Abortion access in the United States has broadened beyond brick-and-mortar health centers to include increasing numbers of telemedicine abortions, self-managed abortions, and travel over long distances to obtain in-person abortion care. Health care workers in abortion-restrictive settings should create safe environments for people with pregnancy complications and for those who need post-abortion care. Clinicians should be familiar with common post-abortion patient concerns, expected symptoms, management of complications, and confirmation of abortion completion.
Key points
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Medication abortion is equally safe and effective whether the medications are obtained via in-person visit or telehealth.
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Procedural abortion is impressively safe; people traveling to obtain abortion typically require minimal to no routine follow-up.
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Currently, no laws in any state require physicians to report abortions or suspected abortions, whether self-managed or not.
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Medical care for miscarriage, pregnancy complications, or post-abortion care is not abortion and should be offered routinely; no laws in any state prevent clinicians from providing this care.
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A negative pregnancy test is not necessary to initiate post-abortion contraception if the medical history indicates a reasonable certainty that the individual is not pregnant.
Background
The legal status of abortion in the United States changed dramatically in September 2021, when Texas became the first state to enforce an abortion ban at 6 weeks; thousands of Texas residents traveled to other states to obtain needed abortion care. In June 2022, the US. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization ( Dobbs ) rescinded the constitutionally-protected right to abortion and reverted abortion policies to each state; partial or total abortion bans expanded beyond Texas to many other states. The Dobbs decision and subsequent state bans have created ongoing confusion about the legality of abortion and by mid-2023 the number of people traveling out-of-state to access abortion nearly doubled. The rapid increase in telemedicine resources during the COVID-19 pandemic, coupled with the Dobbs decision, has broadened abortion access in the United States beyond brick-and-mortar health centers to include increasing numbers of telemedicine abortions and self-managed abortions. ,
People rarely require follow-up care after procedural abortion. Procedural abortion, most commonly uterine evacuation achieved via dilation and curettage or dilation and evacuation, is safer than most outpatient procedures. , Uterine evacuation is one of the most common procedures performed in standard obstetric and gynecologic care because it is indicated for a number of diagnoses, including abortion and early pregnancy loss. Clinicians providing obstetric and/or gynecologic follow-up care, including emergency care, should be familiar with common post-procedure concerns and complications.
Medication abortion in the United States most commonly entails a combination of mifepristone, a selective progesterone receptor modulator, and misoprostol, a prostaglandin E1 analog; misoprostol alone can be used if mifepristone is not available. , People obtain these medications from physical health centers, telemedicine appointments, mail-order services, or other services that operate outside the formal health care system.
Regardless of the origin of the medications, the pregnancy usually expels outside a health care setting, often at home. As of 2024, medication abortion obtained through telehealth accounted for at least 20% of all abortions nationally. Although in-person evaluation is not necessary to confirm abortion completion, clinicians should be familiar with expected symptoms and common patient concerns after medication abortion.
Discussion
History of Self-Managed Abortion and Its Criminalization
Throughout history, people have diagnosed their pregnancies and taken actions to end those pregnancies without interacting with the formal health care system. Midwives, birth workers, and women themselves historically used a variety of methods and procedures to induce abortion. The medical community largely ignored this practice until the formation of the American Medical Association (AMA) in 1847. The AMA began the first push to separate abortion from obstetric care and lobbied to make abortion a criminal offense except in rare, physician-approved cases. This move to take reproductive health care out of the community laid the groundwork for othering abortion care, making abortion separate from mainstream health care and consequently more easily legislated. By 1910 abortion was illegal in every state.
As the AMA lobbied to outlaw abortion, Congress created a series of provisions in federal law known as the Comstock Act of 1873 that additionally limited the distribution of contraceptives, abortifacients, and related educational materials. Throughout the 1900s abortion laws focused mainly on persecuting women who attempted abortion, as well as providers offering this care. With the rise of the women’s liberation movement in the 1950s and 1960s the number of people pursuing abortion in the US also increased, despite abortion remaining mostly illegal across the country.
As few options for legal abortion existed in that era, women turned to alternative abortion methods. Some relied on self-instrumentation or use of substances to induce abortion. The subsequent rise in severe morbidity and mortality led to a public health crisis. Many urban medical centers opened septic abortion wards in response to the number of critically ill patients presenting after unsafe abortion. Public discourse about self-managed abortion often references this period of highly prevalent unsafe abortion.
When abortion became legal across the United States following the 1973 US Supreme Court decision in Roe v. Wade , abortion procedures became more standardized and abortion complication rates fell dramatically. Legalizing abortion removed 1 large barrier to abortion access; financial and logistical barriers remained and self-managed abortion continued, although likely at lower rates.
Medication abortion was a breakthrough for safe and effective self-managed abortion. Misoprostol regimens for medication abortion became common as early as 1986. The US Food and Drug Administration (FDA) approved mifepristone for termination of pregnancy in the United States in 2000. As access to medication abortion has increased, so has its prevalence as a portion of all abortions; in 2024 medication abortion accounted for nearly two-thirds of abortions in the US.
Even before the COVID-19 pandemic, some states and programs began studying no-touch abortion and abortion provided exclusively through telemedicine. During the pandemic, the FDA reduced some of the unnecessary barriers surrounding mifepristone based on evidence of its safety; these changes increased clinicians’ ability to prescribe mifepristone without in-person testing or evaluation. The pandemic and the FDA regulatory changes created ideal circumstances to demonstrate that ultrasound and in-person evaluation are not always necessary for safe abortion care. Research confirmed that medication abortion is safe through no-touch provision and helped establish telemedicine as an alternate form of care delivery. , Since 2020, multiple companies and organizations have developed platforms for no-touch, self-managed medication abortion, and increased access to and awareness about safe self-managed abortion options.
Contemporary self-managed abortion includes self-sourcing medications (eg, misoprostol, mifepristone, or other medications); less commonly, using herbs, plants, vitamins, or supplements; consuming drugs, alcohol, or toxic substances; and using physical methods. Medications for abortion can be easily ordered through the internet and mailed to the patient’s address; third-party analysis has confirmed the authenticity of the medications. Self-managed abortion, particularly with medications, is often less expensive, more private, and more readily accessible than health center-based or clinician-supported abortion.
Legality of abortion in the United States became state-dependent after the Dobbs decision and most commonly refers to whether it is legal for a medical provider to perform a procedural abortion or prescribe medication abortion for a patient. However, self-managed abortion has been conflated with illegal abortion and unsafe abortion. When abortion is illegal, safe abortion methods are often less accessible; however, self-managed medication abortion is not inherently unsafe. Multiple recent studies evaluating self-managed abortion have found that while complications can occur, in general self-managed medication abortion in the US is safe. As the legal status of abortion in the US changes, so might the availability of safe self-managed abortion.
Even in the context of Dobbs and multiple state restrictions, currently only 1 state, Nevada, has a law criminalizing self-managed abortion. Nevertheless, between 2000 and 2020, at least 61 people across the US were arrested or investigated for self-managed abortion, likely an underestimate of the total number of cases. Analysis of those accused of self-managed abortion reveals that 83% were charged under statutes other than laws prohibiting self-managed abortion. Most commonly, individuals were charged under general abortion laws, fetal harm or child abuse laws, or laws prohibiting the desecration of human remains.
The American College of Obstetricians and Gynecologists cautions that the greatest risk to people choosing self-managed abortion in the US is the threat of criminalization. Very little is known about the current environment of self-managed abortion criminalization due to the nature of these cases, which often have sealed records and prolonged litigation time. Following the Dobbs decision and subsequent outlawing of abortion in many states, a continued rise in arrests and investigations for real or suspected self-managed abortion is likely.
General Considerations for Post-Abortion Care and Reporting
The Health Insurance Portability and Accountability Act (HIPAA) protects patient health information. As of 2024, no state laws require physicians to report abortions or suspected abortions, whether self-managed or not, and doing so may be a HIPAA violation. Despite media attention focusing on abortion, emergency visits for miscarriage, ectopic pregnancy, and other pregnancy complications are significantly more common than for abortion. However, an examination of abortion criminalization cases between 2000 and 2020 reveals that nearly half were reported to law enforcement by people who interacted with patients in the health care setting.
Some hospital systems have policies or guidelines about escalating these cases to a risk management team that might report patient information to law enforcement agencies. Health care workers should have a clear understanding of their state’s absolute requirements for abortion reporting, and which requirements are merely suggestions or hospital-specific protocols but are not legal reporting requirements.
HIPAA-protected information may be shared with law enforcement only under very limited circumstances, although this is a dynamic legal and legislative landscape. Even if served with a warrant or subpoena, the information health care workers are permitted to disclose may be limited. Clinicians should seek legal counsel prior to disclosing HIPAA-protected information. Box 1 contains legal resources dedicated to helping physicians with post-abortion reporting requirements and other abortion-related legal concerns.
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If/When/How: Lawyering for Reproductive Justice provides resources about mandatory reporting, self-managed abortion, and legal rights; available at https://www.reprolegalhelpline.org/ and 844-868-2812
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Abortion Defense Network provides access to legal resources to help people navigate the post- Roe legal landscape:
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Know Your State’s Abortion Laws guides for medical providers are available at https://abortiondefensenetwork.org/resources/providers/
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The American Civil Liberties Union (ACLU) undertakes strategic litigation, advocacy, and organizing related to abortion bans and other restrictions on reproductive rights; the ACLU’s Abortion Criminal Defense Initiative is available at https://www.aclu.org/campaigns-initiatives/abortion-criminal-defense-initiative
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The Lawyering Project manages the Abortion Defense Network and provides legal services to abortion funds, practical support organizations, and other grassroots organizations; available at https://lawyeringproject.org/
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The Center for Reproductive Rights is a global human rights organization of lawyers and advocates with expertise in both U.S. constitutional and international human rights law; available at https://reproductiverights.org/
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If/When/How: Lawyering for Reproductive Justice
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The National Women’s Law Center uses the law to fight for gender justice across issues that are central to the lives of women and girls; available at https://nwlc.org/
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Resources for Abortion Delivery ’s legal defense resources include the Abortion Provider Legal Defense Fund and Regulatory Assistance for Abortion Providers; available at https://radprogram.org/for-allies-providers/
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While individual clinicians can control their own reporting practices, other health care workers also have access to protected health information through witnessed interactions, medical records, or other documentation. Health care workers should focus on details necessary for medical care such as onset of bleeding, pain, fever or signs of infection, and any prior ultrasound findings. Details about travel for medical care, how patients obtained medications, or pregnancy intentions are rarely medically necessary. Similarly, documenting pregnancy intentions during prenatal care is unnecessary, particularly because over 40% of all pregnancies are unintended. The Society of Family Planning notes that qualifiers like medically indicated , elective , and therapeutic are not needed when describing abortion or pregnancy loss.
Clinicians should note who is present (eg, nurses, technicians, and students) when collecting a medical history and consider whether patients might be more comfortable with fewer personnel; this recommendation applies to all health care interactions and not only to post-abortion care.
Considerations for Clinicians in Abortion-Restrictive States
In 2023, people traveling from restrictive states accounted for approximately 1 in 5 abortions. While most abortions do not require any additional care or follow-up, clinicians in abortion-ban states should also be familiar with post-abortion patient concerns and uncommon complications. Medical care for miscarriage, pregnancy complications, or post-abortion care is not abortion; clinicians should always provide needed care regardless of state abortion restrictions.
Residents of restrictive states who self-manage their abortions or who obtain abortions in other states express fear of repercussion and can be guarded in information sharing. Patients might withhold information or provide inconsistent histories as a form of self-protection. Limiting the information that is gathered and documented to only what is medically necessary for care is a best practice.
Clinicians working in abortion-restrictive settings should create safe environments for post-abortion care. Preemptive non-judgmental statements and counseling can help establish a trusting relationship. Example neutral statements include:
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“When patients miscarry, doctors will often prescribe medications to help pass the pregnancy. These are the same medications doctors would prescribe for somebody desiring an abortion. Do either of these medications sound familiar?”
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“Procedures such as D&Cs or uterine aspiration are performed for a variety of reasons, including miscarriage and abortion. Does this sound similar to the procedure you might have had?”
Considerations for Clinicians in Abortion-Supportive States
Standard health care, including abortion care, includes providing patients with information about the next steps in their care. Clinicians in less-restrictive states who provide abortion care to people traveling from out-of-state should consider expanding their standard counseling about post-abortion expectations. Box 2 includes details for clinician counseling, which might specifically benefit residents of abortion-ban states.
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