Survey cites race, lower income, and barriers to care as risk factors

In the United States, about 7% of women reported attempting self-managed abortion (SMA)—defined as any action taken to end a pregnancy outside the formal healthcare system—in their lifetime, according to results of a cross-sectional survey published in JAMA Network Open. Further, almost 70% of these attempts were unsuccessful.

Researchers caution that, as access to abortion becomes more restricted, SMA attempts may become more commonplace, and suggests that surveys such as these may capture only one-third of SMA attempts.

“Recent evidence sheds some light on the practice of SMA in the United States, highlighting online searches for information about ways to end a pregnancy without clinical supervision, requests for medication abortion through an online telemedicine service, and preferences for SMA outside the health care system. Abortion clinics and practitioners report caring for an increasing number of individuals who have attempted SMA, and researchers speculate that the decline in the U.S. of facility-based abortion care may, at least in part, be driven by increases in abortions occurring outside of the formal health care system not captured by current measurement efforts,” wrote lead researcher Lauren Ralph, PhD, of the University of California San Francisco, Oakland, CA, and colleagues.

Ralph and colleagues conducted this cross-sectional survey of female panel members of the GfK web-based KnowledgePanel. In all, 7,022 women agreed to take a one-time survey. Mean age was 33.9 years, 57.4% were non-Hispanic white, 20.2% were Hispanic, and 13.3% were non-Hispanic Black. Finally, 15.1% reported that they were living at less than 100% federal poverty level (FPL).

Among these women, 1.4% (95% CI: 1.0%-1.8%) reported a history of attempted SMA while in the United States. After adjusting for abortion underreporting, researchers found a projected lifetime prevalence of SMA of 7.0%,

The most common reasons for SMA reported by women included that it seemed faster or easier (47.2%; 95% CI: 33.0%-61.8%) and that the clinic was too expensive (25.2%; 95% CI: 15.7%-37.7%). Less common concerns included parental consent (13.7%; 95% CI:6.8%-25.8%) and living too far away from the clinic (13.0%; 95% CI: 7.1%-22.8%).

Upon bivariable analyses, Ralph and fellow researchers found that attempted SMA was more likely in non-Hispanic Black women (prevalence ratio [PR]: 3.16; 95% CI: 1.48-6.75) and Hispanic women surveyed in English (PR: 3.74; 95% CI: 1.78-7.87) compared with non-Hispanic white women. In addition, attempted SMA was also more likely in women living below 100% of the FPL compared with those at ≥200% FPL (PR: 3.43; 95% CI: 1.83-6.42).

For their most recent SMA attempt, respondents most commonly reported using herbs (38.4%; 95% CI: 25.3%-53.4%), followed by misoprostol (20.0%; 95% CI: 10.9%-33.8%), another drug or medication outside of misoprostol (29.2%; 95% CI: 17.5%-44.5%), and physical means (19.8%; 95% CI: 10.0%-35.5%).

Only 27.8% (95% CI, 16.6%-42.7%) of SMA attempts were successful. Among those that were not, 33.6% resulted in subsequent facility-based abortions (95% CI: 21.0%-49.0%), and 13.4% of women continued the pregnancy (95% CI: 7.4%-23.1%), 11.4% had a miscarriage (95% CI: 4.2%-27.5%), and 13.3% were unsure (95% CI: 6.8%-24.7%). Finally, 11% (95% CI: 5.5%-21.0%) reported a complication requiring treatment by a physician or nurse.

“There has been much attention focused on the continued decline in the U.S. abortion rate, but that estimate only counts abortions occurring in facilities. This national cross-sectional survey study provides further evidence that SMA is occurring outside of the formal health care system, and people of color, those with lower incomes, and those who face barriers to care were more likely to attempt SMA. As abortion clinics close owing to increased abortion restrictions, a reduced demand for facility-based abortions, and a growing demand for convenience, privacy, and the comfort of self-managed abortion and self-care more broadly, it is likely that SMA will become more prevalent in the U.S., as it is today in other countries. This national estimate serves as an important baseline to track this phenomenon moving forward,” concluded Ralph and colleagues.

Limitations of this study included comparisons with past reports of abortion to national data from clinics to adjust for underreporting, underrepresentation of individuals living in poverty, not specifically listing mifepristone as a response option, exclusion of the use of emergency contraception prior to confirmation of pregnancy, low response rates for the open-ended prompt on complications, and failure to ask how respondents confirmed pregnancy.

  1. Self-managed abortions (SMA) are occurring outside of the formal healthcare system in the United States, and people of color, those with lower incomes, and those who face barriers to care were more likely to attempt SMA.

  2. SMA was successful in only slightly more than 25% of cases, and complications needing physician or nursing care occurred in 11%.

E.C. Meszaros, Contributing Writer, BreakingMED™

This survey was supported by the David and Lucile Packard Foundation, DeMartini Family Foundation, Fidelity Charitable, and an anonymous foundation.

Ralph was supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Office of Research on Women’s Health, Building Interdisciplinary Research Careers in Women’s Health, and reported no other disclosures.

Cat ID: 41

Topic ID: 83,41,585,730,41,192,150,925