Online demand for abortion medicine highest in US states with restrictive abortion policies
The demand for abortion medication through an online service was significantly higher among Americans who live in states with restrictive abortion policies. Overall, 76% of requests came from people living in states with restrictive abortion policy climates, according to research from the LBJ School of Public Affairs at the University of Texas, Austin.
Twenty-four percent of requests came from women living in states considered to have supportive abortion policy climates.
The majority (60%) of people in both hostile and supportive states reported seeking abortion medications online because of a combination of both barriers and preferences. "In both states that have passed many abortion restrictions and states that have passed fewer, people are motivated by a combination of barriers to clinic access and a preference for at-home care," says Abigail Aiken, lead author on the study and assistant professor of public affairs at the LBJ School.
The research team used data from US residents requesting early medication abortion from an online abortion telemedicine service, Women on Web (WoW), a non-profit initiative. They examined requests from US residents to the online service between October 15, 2017, and August 15, 2018.
During the 10-month study period, 6,022 people living in the US requested abortion medications from the online service. Requests came from all 50 states, but states with restrictive abortion policy environments tended to have higher volumes of requests - particularly in the South and Midwest - than states with supportive abortion policy environments.
"Among these (requests), 4,571 (76%) lived in states considered to have a hostile abortion policy climate, and 1,451 (24%) lived in states considered to have a supportive abortion policy climate. (For reference, 58% of women of reproductive age, 15-44 years, live in states with hostile abortion policy climates)," says the study published in the American Journal of Public Health.
According to the findings, the highest volume of requests came from Mississippi (24.9 per 100 000 women, aged 15–44 years), Louisiana (21.3 per 100,000), Alabama (17.3 per 100,000), Tennessee (14.6 per 100,000), and Texas (14.4 per 100,000). The lowest density of requests came from New Hampshire (3.7 per 100,000 women, aged 15–44 years), Oregon (3.8 per 100,000), Minnesota (3.9 per 100,000), California (4.2 per 100,000), and Maine (4.3 per 100,000).
The researchers state that the online service does not send abortion medications to the US, but receives requests from US residents. The consultation forms included information about demographic characteristics, medical history, and motivations for seeking abortion medications online.
According to the team, while little is known about the experiences of those who use online pharmacy sites, online telemedicine abortion services have "demonstrated high levels of safety and effectiveness."
What motivated women to seek medication online?
Women cited a wide range of reasons for preferring self-managed abortion medication, regardless of the state policy environment. Privacy, the comfort of the home environment, autonomy, empowerment, and preference to have someone present during the abortion were cited in very similar proportions and with no significant differences between hostile and supportive states, says the research team.
The most common reason for seeking abortion was not feeling able to have a child or another child at this point in life, accounting for 69% of responses, followed by not being able to afford a child (61% of responses). "Overall, there were few demographic or clinical differences between those living in hostile versus supportive states. Living in a hostile state was significantly associated with the number of children," say researchers.
The team divided motivations into two broad categories: barriers to clinic access and preference for self-management. "The barriers category contains reasons that refer to difficulty accessing abortion services in the clinic setting, whereas the preferences category contains reasons that denote self-managed abortion as a first choice rather than as a recourse," says the study.
In both hostile and supportive states, proportions reporting only barriers (31%) were higher than were proportions reporting only preferences (7%). Overall, the researchers did not find a significant association between the type of motivation and the state policy environment.
A key difference, however, was in the specific types of barriers experienced. The particular types of barriers experienced differed according to the state policy environment. In states with more restrictions, legal barriers to clinic access, such as waiting periods, and the cost of in-clinic abortion care were magnified and more commonly experienced than in supportive states. Preferences, on the other hand, were notably similar across policy contexts.
"Most people (74%) expressed more than one specific reason. Participants reported a wide range of barriers to accessing clinical abortion care in both hostile and supportive states. Cost (71% versus 63%), distance (29% versus 21%), legal restrictions (18% versus 14%), and protestors (15% versus 12%) were more commonly cited as barriers by those living in hostile states. Privacy was the most common preference (49% in both hostile and supportive states). The need to keep an abortion secret (43% versus 40%) was slightly more commonly cited as a barrier by those living in supportive states," shows analysis.
According to Aiken, these results suggest that state policies restricting access to abortion have made it harder for some people to access care in the clinic setting, and so they look online for alternatives.
"Demand for self-managed medication abortion through online telemedicine is prevalent in the US. There is a public health justification to make these abortions as safe, effective, and supported as possible," says the team.
The researchers say that during the study, US residents had no viable option to access medication abortion through online telemedicine. However, the end of the study date coincided with the beginning of AidAccess, a new online telemedicine service that provides medication abortion to those living in the US.
"The service follows the same model as the WoW service, with physician oversight and instructions, advice, and support provided by a trained help desk team," says the team.
They add, "The launch of this service may well fulfill the unmet need we have identified for an online telemedicine service that serves the US. It also ushers in a new era for abortion access in this country, along with a multitude of questions about how the use of the service will affect clinical services and the role of clinicians in fielding questions, giving advice, and providing follow-up care for those who have self-managed."