or allow for pick-up at a retail pharmacy. This would allow patients to reduce their trips to the clinic, especially in states with laws requiring multiple trips for pre-abortion ultrasounds or state-mandated counseling. Removing the REMS and making the medications available by mail or pharmacy pick-up would mean fewer trips to the clinic and alleviate some of the burdens such as paying for transportation, childcare, or taking time off of work.

In addition to removing the REMS, Congress could expand affordable abortion access by passing the Equal Access to Abortion Coverage in Health Insurance, or EACH Woman Act. This legislation would repeal the Hyde Amendment and ensure coverage for abortion through all government-sponsored health insurance plans. It would also prohibit politicians from interfering with private health insurance plans that offer coverage for abortion. This would substantially expand insurance coverage for abortion care and would increase the ability of more people, particularly people with low incomes, to obtain an abortion from a medical provider.

Evidence suggests that self-managed abortion will continue, especially as new abortion restrictions are enacted, such as Texas’ recent law prohibiting abortions at around six weeks’ gestation. For people living in the 19 states that prohibit the provision of abortion by telemedicine, self-managed abortion options are especially important.

However, potential legal risks exist for people who self-manage their abortion. Arizona, Oklahoma, Nevada, South Carolina and Delaware have all passed laws criminalizing self-managed abortion, and people in these states could be prosecuted. Moreover, people with few economic resources or those who are members of groups historically criminalized in the U.S. may be at even greater risk of prosecution. Policymakers could eliminate these risks by repealing laws that criminalize self-managed abortion.

Reference

Johnson, D.M., Madera, M., Gomperts, R. & Aiken, A.R.A., The economic context of pursuing online medication abortion in the United States. (2021). SSM – Qualitative Research in Health. https://doi.org/10.1016/j.ssmqr.2021.100003.

Suggested Citation

Johnson, D.M., Madera, M., Gomperts, R. & Aiken, A.R.A. (2021). What motivates people in the United States to seek medication abortion pills outside of the clinic setting? PRC Research Brief 6(11). DOI: 10.15781/xm1d-t214.

About the Authors

Dana M. Johnson, danajohnson@utexas.edu is a PhD candidate in public policy and demography and an NICHD predoctoral trainee in the Population Research Center at The University of Texas.

Melissa Madera is a senior project manager and research fellow for Project SANA (The Self-Managed Abortion Needs Assessment Project).

Rebecca Gomperts is the founder and director of Women on Waves, Women on Web and Aid Access.

Abigail Aiken is an associate professor in the Lyndon B. Johnson School of Public Affairs and a PRC faculty scholar at The University of Texas at Austin.

Acknowledgements

This study was funded by the Society of Family Planning (SFP), Grant # SFPRF12-MA1 and received infrastructure support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Grant # P2CHD042849). Neither source of funding had any involvement in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; the preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.