Requests for Self-managed Medication Abortion Provided Using Online Telemedicine in 30 US States Before and After the Dobbs v Jackson Women’s Health Organization Decision

Abstract

This study assesses changes in online telemedicine requests to self-manage abortions with medications before vs after the Dobbs v Jackson Women’s Health Organization Supreme Court decision overturning Roe v Wade.

On June 24, 2022, the US Supreme Court decision in Dobbs v Jackson Women’s Health Organization overturned Roe v Wade, creating a patchwork of state abortion laws.¹ We assessed changes in online telemedicine requests to self-manage abortions with medications before vs after this decision.

Methods

The nonprofit Aid Access² is the only online telemedicine service providing self-managed medication abortion (abortion conducted outside the formal health care setting) in the US. We analyzed anonymized requests for medications to the service in 3 periods: baseline (September 1, 2021, to May 1, 2022); after the Dobbs decision was leaked but before its formal announcement (May 2 to June 23, 2022); and after Dobbs was formally announced (June 24 to August 31, 2022). We omitted requests for advance provision of medications before pregnancy occurred and requests from 20 states where Aid Access provides telemedicine abortion within the formal health care setting. We categorized the remaining states as follows: (1) 12 states that banned abortion following the decision (including 3 where bans were enjoined but then reinstated during the study period); (2) 5 states that implemented bans after 6 weeks’ gestation; (3) 10 states that did not enact bans but indicated that bans or restrictions are likely; and (4) 3 states with no current or planned legal changes.³ During each period, we examined the overall rate of requests and, for each state separately, the mean rate of requests per 100 000 female residents aged 15 to 44 years.⁴ All requestors shared the reasons for their request from a list of responses or using open-ended text. We examined changes in requestors’ stated reasons for accessing the service before and after the formal announcement.

P values were calculated using t tests and tests for equality of proportions with statistical significance set at P < .05 (2-sided). We used R version 4.1.1 (R Foundation) for data analysis. Requestors consented to anonymous use of their data for research when making a request. The University of Texas at Austin institutional review board approved the study.

Results

Over the study period, the telemedicine service received 42 259 requests from 30 states. Mean daily requests were 82.6 (95% CI, 80.9-85.8) during the baseline period, 137.1 (95% CI, 128.8-145.5) following the leak (P < .001), and 213.7 (95% CI, 191.5-235.8) following the formal announcement (P < .001). Every state, regardless of abortion policy, showed a higher request rate during the periods after the leak and after the formal decision announcement, with the largest increases observed in states enacting total bans (Figure). The 5 states with the largest increases per week per 100 000 female residents from baseline to after the formal decision were Louisiana (from 5.6 to 14.9), Mississippi (from 2.2 to 7.8), Arkansas (from 2.1 to 7.1), Alabama (from 1.9 to 6.2), and Oklahoma (from 1.9 to 6.0).

Figure. Requests for Self-managed Medication Abortion: Before and After the Dobbs v Jackson Women’s Health Organization Decision.

Weekly requests by state for medication abortion over 3 periods, stratified by state-level abortion policy after the Dobbs decision. “Leak” indicates the unofficial, publicly shared draft of the majority Supreme Court opinion. Per-capita rates were calculated as weekly average requests per 100 000 female residents aged 15 to 44 years. Time periods: before leak, September 1, 2021, to May 1, 2022; after leak, May 2 to June 23, 2022; after decision, June 24 to August 31, 2022.

In states with total bans, 31.4% of requestors cited “current abortion restrictions” as a reason for accessing the service at baseline vs 62.4% after the decision (difference, 31.0%; 95% CI, 29.7%-32.4%; P < .001) (Table). In states with 6-week bans, 3.9% of requestors cited that 6-week ban at baseline vs 28.9% after the decision (difference, 25.0%; 95% CI, 23.3%-26.8%; P < .001). In states where future bans are likely, 12.5% of requestors cited “possible future legal restrictions” at baseline vs 35.5% after the decision (difference, 23.0%; 95% CI, 21.1%-25.0%; P < .001). In states with no planned changes, no statistically significant changes in the proportions of requestors citing any of these reasons were reported.

Table. Requestors’ Stated Reasons for Requesting Self-managed Medication Abortion by State Abortion Policy Category at Baseline and After the Formal Dobbs v Jackson Women’s Health Organization Decision^a.

Reason for request, by state’s abortion policy after Dobbs decision	Baseline (September 1, 2021, to May 1, 2022), %	After decision (June 24 to August 31, 2022), %	Difference, after decision − baseline, % (95% CI)
No ban likely
Current legal restrictions	3.2	9.2	6.0 (−1.6 to 13.6)
Possible future restrictions	11.5	14.9	3.4 (−6.5 to 13.3)
6-Week abortion ban	0.6	4.6	4.0 (−1.5 to 9.4)
Likely or possible ban
Current legal restrictions	8.6	25.5	16.9 (15.2 to 18.7)
Possible future restrictions	12.5	35.5	23.0 (21.1 to 25.0)
6-Week abortion ban	2.3	4	1.7 (0.1 to 2.5)
6-Week ban
Current legal restrictions	10.7	46.6	35.9 (33.8 to 38.0)
Possible future restrictions	14	35.9	21.9 (19.8 to 24.0)
6-Week abortion ban	3.9	28.9	25.0 (23.3 to 26.8)
Total ban
Current legal restrictions	31.4	62.4	31.0 (29.7 to 32.4)
Possible future restrictions	22.8	33.2	10.4 (9.1 to 11.7)
6-Week abortion ban	26.6	20.5	−6.1 (−7.4 to −5.0)

^a All 42 259 requestors provided at least 1 reason for making their request to the service. Requestors could select as many reasons as they thought applied to their situation. The data in the table refer to the percentage of requestors citing each reason. Only reasons relating to state laws/legal restrictions are shown.

Discussion

Requests for self-managed abortion through online telemedicine increased following Dobbs. The largest increases occurred in states that implemented total bans, with requestors frequently citing these bans as their motivation for accessing the service. Increases were also observed in states where the legal status of abortion did not immediately change. Possible explanations include increased awareness of the service, confusion about state laws, and disruption to in-clinic services following increases in out-of-state patients. Findings support prior research that limiting abortion within the formal health care setting is associated with more self-managed abortions.⁵

Study limitations include that the sample is not representative of all people who seek abortions; those who self-manage may systematically differ, for example by being more likely to live with financial hardship or in rural areas.² Also, the sample may not be representative of all people who self-manage abortions, as abortions from only 30 states and 1 pathway to self-management were included.

Section Editors: Jody W. Zylke, MD, Deputy Editor; Kristin Walter, MD, Senior Editor.