By Abigail R. A. Aiken / Special To The Washington Post
This has been the worst legislative year for U.S. abortion rights on record. More restrictions have been passed in 2021 than in any year since Roe v. Wade.
In the most extreme case, Texas banned abortions after six weeks of pregnancy. The Supreme Court may be poised to overturn Roe. Yet despite moves by some states to make abortions harder to obtain from a clinic, an increasing number of people are using abortion pills at home.
Medication abortion, which involves two pills taken 24 hours apart to terminate pregnancies up to 10 weeks, is one of the simplest and safest procedures in all of medicine. The pills cause bleeding and cramping. Afterward, a simple pregnancy test can confirm that the pills have worked. But for many in the United States, obtaining these pills is an obstacle course, thanks to a rash of state-level restrictions blocking clinic access. With no federal and little state funding available, the price tag of $300 to $800 often falls on the individual.
Ironically, it is exactly these restrictions that have sparked innovation in where and how people access the medication. When laws prohibit in-clinic access, people often take matters into their own hands and self-manage their abortions outside of formal health care settings. Indeed, some people prefer self-management; it offers convenience, privacy and an alternative for some who may distrust the formal health care system. A 2020 study suggests that approximately 7 percent of U.S. women have attempted a self-managed abortion — in any form, including pills — in their lifetime.
Though the historical record indicates that people in North America have managed their own abortions for centuries, evidence also suggests that self-managed abortion using pills has been on the rise in recent years. In 2018, an Amsterdam-based doctor launched Aid Access, the first online telemedicine service to provide self-managed medication abortion to people living in the United States. The service operates entirely outside of the formal health care system and outside of Food and Drug Administration regulations, which ban mifepristone imports. Aid Access serves people in all 50 states, providing mifepristone and misoprostol up to 10 weeks of pregnancy for home use. People make a donation of around $110 and fill out an online consultation form, which is reviewed by a doctor, and then medications are mailed to their home. A help desk is available for information and support. Testifying to the scale of demand, the service has received 57,506 requests during its first two years of operation.
At-home medication abortion also could become standard within the formal health-care system. Since its approval in 2000, mifepristone has been subject to an FDA policy that imposes restrictions on its use, including a requirement for in-person dispensing. Health-care professionals have long pointed out that this policy is not based on scientific evidence. But the emergence of covid-19 brought urgency to changing it, since in-person care increases transmission risk. After a court petition led by reproductive rights and justice groups, the in-person dispensing requirement on mifepristone was suspended for the duration of the pandemic. In many states, this decision paved the way for at-home medication abortion services, in which clinic-based providers can teleconsult with their patients and then mail them their medications. What once seemed impossible is now a reality for many across the country.
These new models are a major step forward for patient-centered care. While some will still prefer or need in-person care, at-home models offer increased flexibility with no decrease in safety. Colleagues and I recently conducted a study of over 52,000 medication abortions provided in the United Kingdom using an at-home telemedicine model: We found that 98.8 percent of people ended their pregnancies without any further intervention from a doctor, and fewer than 0.02 percent experienced any serious adverse event. These outcomes are as good as those under traditional in-person provision. Moreover, 96 precent of patients surveyed reported a positive experience with the at-home model.
The greatest barrier to the mainstreaming of at-home medication abortion is not the medical establishment or the preferences of patients, but politics: Nineteen states have laws explicitly prohibiting the use of telemedicine for medication abortion or laws requiring medications to be dispensed in the presence of a physician. It may come as no surprise, however, that these same states also have the highest numbers of people self-managing outside the formal health care system using Aid Access. These abortions, despite the lack of consultation with a doctor, are also extremely safe and effective. The biggest risks involved are legal, not medical. Even in the absence of many state laws explicitly criminalizing the practice, some jurisdictions have unjustly prosecuted people for alleged self-management. The greatest burdens fall on those who face heightened surveillance and historically unequal treatment, including people living in poverty and people of color.
The FDA recently announced a full review of its restrictions on mifepristone, opening the door to a future where one option for medication abortion could be as simple as walking into a pharmacy and picking up pills. Will we accept a two-tiered system based on ZIP code, where some have access to at-home services through the health-care system while others must risk criminalization, or can we envision a future where a full spectrum of options are equally accessible to all? At-home medication abortion is here to stay. The question is: in what form?
Abigail R. A. Aiken is an assistant professor at the LBJ School of Public Affairs at the University of Texas.
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