By Katherine Rivlin, MD, MSc
Associate Professor, Obstetrics and Gynecology, The Ohio State University Medical Center, Columbus
Even before the Dobbs v Jackson Women’s Health Organization decision, access to safe, legal abortion within the formal healthcare system was increasingly restricted. In this context, patients may turn to self-managed abortion (SMA). SMA, also known as self-induced (or self-sourced) abortion, refers to any action that a pregnant person may take to end a pregnancy outside of the formal healthcare system. People who use SMA may avoid the formal healthcare system entirely or may partially interact with it either before, during, or after the SMA process. Clinicians should understand the course of SMA, including its overall safety, rare complications, and potential legal risks to patients. SMA can include self-sourcing the same medications used to induce a facility-based abortion, such as a combination of mifepristone and misoprostol, or misoprostol alone. It also can include the consumption of herbs, botanicals, or toxic substances, or the use of physical methods. Safety data are limited for SMA methods other than for mifepristone and misoprostol.
Prevalence and Safety
A 2020 cross-sectional survey estimated a 7% lifetime prevalence of SMA in the United States.1 Black and Hispanic patients are more likely to attempt SMA (reflecting the effects of systemic racism on who seeks medical care within the formal healthcare system), as are those living below 100% of the federal poverty line. People living in states with abortion restrictions also are more likely to attempt SMA.2 A patient may choose to self-manage their abortion because of barriers to seeking a facility-based abortion, such as cost, distance to the clinic, or legal restrictions. People also report that SMA is easier and more convenient, and that it affords more privacy and autonomy.3 SMA has been around since before Roe v Wade legalized abortion in the United States in 1973. During that time, although some SMA was safe, people also used unsafe or invasive SMA methods, which contributes to the widespread understanding of SMA as dangerous. The “coat hanger” image is a ubiquitous but inaccurate image of modern SMA. With the availability of medications to induce abortion, particularly misoprostol, the safety and efficacy of SMA has improved dramatically, and associated abortion-related morbidity and mortality has declined.
In a prospective cohort study, SMA using either a com-bination of mifepristone and misoprostol or misoprostol alone was noninferior to clinic-based medication abortion up to 63 days’ gestation.4 In the United States, the approved regimen of medication abortion includes 200 mg of oral mifepristone followed by 800 mcg of buccal misoprostol 24-48 hours later. The World Health Organization recommends the same regimen for self-managing an abortion, and to consider its use up to 12 weeks of gestation.5 For those using misoprostol only, a regimen of 800 mcg buccally every three hours can be used up to three doses until the pregnancy expels. Efficacy of SMA using misoprostol alone appears similar to clinic-based regimens.6
Eligibility and Assistance
SMA requires self-assessment to determine eligibility, access to abortion medications, and self-assessment of abortion completion. To determine individual eligibility, people can estimate gestation using the last menstrual period alone or using a series of self-reported pregnancy dating questions, which may improve accuracy.7 Online pregnancy calculators also can be helpful. To access abortion medications, people may look to organizations and resources that function outside of the formal healthcare system. The website Plan C (https://www.plancpills.org) provides information on obtaining abortion pills both in person and online for people living in the United States. Aid Access (https://aidaccess.org/en/) is a global service that provides SMA information, such as assistance in evaluating SMA eligibility, and can send abortion medication to those who are eligible.
To determine abortion completion, checklists of symptoms during and after the abortion process as well as home urine pregnancy tests can be helpful. Checklists can ask about cramping, bleeding, and passage of clots following the administration of misoprostol, followed by the resolution of pregnancy symptoms. Checklists and home pregnancy tests can guide patients to seek in-person care should it become necessary.
Harm Reduction Approach
Healthcare providers should use a harm reduction approach to care when interacting with patients considering or attempting SMA. Harm reduction models of care seek to reduce the negative consequences of a criminalized behavior when healthcare providers are unable to intervene. It centers on patient autonomy rather than the elimination of the behavior. When abortion is severely restricted, a harm reduction approach improves patient outcomes and reduces abortion-associated morbidity and mortality.8 Data from Uruguay’s harm reduction program, implemented when abortion was criminalized across the country, reduced maternal mortality from unsafe abortion from 37.5% to 8.1% over a decade.9
In a U.S.-based harm reduction approach to abortion care, providers can intervene prior to and following the SMA process. For people considering SMA, providers can provide nondirective and nonjudgmental counseling about pregnancy options, provide appropriate counseling on the safest, most effective SMA methods, and assist individuals in eligibility self-assessment by confirming gestational dating and assessing for contraindications to medication abortion. This anticipatory guidance may enable people to feel safe seeking post-abortion care should concerns arise. For those presenting after SMA, providers should be prepared to intervene to treat complications and to provide post-abortion care, including contraception counseling when patients desire it. Harm reduction models should be shared broadly across the healthcare system, since emergency medicine and primary care clinicians are likely to interact with people considering or attempting SMA.
Legal Risks
Although the medical risks of SMA are rare, legal risks may be much higher. SMA currently is not criminalized in most states, but several states have laws that could be used to prosecute people attempting or assisting with SMA. Unfortunately, in situations where SMA has been criminalized in the United States, unnecessary reports to the police by clinicians have played a significant role.10 It is vital that clinicians consider what information must be documented in the electronic medical record for patient care and what information only exposes patients to risk.
A harm reduction approach to caring for patients attempting SMA involves seeking only the information that is necessary to provide compassionate and nonjudgmental care. This centers on patient autonomy and avoids risks of criminalization. In most cases of SMA, the necessary care is identical to the care required to manage a miscarriage. Determining and documenting whether SMA occurred is unnecessary. If clinicians are in a situation of mandatory reporting, they should ensure that patients are aware of what information is reportable before requesting it. The Society of Family Planning, the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, and the American Public Health Association all strongly oppose the criminalization of SMA.10
Clinicians must advocate for the repeal of laws used to criminalize patients for SMA. They also must be thoughtful in how they discuss SMA. Rather than propagating coat hanger imagery, which inaccurately portrays SMA as dangerous, clinicians should discuss SMA’s safety and the importance of a harm reduction model and provide SMA resources and anticipatory guidance. Hospitals should design and implement policies that protect clinicians and allow them to engage in harm reduction models. Such policies, in turn, protect patients from medical and legal risk and may improve patient trust in the formal healthcare system. Beyond the devastating personal consequences to individuals, criminalization of SMA makes everyone less safe, as it violates the clinician-patient relationship and makes people less likely to seek medical help when they need it.
REFERENCES
- Ralph L, et al. Prevalence of self-managed abortion among women of reproductive age in the United States. JAMA Netw Open 2020;3:e2029245.
- Upadhyay UD, et al. Barriers to abortion care and incidence of attempted self-managed abortion among individuals searching Google for abortion care: A national prospective study. Contraception 2022;106:49-56.
- Aiken ARA, et al. Motivations and experiences of people seeking medication abortion online in the United States. Perspect Sex Reprod Health 2018;50:157-163.
- Moseson H, et al. Effectiveness of self-managed medication abortion with accompaniment support in Argentina and Nigeria (SAFE): A prospective, observational cohort study and non-inferiority analysis with historical controls. Lancet Glob Health 2022;10:e105-e113.
- World Health Organization. Abortion care guideline. Published March 8, 2022. https://www.who.int/publications/i/item/9789240039483
- Raymond EG, et al. Efficacy of misoprostol alone for first-trimester medical abortion: A systematic review. Obstet Gynecol 2019;133:137-147.
- Ralph LJ, et al. Accuracy of self-assessment of gestational duration among people seeking abortion. Am J Obstet Gynecol 2022;226:710.e1-710.e21.
- Tasset J, et al. Harm reduction for abortion in the United States. Obstet Gynecol 2018;131:621-624.
- Briozzo L, et al. Overall and abortion-related maternal mortality rates in Uruguay over the past 25 years and their association with policies and actions aimed at protecting women’s rights. Int J Gynaecol Obstet 2016;134:S20-S23.
- Verma N, et al. Society of Family Planning interim clinical recommendations: Self-managed abortion. Society of Family Planning. Updated Sept. 8, 2022. https://www.societyfp.org/wp-content/uploads/2022/06/SFP-Interim-Recommendation-Self-managed-abortion-09.08.22.pdf
