Medication Abortion: Current State and Changing Information on University Student Health Center Websites

ABSTRACT

Background

The reversal of the federal right to abortion through the 2022 US Supreme Court ruling in Dobbs v. Jackson Women's Health Organization is changing the landscape for medication abortion access. Several states with supportive abortion laws are expanding access to medication abortion by mandating that university Student Health Centers (SHCs) provide this service. Meanwhile, other states are limiting even the information that medical providers can give to patients. In this environment, we document changing information on medication abortion on university SHC websites.

Methods

We conducted thematic content analysis for medication abortion‐related information on 549 SHC websites at 4‐year bachelor's degree granting public universities/colleges across the United States. We examined information on medication abortion at four timepoints: March 2022, August 2022, February 2023, and February 2024 using computer‐assisted software.

Results

Only 1% of the SHC websites detailed information on access to medication abortion in March 2022. By February 2024, 7.5% of SHC websites provided some information on how to access medication abortion. This increase was driven primarily by SHC websites of public colleges in California, New York, and Massachusetts, where legislation required SHC to provide medication abortion services on campuses. For universities that provided any information on medication abortion, the websites had varying details on access and responses to changing state‐level legislation and federal regulations.

Conclusions

Overall, university SHC websites are increasingly mentioning medication abortion, though mostly in states with supportive abortion laws. We anticipate more SHCs will post such information on their websites in response to legal requirements set by state legislatures.

1. Introduction

The June 2022 US Supreme Court decision in Dobbs v. Jackson Women's Health Organization, which reversed the federal right to abortion established under the 1973 Roe v. Wade decision, is expected to profoundly affect educational equity, as it enables states to impose complete abortion bans [1, 2]. One in five abortion patients reports that pursuing education and career goals was the reason they sought an abortion [3]. Annually, about 1% of sexually active college students report becoming unintentionally pregnant [4]. Though easy access to abortion has long varied by geography, the disparities in access to abortion for college students have now substantially changed as state abortion policies are diverging. Some states have now banned access to abortion altogether, even in instances of pregnancies resulting from rape or incest, or have placed prohibitive restrictions on the gestational age for abortion that limit the service to a very early gestations before most unintended pregnancies would normally be diagnosed [5]. Meanwhile, other states are increasing access to abortion through legislative initiatives to expand abortion services [6], including medication abortion provisions on college campuses.

In this changing landscape, Student Health Centers (SHCs) have an opportunity to provide their college communities with timely and accurate information on medication abortion and its accessibility. Students value increased communication about sexual health resources from SHCs on campus [7], and previous studies have found that college students faced cost, scheduling, and travel barriers to obtaining medication abortion services [8, 9, 10, 11, 12]. In 2019, these barriers persuaded the California legislature to pass the nation's first law requiring SHCs at public universities to offer medication abortion. In 2023, Massachusetts and New York followed suit and passed legislation requiring the states' public university campuses to help students access medication abortions, either directly through campus health centers or through referrals [13]. Other states, like Connecticut, have recently enacted similar though less comprehensive laws [14]. Meanwhile, Washington has mandated that any student insurance covering maternity care must also cover abortion [15]. Students were the driving force behind the legislation in California and New York. Likewise, students are advocating for similar policies within the University of Minnesota [16]. Thus, some state legislatures are asking the SHCs to take an active role in abortion care.

At the same time, other states are adding restrictions to abortion access, such as Texas, where abortion is now banned except to save the life of the pregnant person, and any citizen may sue an individual for aiding and abetting abortion provision. Since SHCs at public universities are funded by the state and SHC employees are state employees, they may feel constrained in their ability to communicate options to pregnant students.

Meanwhile, changing FDA labeling surrounding emergency contraception and legal challenges to medication abortion access may have influenced what information SHC leaders would need to communicate to students. In December 2022, the FDA ruled to require manufacturers of Plan B (a type of emergency contraception) to remove references on the contraception's packaging that claim, without evidence, that the pill prevents a fertilized egg from implanting. In a statement, the FDA reiterated that taking Plan B pills is not the same as an abortion and intended to clarify the packaging to reflect this fact [17]. Further, some have argued that there has been a long‐standing strategic campaign to conflate emergency contraception and medication abortion [18]. Likewise in early 2023, there was substantial media coverage of the Supreme Court case, FDA v. Alliance for Hippocratic Medicine, which aimed to highlight safety risks and challenge the FDA's assessment of the safety profile of medication abortion. These changes in the labeling of emergency contraception and the publicity around the Supreme Court case might affect how SHCs present information on emergency contraception and medication abortion to their students [19].

In this evolving information environment and regardless of state laws, SHCs can serve as a hub for trusted, timely, and accurate health information, including information on abortion. With the repeal of Roe v. Wade, there is increasing confusion and misinformation about access to abortions [20]. More than ever, having rapid access to accurate information on how to obtain an abortion, particularly medication abortion, is vital. Medication abortions are now the most common type of abortion [21] and in some states can be provided with out‐of‐state telemedicine services [22]. Since medication abortion must be completed within the first 10 weeks of pregnancy, providing information to help navigate access, even if the SHC does not have the legal or practical capacity to provide abortion services on‐site, is increasingly important. Previous studies find that individuals facing unwanted pregnancies who turn to online forums or resources such as Reddit for abortion information do not get all the support they need and desire more accurate legal and medical information [23]. Providing complete and accurate information on medication abortion and links to resources and qualified providers could increase support and safety for college students seeking abortions, especially as the demand for self‐managed abortions accessed through telehealth increases [24, 25, 26, 27].

2. Methods

In this study, we document the changing nature of information on medication abortion on university SHC websites across 4‐year public institutions using a computer‐assisted content analysis of the 4‐year public SHC websites. Figure 1 outlines events and the timing for data collection. We examine information on medication abortion posted on university SHC websites at four time points:

1. February 28 to March 2, 2022—before the Dobbs decision or the leaked version of the decision,

2. August 15, 2022—just after the Dobbs decision but before the implementation of a 2019 California law legislation mandating public university SHC to provide medication abortion (SB24),

3. February 1, 2023—just after the implementation of the SB24, and

4. February 21, 2024—after several other states passed legislation on medication abortion access at public universities SHCs and after the Supreme Court agreed to hear the case on maintaining access to medication abortion (FDA v. Alliance for Hippocratic Medicine).

FIGURE 1.

Timeline of data collection and relevant policy changes.

These time points allow us to understand how SHCs alter the information they present to students in response to various legislation and court actions after the Dobbs decision. Furthermore, we comment on the content of California, New York, and Massachusetts public universities' SHC websites because public universities in these states are required by law to provide medication abortion services or referrals.

3. Study Population

Our study population was the 591 4‐year bachelor's degree‐granting public universities in the United States. This list of institutions was based on a query of the Integrated Postsecondary Education Data System [28].

We used Quantitative Measures of Online Health Information (QMOHI), a newly developed open‐source software tool that gathers relevant information about keywords from SHC websites. This tool was designed to find SHC websites and then scrape information from these websites based on provided keywords. This tool first finds SHC websites for the prespecified list of universities and searches each SHC website for the given keywords [29, 30]. Because there are no standards for SHC naming, hosting structure, or website changes, the tool uses a dynamic algorithmic approach to find SHC websites using a commercial search engine (e.g., Google Custom Search API). Of the 591 4‐year bachelor's degree‐granting public universities in the United States, the tool found 549 SHC websites. Those that could not be found either did not have an SHC website (n = 33) or had a separate health system outside the university (n = 9; Native American and Veteran serving institutions have separate health systems for their students). Furthermore, two SHC sites were not found in August 2022 and February 2023 because the custom search timed out, meaning the university website took too long to respond to the custom query. There were, therefore, 547 found SHC websites in these two time periods. One site timed out in February 2024, leading to 548 found SHC websites in that period. We report results for a consistent set of 546 universities whose SHC website was found at all four time points.

3.1. Measures

University SHC websites were searched for the following words: “abortion pill,” “nonsurgical abortion,” “medication abortion,” “mifepristone,” “misoprostol,” “mifeprex,” and “RU‐486” as well as small spelling variations of these words. These terms were chosen because they represent the most common names and variations associated with medication abortion. If any of these terms were found, the software extracted the webpage link, created a local copy of a webpage, and created a second copy of the text on the webpage where it highlights the sentences near each keyword. These saved files are an archive of what was posted on the websites at a point in time and can then be reviewed offline.

Gathering information posted on SHC websites does not require interactions with human subjects, and this study was found by the IRB to be exempt from human subject review.

3.2. Analysis

The first author and a research assistant independently examined the content of each extracted webpage where the term was found and specifically the surrounding text where the word was found. Based on prior work [30, 31] and the initial reading of the webpages, a rubric of recurring information was developed. The first author and a research assistant then refined the rubric and created codes and aggregated codes into themes. The retrieved text was coded based on the rubric. All disagreements were either reconciled or adjudicated by another author.

We counted the number of university websites at each time point that had any mention of “medication abortion.” For those where it was found, we differentiated for the presence of four specific and common pieces of information: service listed, referral provided or process detailed; information meant to compare emergency contraception with medication abortion only; State laws mentioned (only post Dobbs); mentions costs of medication abortion (only post SB 24). To show the spatial distribution of universities and the main type of information posted, we map the location of universities and the information posted. To illustrate the type and changing nature of the information posted, we also provide illustrative examples of responses to the changing legal landscape.

4. Results

Across the four time points of data collection, there was a rapid (but limited) increase in the percentage of public 4‐year universities that posted any information about medication abortion on SHC websites, from 4% in 2022 to 11% in 2024.

4.1. Themes

Generally, there was minimal information available on medication abortion. For universities that provided any information on medication abortion, the details of the information varied, ranging from several detailed paragraphs about the process of how to access medication abortion on campuses or at a proximate area clinic to one sentence that states medication abortion is not the same as emergency contraception and nothing else. Some websites described medication abortion as a provided service (with or without details) or provided referral to most proximate clinics (with contact information only or details). Most other mentions only contrasted medication abortion to emergency contraception or described how abortion was not provided or covered by student health insurance. In the later data retrieval period, there is also information about state abortion laws and costs. Table 1 provides the list of the common types of information and example texts.

TABLE 1.

Common types of information on medication abortion on Student Health Center websites and example text.

Common types of information	Example text
Service listed on campus/on Campus process detailed	Medication abortion services available up to 10 weeks gestation. Medication abortion how to access To ensure that you receive timely care, please call XXX‐XXX‐XXXX to schedule a Pregnancy Testing nurse visit. You can state your reason for visit as Pregnancy Testing or Pregnancy Options if you are not yet certain how you would like to proceed, or Medication Abortion if you have already decided you would like an abortion.
Provide proximate clinic referral information (with or without detail)	“Health Services providers are also available to counsel pregnant students about their options. Women who choose to terminate a pregnancy via surgical or medical (including RU‐486) abortion will be referred to qualified specialists who have the training, facilities, and technology to provide the best possible care for our patients. Women who choose to continue a pregnancy will be referred to qualified obstetricians in the community.”
Comparison with emergency contraception only	“Plan B is available for women who have had unprotected sex within the last 72 to 120 hours. It can prevent pregnancy after having a contraception failure. The sooner Plan B is taken, the more effective it is. Plan B is Levonorgestrel 0.75 mg. It prevents fertilization and implantation. It will not work once implantation has begun. Plan B is not the abortion pill. It will not work if a woman is already pregnant. Women can obtain Plan B by making a nurse visit.”
Cost Information	“Medication abortions at SHCS are covered for students who have SHIP, meaning they pay nothing out‐of‐pocket. For students who do not have SHIP, the cost of a medication abortion at SHCS is $450 plus the cost of medication which can range from $65–$100 depending on their clinical need. If you do not have insurance, you can contact ….”
Does not provide or insurance does not cover medication abortion	“University Health Services does not offer RU‐486 Abortion Pill” On student insurance information page “General exceptions and exclusions Family planning services—other. Abortion except when the pregnancy is the result of rape or incest or if it places the woman's life in serious danger.” “Exceptions and exclusions that apply to outpatient prescription drugs Abortion drugs”

4.2. Changes Over Time

Table 2 presents the counts of SHC websites with any mention of medication abortion and the common information in the surrounding text on medication abortion over four time points. The themes presented are similar to those in Table 1 but the first two categories are collapsed, and we do not include counts of SHC that just say they do not provide or do not cover medication abortion. While the mentions of medication abortion increase over time, even by February 2024, only 11% of SHCs have any mention of medication abortion.

TABLE 2.

Counts of mentions and themes about medication abortion on university Student Health Center websites (N = 546).

	February/March 2022	August. 2022	February. 2023	February2024
Number of SHC websites with no mention of ‘medication abortion’	522	523	513	487
Number of SHC websites with any mention of ‘medication abortion’	24	23	33	60
If found, primary content
Service listed on campus/on campus process detailed/provides a proximate clinic referral information	5	7	17	41
Comparison with EC only	17	13	13	16
Mentions state laws		4	6	12
Mentions cost			4	13

4.3. March 2022 (Before the Dobbs Decision or Leaked Version of the Decision)

In March 2022, 546 SHC websites were searched. Only 24 (4%) of these SHC websites had any mention of medication abortion‐related keywords. Of the 24, only five SHC websites had information about how to access medication abortion either through the university or locally. Seventeen of the SHC websites, over 70% of those with any reference, mentioned medicated abortion only to contrast it with emergency contraception. The statements aimed to ensure that the reader knew that drugs for emergency contraception are not the same drugs as those used in medication abortion, but there was no other information on medication abortion on these websites.

4.4. August 2022 (After Dobbs Decision)

In August 2022, shortly after the reversal of Roe v. Wade, the same 546 SHC websites were searched. Only 23 (4%) of these SHC websites had any mention of medication abortion‐related keywords. The information on websites varied substantially. Three California universities provided detailed information on how to access medication abortion on the university campus. Four California universities reiterated that abortion was still legal in California and detailed that the students would be able to access medication abortion through universities (either currently or shortly), provided detailed information about how medication abortion works, and contact information to access the service locally. One Indiana university detailed information on local restrictions on access to abortion in general and the process to get an abortion (medication or otherwise) in the state. Three universities (Tennessee, Louisiana and Wisconsin) provided contact information to local organizations that provide abortions and no other details. Two California universities mentioned medication abortion as a new service that will be added shortly. One Georgia university only stated that the SHC does not offer medication abortion.

In the remaining 13 universities, 57% referenced medication abortion only to compare it with emergency contraception. There were fewer university SHC websites that only presented comparison information to emergency contraception compared to March 2022.

4.5. February 2023 (After Implementation of the California's SB24 Law)

In February 2023, 33 (6%) of the SHC websites searched had some mention of medication abortion‐related keywords. All but one of the 12 universities that listed medication abortion as a provided service or provided detailed access information were in California. The other university was in Massachusetts, where legislation similar to California's has been passed (but not yet implemented) to mandate access to medication abortion. Thirteen universities referenced medication abortion only to compare it with emergency contraception. A similar number of universities with SHC websites only presented comparisons to emergency contraception in August 2022 and February 2023.

4.6. February 2024 (After FDA Relabeling/Supreme Court Challenge and More State Mandates)

In February 2024, 60 (11%) of the SHC websites had some mention of medication abortion. Forty‐one campuses detailed how to access medication abortion, and there was a general increase in information posted about the service, with 36 (88%) of them being in California, New York, or Massachusetts. Interestingly, not all campuses in these states posted information about medication abortion. SHCs outside of the three mandated states that post information about access to medication abortion or local laws are mostly at large high‐ranking institutions within their state's public university system. Thirteen university SHC websites provide information on the costs of medication abortion.

While 24 more schools posted information on medication abortion in February 2024 compared to February 2023, four of the new schools only posted information to contrast it with emergency contraception. Among the 16 SHC websites that provided information about medication abortion solely in comparison to emergency contraception in February 2024, 10 were from the same universities that had similarly limited information in February 2022, with no updates on medication abortion.

4.7. Spatial Patterns Medication Abortion Information

Figure 2 presents the location of universities whose websites post information on medication abortion and those where the posted information is only to contrast medication abortion with emergency contraception as of February 2024. Universities in only 21 states posted any information on medication abortion, and only 12 states' SHCs had any information about access or local laws. In the other nine states, the few universities that post anything only include information to contrast medication abortion with emergency contraception. Further, a clear geographic divide is shown. SHCs in geographic southern states post information only to contrast medication abortion with emergency contraception. These SHCs are also in states with abortion bans or severe abortion restrictions.

FIGURE 2.

Universities whose Student Health Center website mentioned medication abortion, February 2024. Note: Alaska or Hawaii is not included because no schools in these states mention medication abortion.

4.8. Illustrative Qualitative Examples

We found that there was an increase in information about the local legal context of abortion, from two SHC websites immediately after the Dobbs ruling to 12 by February 2024. Below we document specific cases and language in response to Dobbs, the California, New York, and Massachusetts laws, and the FDA to highlight cases of proactive response to the changing legal landscape.

4.9. Response to Dobbs at Indiana University

On August 6, 2022, Indiana became the first state to pass a new near‐total abortion ban after the Dobbs v. Jackson decision [32]. The ban was to go into effect on September 15, 2022. Thus, in anticipation of confusion to come around abortion and medication abortion, a large Indiana research university detailed the laws and procedures for students to access abortion as of mid‐August 2022.

In the state of Indiana, only first trimester abortions (the first three months of pregnancy) are permitted in outpatient clinics. If a person is under the age of 18, parental consent or judicial bypass is required. … For medical abortions it must be no more than 70 days from the first day of your last period. Indiana law requires that a person provides consent at least 18 hours before an abortion. The clinic you contact will give you the details about informed consent. What do I need to do to have an abortion? You will need to have an intake interview, sign a consent form, give a medical history, have laboratory tests and have a physical examination…. The Student Health Center can provide all paper work that most clinics require, although we do not perform abortions at the Student Health Center. (August 2022)

The same university updated its website information by February 2023 (and 2024) to reflect the updated legal restrictions on abortion. Although Indiana had passed a total ban on abortion in August 2022, it did not go into effect until August 2023 [33].

The Student Health Center does not provide surgical or medical abortions, but we provide other reproductive health related services and can answer questions and discuss options for pregnancy and childbirth. What is Indiana's law regarding abortions? Effective September 15, 2022, abortions are permitted in cases of rape and incest, before 10‐weeks post‐fertilization; to protect the life and physical health of the mother; or if a fetus is diagnosed with a lethal anomaly. Abortions can be performed only in hospitals or outpatient centers owned by hospitals. For further information, pregnancy testing and/or support services you may contact…. (February 2023; similar in February 2024)

These passages highlight the SHC website's responsiveness to rapid legal changes and how even when abortion was banned the SHC website continued to provide neutral and detailed information.

4.10. Response to State Laws Requiring SHCs to Support Abortion Care

California's Senate Bill 24 required all public 4‐year universities' SHCs to offer medication abortion by January 2023. By February 2023, only 11 of the 32 Californias public 4‐year institutions in our sample had SHC websites that listed medication abortion as a provided service. This does not mean that the other campuses in our sample did not provide the service, but it does mean that the service was not advertised on their website in early February 2023 when SB 24 required the onset of services.

Some SHC websites cited the law to convey the information more broadly. Thus, it is possible that students can find information about their own campus services by looking at other university websites. Two examples that show SHC advertising the bill broadly are below:

Senate Bill (SB) 24 requires all CSU [California State University] campuses to offer medication abortion to students. If you receive a positive pregnancy test during an exam at the Student Wellness Center, we'll provide you with pregnancy options counseling and, if requested, medication abortion from trusted healthcare providers. (February 2023)

On October 11 [YEAR MISSING SIC], Governor Gavin Newsom signed Senate Bill 24, giving UC and CSU students access to medication abortions on‐campus. The 34 academic institutions must comply with the law by January 2023. (February 2023)

Language detailing issues of legality of abortion in Massachusetts was also posted on an SHC website in Massachusetts by 2024:

Both medical and surgical abortions are legal in Massachusetts. Medical abortions by telehealth are also legal in Massachusetts. In order to see what restrictions exist in each state, the map from the Guttmacher Institute may be useful [link] …. (February 2024)

5. Discussion

As states diverge in their policies toward abortion in the aftermath of the Dobbs decision, there is increasing confusion about access to care. Immediately after the Dobbs decision, there was an increase in internet searches on abortion, abortion pills, and contraception, especially in states with restrictive abortion policies [34]. Given the privacy concerns and the need for timely information on abortion access, SHCs can serve their students as a hub for trusted and accurate information on state regulation regarding abortion and local service provision of medication abortion. We documented the very limited but increasing information on SHC websites on medication abortion. Most of the SHCs with information on medication abortion were in California, New York, or Massachusetts, where the service or information about the service is now mandated, suggesting that new laws are impacting the information SHCs present. However, not all campuses subject to the new mandates in these states currently post information on their SHC websites. Recent research suggests that California students trust SHCs to provide medication abortion information and services [35, 36]; thus, this lack of comprehensive information is concerning.

We also highlighted the increase in information about the local legal status of abortion on SHC websites. In Indiana, where the legal restrictions on abortion were initially in flux, we found one SHC website that informed students about laws and the evolving role of SHCs across multiple time points. The information was responsive to the legal changes and explained in a neutral manner the conditions under which students can access abortion and the role of the SHC in supporting students. This detailed level of information from a trusted source is an outlier by a state institution that chose to have a proactive response [32]. Other universities did not offer the same information to their student populations. Indeed, the vast majority of SHC websites eschew the topic of medication abortion and its local accessibility altogether, even in states that have permissive abortion laws [37]. While universities offer pregnancy tests and may provide information after a pregnancy consult, they do not advertise medication abortion on their websites, so it may be difficult for students to know which services are supported or available to them ahead of time. Even in states where abortion remains accessible, SHCs may choose to self‐censor and thus limit the information available to students on their websites. Specifically, even by February 2024, California campuses that did not advertise the provision of medication abortion on campuses on their SHC websites tended to be located in the Central Valley or other rural areas of California where access to community abortion clinics is already limited [38].

We also observe that SHC websites frequently mention medication abortion only in the context of emergency contraception, emphasizing the distinction between the two. The potential for confusion might explain the need for some SHCs to reiterate the difference between emergency contraception and medication abortion on their websites. Previous studies suggest that some populations increase acceptance of emergency contraception after they are assured that it does not cause an abortion [39]. Nonetheless, without providing further information on medication abortion, the websites may inadvertently be stigmatizing medication abortion [31]. In March 2022, over 75% of references to medication abortion were actually meant to provide information for emergency contraception, that is, to differentiate it from medication abortion. By February 2024, the proportion had fallen to 27%, largely because there were references to medication abortion more generally.

A strength of our approach is that we can monitor information posted on websites across time and evaluate the rapidly changing information in response to changing abortion laws. We had data from before the Dobbs decision, which serves as a baseline for future comparisons. A key limitation of our approach is that our analysis included information on SHC websites and did not examine external links or related brochures. We also did not have information on campus campaigns targeted at residential halls or information on posted advertisements or campus flyers. SHCs may be disseminating this information through other outlets that we are not capturing. Furthermore, our focus is on 4‐year public universities, which usually have a SHC and a corresponding website, but there may be greater needs for medication abortion information for community college populations [10]. Previous studies suggest that less than half of community colleges have a SHC and those that do offer limited services, have few clinicians, and may not have a website [40].

6. Conclusion

Our study and design demonstrated that we can monitor SHC messaging around medication abortion in an efficient and scalable way. As more states pass legislation to either expand access to medication abortion (such as Connecticut) or reduce access, we can document the information students receive from their SHC websites. Given that in the 2024 elections, 10 states voted on ballot measures on abortion, either affirming or restricting abortion rights, we anticipate continuing confusion about abortion access and that more SHCs will post information on abortion and medication abortion access on their universities' SHC websites to reflect state laws. Documenting information on SHC websites in states where medication abortion is prohibited serves as a vital tool to assist university SHC staff in understanding and implementing language that can provide neutral, effective contraceptive information. By showcasing examples of such content, we can empower university staff members to navigate the challenging legal landscape around abortion. In states where SHCs must offer medication abortion services or referrals, documenting information on SHC websites can help keep SHCs accountable to the students who have been pushing for these services through state legislation.

Supporting information

Data S1. Supporting Information.