The future of medication abortion in a post-Roe worldBMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1393 (Published 02 June 2022) Cite this as: BMJ 2022;377:o1393
- 1LBJ School of Public Affairs, University of Texas, Austin, Texas, USA
- 2University of California, San Francisco, California, USA
Abortion in the United States currently stands at a crossroads. The landmark 1973 Supreme Court decision Roe v Wade will almost certainly be overturned this summer, allowing states to implement outright abortion bans. But US history before 1973 and experiences from other countries show clearly that people will still need abortion.12
Over the past decade, several states have already created a post-Roe world for the most vulnerable—particularly people from ethnic minorities and other marginalised groups—due to restrictive laws that negate access. A recent ban on abortion in Texas after approximately six weeks of pregnancy offers a glimpse of what will happen after Roe in the 26 states where outright bans are certain or likely.3 People in Texas either have to travel out of state to seek an abortion (an option that will become increasingly difficult when contiguous states covering large geographic areas have bans in effect), remain pregnant against their will, or self-manage their abortions at home.
A self-managed abortion is one that occurs outside of the formal healthcare setting. A range of methods may be used, but medication self-management using abortion pills has become increasingly available, particularly through the internet. Texas, along with 18 other states, bans telehealth for abortion. But since 2018, the non-profit Aid Access has been providing supported, self-managed medication abortion through an online platform. Over the first two years, the service received 57 000 requests, with 85% from states with restrictive access.4 Policy shocks, such as state level executive orders that halted in-clinic abortion provision early in the covid-19 pandemic and Texas’s six week ban, have consistently shown that increasing restrictions on abortion increases demand for self-managed abortion through Aid Access.56 Requests from Texas tripled in the month following the ban and have remained at this level ever since, despite laws that prohibit mailing abortion pills in Texas. After Roe, we can expect to see at least the same increases across many states.
Data show that medication self-management is safe and effective, but the experience may also be isolating and fraught due to shipment delays, fear of telling others, and a feeling of being cut off from help and support within the formal healthcare setting.789 Moreover, while very few states have laws that explicitly criminalise self-management, unjust prosecutions have occurred, with people from ethnic minorities and people with low incomes at disproportionate risk.10
While many in states with restricted access will rely on Aid Access post-Roe, residents of 23 states with protected access where telehealth abortion is allowed will be able to rely on a similar abortion care model within the formal healthcare setting.11 Many clinics in these states offer no-test medication abortion, determining eligibility based on medical history without ultrasound or in-person tests.12 Some communicate with patients entirely through secure messaging while others use video or phone consultations. A clinician sends a prescription to an online mail order pharmacy that mails the medications to patients. The protocol is based on guidelines from several professional organisations.131415 Telehealth providers can refer patients for in-person follow-up care should concerns arise.
Direct-to-patient telehealth models are safe and effective.121617 Patients appreciate the convenience, accessibility, and privacy that telehealth offers, particularly when intimate partner violence or protesters are concerns.18 Preliminary data from the CHAT study (www.chatstudy.org) finds that patients are able to integrate telehealth abortion care into their workday to avoid taking time off.
The availability of telehealth in protected access states may reduce pressure on clinics due to surges in travel expected after Roe, particularly in Illinois, Colorado, New Mexico, and Minnesota, which border states with restricted access. Some patients may avoid travel by using telehealth services to have abortion pills mailed to a Post Office Box just across the border in a nearby protected access state. Or they could use a mail forwarding service to arrange delivery to their home. One service, Just the Pill, is already parking their mobile clinics in towns close to the Texas and Oklahoma borders. People will use creative methods to obtain these medications that are approved by the US Food and Drug Administration and which are so easily available to their counterparts across state borders. However, they may be still at risk of surveillance or criminalisation depending on post-Roe laws in their home state.
Since prescribing medication abortion does not require expensive equipment or a physical exam,16 more primary care providers can begin to provide it. Where telemedicine is banned, but abortion is still legal, pills could be mailed from an online pharmacy to the provider’s office, allowing patients to avoid an out-of-state trip.
Medication abortion provided by telemedicine or supported self-management will not solve the suffering and oppression people will experience after Roe. These models are not feasible, accessible, or preferable for all, and they do not address the core problem: that people should have reproductive autonomy, including access to legal, clinically supported healthcare if they want it. Yet access to safe, effective, and supported medication abortion will prevent a tragic return to the pre-Roe era.
Declaration of interests: Abigail Aiken’s research is supported by grants from the Society of Family Planning (SFP) and the National Institute of Child Health and Human Development (NICHD) awarded to the University of Texas at Austin. She is a council member for the British Society of Abortion Care Providers (BSACP).
Ushma Upadhyay’s research is supported by grants from the BaSe Family Fund, the Lisa and Douglas Goldman Fund, the Preston-Werner Foundation, the Isabel Allende Foundation, and the Grove Foundation.
Provenance and peer review: Commissioned; not peer reviewed.