Motivations and Experiences of People Seeking Medication Abortion Online in the United States

Abstract

CONTEXT:

State legislation restricting access to abortion in the clinic setting raises the possibility that an increasing number of individuals in the United States will self-manage their abortion at home. Medications sourced online represent a potential pathway to abortion self-management. Yet, very little is known about the reasons U.S. residents may seek abortion online or their experiences finding medications and information.

METHODS:

In January–June 2017, anonymous in-depth interviews were conducted with 32 people from 20 states who sought abortion medications online (30 women and two men seeking medications for their partners). Participants were asked about their (or their partners’) motivations for considering self-managed abortion, the sources of medications they identified and any other methods they considered. Transcripts were coded and analyzed according to the principles of grounded theory.

RESULTS:

The analysis revealed four key themes: Seeking abortion medications online can be a response to clinic access barriers both in states with and in ones without restrictive abortion laws; self-managed abortion can be a preference over clinical care; online options offer either information or medications, but not both; and the lack of trusted online options can delay care and lead to consideration of ineffective or unsafe alternatives.

CONCLUSION:

Current online options for abortion medications leave many important needs unmet, particularly for women who encounter barriers to obtaining clinic-based abortion services. There is a public health justification to reduce clinic access barriers and to make medication abortion that is sourced online and managed at home as safe and supported as possible.

In 2014, the abortion rate in the United States reached its lowest level since 1973—14.6 per 1,000 women aged 15–44.¹ Two main factors likely explain much of this decline. First, the number of people seeking abortion may have declined because of increased use of highly effective contraceptive methods and a contemporaneous decrease in unintended pregnancies.^1,2 Second, the number of people obtaining abortions may have declined because of a rise in state-level policies restricting access to abortion clinics.¹ Another possibility, about which there is very little data, is that more women may be managing their abortions at home without visiting a clinic;³ because any such abortions take place outside of the formal health care setting, they are not counted in the abortion rate.

The history of self-managed abortion in the United States during the pre–Roe v. Wade era is well documented,⁴ and a small body of literature provides evidence that self-managed abortion continues to occur in this country.^5,6 In 2012, Grossman and colleagues estimated that 100,000 women in Texas had ever tried to end a pregnancy without medical assistance.⁷ Studies conducted since 2010 have described women’s attempts to end pregnancies by using botanicals, coffee and soft drinks, vitamin C, medications such as aspirin and contraceptives, menstrual extraction and misoprostol obtained from shops in the United States and pharmacies across the border in Mexico.^5–7

Another potential option for abortion self-management is the use of mifepristone and misoprostol obtained through online telemedicine, or Web-based providers outside the formal health care sector. For more than a decade, online telemedicine organizations such as Women on Web (WoW) have provided medication abortion by mail to women in countries where safe abortion is restricted or unavailable.⁸ Online telemedicine abortion services are not available in the United States. However, despite a Food and Drug Administration risk evaluation and mitigation strategy specifying that mifepristone may not be sold by retail or mail-order pharmacies,⁹ mifepristone and misoprostol are available for purchase in the United States through several commercial online pharmacies.¹⁰

In 2017, Jerman et al. conducted a novel survey of individuals who sought information about self-managed abortion online, finding that 41% were under the age of 17, and that 11% had previously attempted to end an unwanted pregnancy on their own, largely through the use of herbs, vitamins, alcohol or drugs.¹¹ Given the increasingly relevant role of the Internet in the rapid exchange of goods and information for self-care,¹² it is vital to understand the clinical and public health implications of this pathway. Yet, very little is known about what motivates people to seek medication abortion self-management via the Internet or how they react to what they find. Through in-depth interviews with U.S. residents who sought abortion medications online, we address this major knowledge gap. Our objectives are to examine the reasons people in the United States seek medication abortion online and to describe their experiences finding information, support and medications.

METHODS

We conducted in-depth interviews with individuals living in the United States who sought medications online for self-managed abortion. We recruited participants from two nonprofit organizations that provide early medication abortion through online telemedicine in countries where safe abortion is restricted or unavailable: WoW and safe2choose (s2c). Although neither serves the United States, both receive requests for abortion medications from U.S. residents. People who requested medications from WoW or s2c between January and June 2017 were invited by these organizations to participate in anonymous interviews with researchers about their experiences seeking abortion medications online. Interested individuals contacted the study team for further information and to set up a convenient interview time. All individuals who were seeking abortion medications for themselves or for a partner, could complete the interview in English or Spanish, and were aged 18 or older were eligible to participate.

The principal investigator or a member of the research team conducted all interviews. To facilitate both anonymity and geographic diversity in the sample, we conducted interviews by phone; we did not retain records of any potentially identifying personal information. All participants gave verbal informed consent to participate and to be audio-recorded. We did not ask participants to reveal their real names and instead assigned each a pseudonym for use during the interview, as well as a unique study identification number for data storage purposes. To further protect anonymity, we collected very limited demographic information (age, state of residence, number of children and employment status). Participants’ states of residence were categorized as “extremely hostile,” “hostile,” “middle-ground” or “supportive,” following the state abortion policy classifications developed by Nash et al.¹³

The interview was semistructured, allowing for specific topics of interest to be addressed, while giving respondents freedom to discuss issues unique to their experience. Topics of interest were derived from current gaps in scientific knowledge on self-managed medication abortion in the United States,¹⁴ as well as fruitful lines of inquiry from other settings in which online medication abortion self-management is common.^15–17 Key topics included reasons for seeking abortion medications online; experiences seeking abortion medications online, including sources, challenges encountered, perceptions of risk and unmet needs; and alternative methods tried or considered. We conducted pilot interviews with two study participants to refine the interview guide. Interviews lasted between 35 and 65 minutes, and we offered respondents $100 in appreciation for their time.

We recorded detailed field notes after each interview, transcribed audio recordings verbatim and coded interview transcripts using an iteratively developed coding guide. All team members coded each transcript and then met weekly to resolve discrepancies, discuss emerging themes and evaluate thematic saturation. We performed thematic analysis according to the principles of grounded theory¹⁸ to identify key themes based on the range of participant experiences. Recruitment of new participants continued until little new information was obtained with each additional interview. We used Dedoose version 7.6.21 for transcript coding and qualitative data management. The University of Texas at Austin Institutional Review Board granted study approval.

RESULTS

Sample Description

Our sample consisted of 30 women and two men, who had sought abortion medications online on behalf of their female partners. Although we offered the interview in Spanish, all respondents, including several who were bilingual, preferred to be interviewed in English. Participants ranged in age from 18 to 42 and were diverse in terms of employment status and number of children (Table 1). They came from 20 states. We spoke with individuals living in both rural and urban locations, and in states with very limited abortion access, such as Louisiana and Ohio, as well as states where abortion care is more readily available, such as California and New York. Seventy-two percent of participants came from states in which the abortion policy climate was classified as extremely hostile; 6% lived in states considered hostile, 9% lived in middle-ground states and 13% lived in states that have a supportive abortion environment.

TABLE 1.

Percentage distribution of a sample of U.S. residents who sought abortion medications online, by selected characteristics, January–June 2017

Characteristic	% (N=32)
Age
18–19	9.4
20–24	40.6
25–29	28.1
30–34	9.4
35–39	9.4
40–44	3.1
Gender
Female	93.8
Male	6.3
Employment status
Employed	50.0
Student	28.1
Not employed, not a student	21.9
No. of children
0	46.9
≥1	53.1
State abortion policy environment*
Extremely hostile	71.9
Hostile	6.3
Middle-ground	9.4
Supportive	12.5
Total	100.0

^*Participants came from 13 states that were classified as extremely hostile (Alabama, Florida, Kentucky, Louisiana, Michigan, Missouri, Nebraska, Ohio, South Carolina, South Dakota, Tennessee, Texas and Virginia), one classified as hostile (Georgia), three categorized as middle-ground (Colorado, Illinois and Wyoming) and three categorized as supportive (California, New York and Montana). Notes: Percentages may not add to 100.0 because of rounding. Source: State abortion policy environment—reference 13.

At the time of the interview, the majority of the respondents or their partners (22) had already obtained an abortion from a clinic. Of those who had not, three reported experiencing pregnancy loss, two continued their pregnancy because they were unable to access clinical care and five had an upcoming clinic appointment.

Emergent Themes

Four major themes emerged among both male and female participants: Seeking abortion medications online can be a response to clinic access barriers in states with restrictive abortion laws and those without; self-managed medication abortion can be a preference over obtaining care in a clinic; current online options offer either medications or information and support, but not both; and the lack of trusted online options can delay care and lead to consideration of ineffective or unsafe alternatives.

• Barriers to clinic access.

A key reason for participants’ seeking abortion medications online was that they had encountered barriers to clinic access. A major barrier for participants living in states with restrictive laws was the high cost of clinical care. Vonda, who is 35 years old, has two children and lives in Texas, explained:

“After I’d made my decision to end the pregnancy, I didn’t know where the money could come from. It was going to have to come out of my rent money. So, for me, it was a matter of having to decide: Pay my rent or pay for the abortion…. So, I just typed in ‘abortion pills’ online, and then I looked on social media, and I found different articles. I was amazed…. I spent probably three weeks looking for and trying other methods, but none of it worked. So, I had to go back to the original option to go to the clinic, be late with the rent and pay the consequences.”

Tami, who is 32 years old, has three children and lives in Louisiana, described major logistical challenges resulting from state abortion laws:

“Originally, I had Googled abortion clinics near me, but when I started calling a bunch of them, they were like ‘No, we don’t do that.’ I found out that every clinic in Louisiana except three have been shut down. So, my next thought was ‘I need to do this on my own,’ and you can buy anything online, so my second thought was basically to order an abortion kit online…. I’m hours away from a clinic, and I would literally have to go through counseling at 8 a.m. and then stay there seven hours to speak to a doctor and get an ultrasound. And after that, I’m gonna have to have another consultation to get the abortion done, and then a third appointment to see how I am physically and emotionally. They are gonna make me listen to the heartbeat, they’re going to make me have counseling, and then I have to watch a video, and I just feel like that’s a bunch of bullshit. I know what I want, but the laws in the state make it so hard.”

Logistical and financial difficulties often intersected with concerns about the gauntlet of harassment posed by clinic protestors. As Monica, who is 23 years old, has one child and lives in Nebraska, explained:

“I’m pretty sure that the at-home stuff would be cheaper, but also I wouldn’t have to worry about all those protestors that decide to gather around clinics. I wouldn’t have them judging or bombarding me. They don’t know because they’re not in your situation. I was once against abortion. But you don’t know anything until you have to make a decision like that yourself.”

One participant, Cristina, a 25-year-old student with no children who was traveling abroad when she learned of her pregnancy, found it easier to use the WoW service in another country than to return to the United States and access a clinic in her home state of Florida:

“It would have been much harder to come back into the country and get it done here. I would not have been able to pay the $800. And that’s crazy, because where I was, abortion is illegal. And yet, when I found Women on Web, literally everything was there. They gave me all the information I needed, and they were there for me.”

But even in states with more supportive abortion laws, participants cited barriers to clinic access as reasons for considering sourcing abortion medications online. A major challenge was distance to a clinic, often combined with difficulty finding transportation. Annika, a 28-year-old with no children who lives in Colorado, explained:

“It’s 50 minutes to an hour to the nearest clinic, and I don’t have any way of getting there myself. There’s no public transport that goes there, and a taxi or Uber would just be too much on top of the cost of the procedure. So, I did a Google search and found Women on Web, but they couldn’t send the pills…so, I looked some more and found herbs and stuff, as well as pharmacy sites.”

Participants in more supportive states also encountered difficulty finding information and experienced stigma when trying to obtain abortions through general obstetrics-gynecology clinics. Marianela, who is 32, has one child and lives in California, explained:

“I found it really, really difficult to get information on what clinics provide. It’s hard having to call people directly and ask ‘Do you guys offer this?’ because there’s so much stigma attached to it. It would be so much easier if abortion were listed, just like every other service they offer in the clinic. So, I Googled ‘medical abortion.’ I came across the site [of the online telemedicine service], and it seemed like such a cool service where they would mail the medication.”

• Preference for self-management.

Although many participants cited barriers to clinic access as the reason they considered ordering medications online, others explicitly preferred the idea of managing their abortion to seeking care within the formal health care setting. Underlying these preferences were the perceived advantages of convenience, privacy, and the comfort and familiarity of one’s own home. Notably, although people living in states with more liberal abortion laws might be expected to find self-management acceptable because of greater visibility and support for abortion more generally, these attitudes were not limited to those living in liberal states. Anita, a 38-year-old woman with three children who lives in Texas, described her preference for her home environment:

“I wanted to stay at home with my children, and I read online there were pills now available that you can take at home if you’re quite early on. It would have been a much easier process, doing it at home, in the comfort of my own home. If they could have mailed me those pills, I could have done the abortion safely at home.”

Lorna, who is 22, has three children and lives in South Dakota, echoed many others when she explained that the most important factor influencing her preference was privacy:

“Privacy was a huge thing. I just really didn’t want my business out there. People don’t know my situation or circumstances, and plus it’s my business. [The online telemedicine service makes] it very safe. I just wanted something private, convenient and personal. For sure, it would definitely be the way to go if it was an option.”

For a few women, autonomy and belief in self-care played a key role in the preference for self-management. Janice, a 29-year-old Montana resident who has no children, explained:

“As a woman, you are the authority on your body. You know the best about what your body should feel like. I think I should be able to make the decision as I see fit. I’ve successfully used natural or self-care remedies for many other things in the past. That is why having an at-home abortion makes so much sense to me. I definitely think that at-home abortions should be available to all of us.”

Similarly, Wendy, who is 28 and lives in Virginia with her two children, explained that a nonmedical environment was a major factor underlying her preference for self-management:

“My first thought was ‘the abortion pill, like where can I find that?’ I just wanted to take care of this myself on my own and in my own way. I’m more of like a natural kind of person, and I try to keep it that way. But it was not that simple. There wasn’t as much access as I would have thought for something like at-home abortion. I was like, ‘Okay, I don’t really have a choice but to go to a clinic.’”

• Inadequate online options.

A key theme, regardless of participants’ motivations for seeking medication abortion online, was that the current options did not meet their needs. None of our participants had prior knowledge of either WoW or s2c, but they all had little difficulty finding these sites during their online searches. Participants noted that both organizations provided instructions for using the medications, accurate information about effectiveness and safety, and advice about how to recognize the symptoms of potentially serious complications. Many also felt reassured by the online testimonials and stories shared by others from all over the world who had completed a self-managed medication abortion. Amirah, a 20-year-old student with no children who lives in Missouri, explained:

“I felt like it was really safe and legit on the [online telemedicine] website. I read the stories from other women, and I had no one to support me in my life, so that really helped me. Once I found out they couldn’t help me, I felt so disappointed.”

Almost all of the participants also searched other sites after realizing they could not obtain medications from WoW or s2c. However, these sites tended to be online pharmacies, and participants described the information available on them as either minimal or inconsistent. Most participants expressed concerns that online pharmacy sites were scams that would take their money and send either fake pills or an unsafe product that might cause harm. Stephanie, a 20-year-old student with no children who lives in Georgia, described her concerns about online scams:

“After I found that they [the online telemedicine site] couldn’t send pills to me in the U.S., I found some other websites that sell abortion kits. I had like 25 tabs open trying to find out what’s going on. A lot of them were scams. I had to really look for the good ones. They all want to make a profit, too. What if they’re not really the drugs you need? What if it’s a scam, and they just take your money? And it’s such an easy market to do that in, because I’m just so desperate.”

Some participants became skeptical because of cumbersome or unusual billing processes. Tiffany, who is 36, has no children and lives in Tennessee, said:

“There was a handful of websites, and a couple I tried to order from, but they had overseas banks, and my bank wouldn’t work to give them money. So, I just started thinking they were sketchy as hell.”

Others were less concerned that sites might be fake or untrustworthy, but instead found the costs (around $250–300 for a mifepristone-misoprostol combination pack) out of reach. Others found that any sites they were willing to consider required a prescription before the pills could be purchased. John, a 20-year-old with no children who researched pills online to help his partner, explained:

“I tried to look at this from her angle and spent a lot of time researching. Access to the pills from a safe-looking site without a prescription was a very scarce thing.”

Very few participants mentioned concerns about the legality of obtaining medications online. When state laws were mentioned, discussion centered on their role in imposing barriers to clinic access. The greatest unmet need identified by participants was for a site that provides accurate information and interactive question-and-answer support, as WoW and s2c do, but that also provides genuine medications in the correct dose and at an affordable price. As Lorna, a 22-year-old woman with three children living in South Dakota, said:

“I had no trouble finding information I trusted about what the pills do and how to use them. Those [online telemedicine] sites also had lots about how you know if something’s not right during the process. But none of these sites could give me the pills!”

• Less effective and unsafe methods.

The lack of availability of trusted sources of abortion medications online led some to research and consider options without strong evidence of efficacy. These options included various supplements and botanicals, as Gloria, a 29-year-old South Carolina resident with no children, reported:

“I looked at home remedies online and saw that vitamin C was the big one. And then the black cohosh, and also vinegar. I was thinking the natural remedies might not be so bad because it wouldn’t be putting extra hormones or chemicals in my body.”

Others considered unsafe methods, including strenuous exercise, physical trauma, use of sharp objects, or ingestion of alcohol or household cleaning substances. As Sonia, who is 21, has no children and lives in Michigan, commented:

“No doubt I would have ended up hurting myself. I honestly would have got the hanger in there. I would have done something physical to myself to get the baby out of my body. I wouldn’t have been able to cope with carrying to term. I absolutely would not have been able to.”

Some easily came across information about these kinds of methods online. Jovita, a 23-year-old from Illinois with no children, said:

“I was really desperate. I heard you could try drinking gin. I found YouTube videos that tell you how to do it with a hanger. Once he started explaining what you’re literally doing, I was shocked. I’m not gonna lie—it made me cry. Because if you’re young and you’re desperate, it’s like, you live in this space where you will go that extreme.”

DISCUSSION

Our findings demonstrate that there are many reasons people in the United States may seek self-managed medication abortion from online sources. The financial and logistical challenges those living in states with hostile abortion policies experienced when trying to access clinical care are consistent with those described in prior work examining the effects of restrictive abortion laws.^19–21 However, those living in states with middle-ground and supportive laws also experienced access barriers, including long distances to clinics, lack of transportation and difficulty finding information. These issues echo women’s reasons for seeking medication abortion online in countries with few legislative barriers to clinical care, such as Great Britain.²² Also, we found that self-managed medication abortion can be a preference for some women, regardless of state legislative context. Factors underlying this preference included the perception of greater comfort, privacy and convenience in the home environment, and the desire to practice self-care, to engender a sense of empowerment.

Although the majority of study participants did eventually obtain care at an abortion clinic, the barriers they encountered represented serious challenges. Needing to go into debt or failing to keep up with rent or utility payments to pay for an abortion does not reflect accessible, affordable and acceptable health care. Moreover, not all who encounter such barriers are able to overcome them. Indeed, two participants in our study ended up continuing their pregnancies because they were not able to access care at a clinic.

Our study answers a call from clinicians and researchers for insight into the reasons U.S. residents may seek to source and manage medication abortion on their own.¹⁴ The firsthand narratives from across the country and the novel data we have collected lay the groundwork for larger scale survey work and for comparative work with other pathways to abortion outside of the formal health care setting, including community-based provision.²³

A major unmet need among participants seeking abortion medications online was for a trustworthy source offering both medications and information. The skepticism toward online pharmacy sites is particularly interesting in light of findings from a 2017 study in which investigators ordered abortion medications from 20 online sites: Eighteen combined mifepristone-misoprostol products were received, and 13 contained active ingredients in amounts consistent with World Health Organization recommendations for early abortion.¹⁰ These results suggest that the skepticism of our participants was warranted, since they had no prior information about the reliability of any site, and not all sites provided a product in its advertised dose. However, the possibility of ordering genuine medications in correct doses from online pharmacy sites raises two important questions: First, would the participants in our study have used one of these sites if they had known which were reliable? And second, would they have found their ensuing abortion experience acceptable? Various models of self-managed medication abortion have been shown to be safe, effective and acceptable to users in a variety of settings,²⁴ including online telemedicine in Ireland,²⁵ community-based distribution at the Thailand-Burma border,²⁶ and a service providing preabortion care with instructions about misoprostol use and postabortion follow-up in Peru.²⁷ However, the role played by the accurate instructions, medical advice and emotional support that were part of all of these models is likely to be a factor in their positive outcomes,²⁸ and such information and support may not be offered by pharmacy sites simply selling medications.

Moreover, self-management is not without legal risks. Although few participants raised concerns about legality, self-managed medication abortion has been criminalized in the United States in a variety of ways, and at least 18 women have been arrested for allegedly ending their own pregnancies.²⁹ Such arrests typically target people of color and those living in poverty. State-by-state codification of abortion law means variation in scope and type: Seven states have all-out bans on self-induced abortions, and 10 states have fetal harm laws, some of which explicitly allow prosecution of pregnant women for alleged damage to the fetus. Fifteen states have laws that are aimed at criminalizing those who provide self-induced abortion, but that, because of vague language, have also been used to criminalize people who have abortions. In addition, prosecutors may take punitive action, even in the absence of a specific statute.³⁰ Despite the potential for criminalization, one-third of respondents in the study by Jerman et al. who sought abortion medication online did not know if abortion was legal in their state of residence, suggesting that individuals who seek medication are not necessarily deterred by restrictive laws.¹¹ Groups like the SIA (Self-Induced Abortion) Legal Team, a consortium of national and state organizations that uses law and policy tools to ensure that people throughout the country can end their own pregnancy with dignity, are working to ensure that everyone in the United States has the ability to end a pregnancy free from the threat of arrest.³⁰

Limitations

The main limitation of our study is that our sample was necessarily self-selected, and so our results may have limited generalizability. Moreover, we were not able to include the experiences of those who may not have found WoW or s2c when searching online, or who found these sites but did not request help from them. However, as is the case with most qualitative studies, our goal was not to gather a representative sample of any specific population, but rather to explore the range of experiences of U.S. residents seeking medication abortion from online telemedicine sites.

Conclusion

Given that U.S. residents are seeking to source abortion medications online and manage their abortions at home, clinicians, public health practitioners and policymakers must consider what action, if any, to take. From a public health perspective, there is a harm-reduction justification for helping people to avoid resorting to ineffective or unsafe abortion methods. The unmet needs highlighted in our study support prior calls for coordinated dissemination of information about abortion medications and efforts to reduce barriers to access.^31,32 Clinicians could provide information about abortion medications and how to use them safely and correctly; doing so could play an important part in harm-reduction strategies and eventual policy change, as it famously did in Uruguay.³³ Also, giving women accurate and reliable information on abortion medications is vital for ensuring reproductive health equity: Women who are poor or who are marginalized by the health care system may be at higher risk than others of considering unsafe methods to end their pregnancies because they do not have the information or resources to pursue a safer option.

Abortion is still legal in all 50 states and Washington, DC, and from a reproductive rights perspective, removing barriers that delay or prevent the provision of care in clinics is essential to ensuring women’s right to choose abortion. The wide range of reasons participants described for seeking to manage their own medication abortion also demonstrates that no one model of abortion care best suits the needs of all those seeking services. Some women may prefer full medical supervision and support, while others may prefer an autonomous process; still others may prefer something in between. The diversity of reasons we found for seeking to self-manage supports prior work advocating for abortion medications to be available over the counter in pharmacies³⁴ and through a variety of clinical telemedicine models.^35,36 We hope that they also inspire creative thinking about how providers and public health practitioners can design and implement new models that ensure safe, supported and accessible abortion care for all.