Background
A rapid increase in restrictive abortion legislation in the United States has sparked renewed interest in self-managed abortion as a response to clinic access barriers. Yet little is known about knowledge of, interest in, and experiences of self-managed medication abortion among patients who obtain abortion care in a clinic.
Objectives
We examined patients’ knowledge of, interest in, and experience with self-managed medication abortion before presenting to the clinic. We characterized the clinic- and person-level factors associated with these measures. Finally, we examined the reasons why patients express an interest in or consider self-management before attending the clinic.
Materials and Methods
We surveyed 1502 abortion patients at 3 Texas clinics in McAllen, San Antonio, and Fort Worth. All individuals seeking abortion care who could complete the survey in English or Spanish were invited to participate in an anonymous survey conducted using iPads. The overall response rate was 90%. We examined the prevalence of 4 outcome variables, both overall and separately by site: (1) knowledge of self-managed medication abortion; (2) having considered self-managing using medications before attending the clinic; (3) interest in medication self-management as an alternative to accessing care at the clinic; and (4) having sought or tried any method of self-management before attending the clinic. We used binary logistic regression models to explore the clinic- and patient-level factors associated with these outcome variables. Finally, we analyzed the reasons reported by those who had considered medication self-management before attending the clinic, as well as the reasons reported by those who would be interested in medication self-management as an alternative to in-clinic care.
Results
Among all respondents, 30% knew about abortion medications available outside the clinic setting (37% in Fort Worth, 33% in McAllen, 19% in San Antonio, P < .001), and among those with prior knowledge, 28% had considered using this option before coming to the clinic (36% in McAllen, 25% in Fort Worth, 21% in San Antonio, P = .028). Among those without prior knowledge of self-management, 39% expressed interest in this option instead of coming to the clinic (54% in San Antonio, 30% in McAllen, 29% in Fort Worth, P < .001). Overall, 13% had sought out or tried any method of self-management before presenting to the clinic (16% in McAllen and 15% in Fort Worth vs 9% in San Antonio, P < .001). Experiencing barriers to clinic access was associated with having considered medication self-management (odds ratio, 2.2; 95% confidence interval, 1.7−3.0) and with seeking or trying any method of self-management before attending the clinic (odds ratio, 1.9; 95% confidence interval, 1.3−2.7). Difficulty affording the cost of in-clinic care was the most commonly cited reason for having considering medication self-management before attending the clinic. Reasons for interest in medication self-management as an alternative to clinic care included both access barriers and preferences for the privacy and comfort of home.
Conclusion
Considering or attempting self-managed abortion may be part of the pathway to seeking in-clinic care, particularly among those experiencing access barriers. However, considerable interest in medication self-management as an alternative to the clinic also suggests a demand for more autonomous abortion care options.
A rapid increase in restrictive abortion legislation in the United States has sparked renewed interest in self-managed abortion (ie, abortion conducted outside the formal healthcare setting) as a response to clinic access barriers. , At the same time, rising interest in self-care and the role of the Internet as a go-to source of goods and services raises the possibility that some patients may prefer self-managed medication abortion over a traditional clinical service. Perhaps for these reasons, self-managed abortion is often presented as an alternative to in-clinic care. , There is evidence, for example, that some women in Texas are foregoing clinic visits and self-managing their own abortions using misoprostol (with or without mifepristone) obtained online or from pharmacies in Mexico, or using nonmedication methods such as botanicals or vitamin C.
Why was this study conducted?
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To measure knowledge of, interest in, and experiences with self-managed medication abortion among patients attending abortion clinics.
Key findings
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Of patients at 3 Texas clinics, 30% had prior knowledge of medications that could be used to self-manage an abortion. Among these, 28% had considered medication self-management before attending the clinic.
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In all, 13% of patients sought or attempted any method of self-management before attending the clinic.
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Those experiencing clinic-access barriers were more likely to have considered or attempted self-management.
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Among patients without prior knowledge of medication self-management, 39% expressed interest in this option as an alternative to in-clinic care.
What does this add to what is known?
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Considering or attempting self-managed abortion may be part of the pathway to seeking in-clinic care, particularly among those experiencing access barriers. Moreover, considerable interest in medication self-management suggests a demand for more autonomous abortion care options.
However, it is also possible that considering or attempting self-managed abortion may be part of a pathway to accessing care in the clinic setting rather than a mutually exclusive alternative. Little is known about the self-management experiences of those who ultimately do present to clinics. The few previous studies that have addressed self-managed abortion among clinic populations have focused on quantifying the lifetime prevalence of self-management. A 2014 study estimated that 1.2% of U.S. abortion clinic patients had ever attempted to self-manage using misoprostol, whereas a 2000 study of Dominican women at 3 obstetrics-gynecology clinics in New York found that 5% reported misoprostol self-use. Another small study of 318 women at Texas abortion clinics found that 7% had previously attempted to induce an abortion by any means.
In this paper, we address a different set of questions surrounding self-managed abortion. Drawing on a sample of 1502 women from 3 clinics in Texas, we seek to characterize knowledge of, interest in, and experience with self-managed abortion among women who ultimately do obtain care in a clinic, as follows: (1) what do women presenting at a clinic know about self-management, and how do they know it? (2) Among those with prior knowledge of self-management, had they considered or attempted it before coming to the clinic—and if so, why? (3) Among those without prior knowledge, what were their attitudes toward it? We also seek to examine whether these answers vary among different clinic settings, and whether they are associated with person-level attributes, such as race, ethnicity, or financial hardship. Understanding this variation provides a critical window on the landscape of self-managed abortion in the United States, and provides insight into how providers might best respond to their patients’ needs, especially in a political climate where many states continue to pass restrictive abortion legislation.
Materials and Methods
Between January 2017 and March 2018, we conducted a survey of abortion patients at 3 clinics in Texas: Whole Woman’s Health of McAllen, San Antonio, and Fort Worth. Clinic sites were chosen for geographical spread and racial/ethnic diversity to allow comparisons among settings. Each clinic has a unique local context that could plausibly affect perspectives on self-management (eg, proximity to the Texas−Mexico border), as well as a different patient mix in terms of key social and economic factors that may affect knowledge and experiences (eg, the proportion of patients who are immigrants or persons of color). Thus sampling from each site allows us to assess potential differences in knowledge of, experiences of, and interest in self-management both by clinic context and by patient-level factors. The process of accessing abortion care is similar across the 3 clinic sites in terms of cost, appointment scheduling, and state-mandated procedures including a required ultrasound, a 24-hour waiting period, and provision of counseling materials.
We aimed to survey 500 patients from each clinic (1500 patients total), with sample sizes chosen to give 80% power to detect between-site differences in proportions of 5% for outcomes with 10% prevalence or less.
At each clinic, patient educators informed patients about the opportunity to participate in the study at the end of their education session. Patients were eligible for the survey if they were seeking abortion care at the clinic and could complete the survey in English or Spanish. Patients electing to participate gave their informed consent and completed the survey on iPads. We used REDCap software to program the consent form and survey. Data were submitted in real time to University of Texas (UT)−Austin’s REDCap server; no data were stored on the iPads. The survey was anonymous and completely separate from clinics’ patient records. No potentially identifying data were collected. Depending on their experiences with self-managed abortion, patients took between 5 and 12 minutes to complete the survey. No compensation was offered. Patient educators also used the iPads to record the number of patients who declined to participate. To optimally integrate the survey with clinic workflow, we first conducted a 3-week pilot phase at each clinic. The study received human-subjects approval from the UT-Austin Institutional Review Board.
The survey included a series of “yes/no” response questions assessing patients’ knowledge of self-managed medication abortion, their interest in medication self-management, and their experiences with self-management methods before coming to the clinic. Patients were first asked whether they had heard of pills that they could buy and use at home to conduct an abortion without going to a clinic or consulting a doctor. Those who answered “no” to this first question were asked whether they would be interested in using such pills to conduct their own abortion at home, whereas those who answered “yes” were asked whether they had considered using such pills before coming to the clinic, and whether they had tried using such pills before coming to the clinic. All participants were then asked whether they had sought or tried any other ways of conducting their own abortion before coming to the clinic. Those indicating interest in medication self-management or who had considered it before coming to the clinic were also asked about their reasons why. Answer options included the following: the cost of clinical abortion care; difficulty making a clinic appointment because of work or school commitments; difficulty traveling to the clinic because of distance or lack of transportation; the need to keep an abortion private; and preference for the home environment. (Answer options were devised based on a sample of free-text responses from participants in the pilot surveys.) Participants could choose multiple reasons and could also respond through a free-text response. The free-text responses were reviewed by the study team and were included under the appropriate answer category. None of the responses required a new answer category to be devised. The survey also included a panel of demographic and clinical questions, including age, race/ethnicity, country of birth, number of children, receipt of government assistance programs (as a measure of financial hardship), knowledge of anyone else who had ever self-managed their own abortion, gestational age of the current pregnancy, and barriers encountered to accessing care at the clinic (see Supplemental Table 1 for details of each survey question). We compared patient demographic and clinical characteristics across sites using χ 2 tests.
We then analyzed several key proportions of interest, both in the overall sample and separately across sites: (1) How many patients had prior knowledge of abortion medications that could be purchased and used outside a clinic? (2) Among those with prior knowledge of these medications, how many had considered using them to self-manage their own abortions before presenting for in-clinic care? (3) Among those without prior knowledge, how many were interested in using these medications to self-manage their own abortion? (4) Regardless of prior knowledge, how many had sought or tried any method of self-management (medication or otherwise) before presenting to the clinic?
We compared these rates across clinics using χ 2 tests.
To explore the clinic- and patient-level factors associated with our self-management outcome variables, we fit 4 logistic regression models, 1 with each of the following 1 binary outcomes: (1) knowledge of medication self-management; (2) consideration of medication self-management before attending the clinic (among those with prior knowledge of medication self-management); (3) interest in medication self-management (among those without prior knowledge); and (4) having sought or tried any method of self-management before attending the clinic. Independent variables in each model included the full set of patient-level characteristics, as well as dummy variables for each clinic. To correct for multiple testing, we used the Benjamini−Hochberg procedure at a false discovery rate of 0.05.
Finally, we analyzed the reasons reported by those who had considered medication self-management before attending the clinic, as well as the reasons reported by those who would be interested in medication self-management as an alternative to in-clinic care. Each reported reason was analyzed by prevalence in the overall sample and separately by clinic site. We used Stata version 15 for all analyses (Stata Corp, College Station, TX).
Results
Overall, 1502 patients participated in the survey (n = 500 in McAllen, n = 501 in San Antonio, and n = 501 in Fort Worth). The participation rate across the 3 sites was 90% (1502 of 1661 patients approached). The vast majority of participants completed the entire survey in full; the proportion of missing data for each variable is shown in the footnotes to Tables 1 and 2 .
| Characteristic | Full sample frequency (%) (N = 1502) | McAllen frequency (%) (n = 500) | San Antonio frequency (%) (n = 501) | Fort Worth frequency (%) (n = 501) | P value for clinic differences |
|---|---|---|---|---|---|
| Age, y | |||||
| <20 | 160 (11.1) | 55 (11.4) | 50 (10.7) | 55 (11.1) | .088 |
| 20–24 | 458 (31.7) | 174 (36.1) | 148 (31.7) | 136 (27.5) | |
| 25–29 | 450 (31.2) | 134 (27.8) | 158 (33.8) | 158 (31.9) | |
| 30–34 | 236 (16.3) | 72 (14.9) | 75 (16.1) | 89 (18.0) | |
| 35+ | 140 (9.7) | 47 (9.8) | 36 (7.7) | 57 (11.5) | |
| Gestational age, wk | |||||
| <10 | 1161 (80.6) | 416 (86.3) | 379 (81.2) | 366 (74.4) | <.001 |
| 10–16 | 258 (17.9) | 62 (12.9) | 78 (16.7) | 118 (24.0) | |
| >16 | 22 (1.5) | 4 (0.8) | 10 (2.1) | 8 (1.6) | |
| Race/Ethnicity | |||||
| Black | 188 (13.1) | 1 (0.2) | 43 (9.2) | 144 (29.4) | <.001 |
| US-Born Hispanic | 768 (53.6) | 362 (75.9) | 278 (59.7) | 128 (26.1) | |
| Foreign-born Hispanic | 138 (9.6) | 80 (16.8) | 27 (5.8) | 31 (6.3) | |
| Non-Hispanic white | 271 (18.9) | 29 (6.1) | 97 (20.8) | 145 (29.6) | |
| Other | 68 (4.8) | 5 (1.1) | 21 (4.5) | 42 (8.6) | |
| No. of children | |||||
| 1+ | 971 (67.3) | 316 (65.7) | 308 (66.0) | 347 (70.2) | .236 |
| 0 | 471 (32.7) | 165 (34.3) | 159 (34.0) | 147 (29.8) | |
| Financial hardship | |||||
| Yes | 698 (49.8) | 252 (53.7) | 233 (50.9) | 213 (44.7) | .019 |
| No | 705 (50.3) | 217 (46.3) | 225 (49.1) | 263 (55.3) | |
| Barriers accessing clinical care | |||||
| Yes | 530 (41.0) | 141 (44.2) | 194 (40.2) | 195 (39.7) | .401 |
| No | 763 (59.0) | 178 (55.8) | 289 (59.8) | 296 (60.3) | |
| Knows somebody who self-managed a | |||||
| Yes | 164 (39.0) | 71 (45.2) | 25 (27.5) | 68 (39.3) | .022 |
| No | 257 (61.0) | 86 (54.8) | 66 (72.5) | 105 (60.7) |
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