What is Self-Managed Abortion?
Any conversation we have about reproductive health, reproductive freedom, bodily autonomy, or abortion should include detailed discussions of all of the available options on how abortion care can be accessed-- and that includes self-managed abortion. Self-managed abortion is not a new concept, but it has been historically accessed in unsafe and secretive ways. With the current administration’s constant attacks on reproductive health and rights, as well as the shifting of the Supreme Court with the confirmation of Brett Kavanaugh, abortion rights are being undermined and many fear the return of unsafe, self-managed abortion methods. Megan Donovan with the Guttmacher Institute talks to us about the evolving ways in which self-managed abortion is becoming a more easily accessible, safe, and effective option.
Safe and legal abortion in the United States doesn’t solely take place under the ceilings of medical centers and reproductive health clinics. In fact, there are a variety of ways in which people may self-manage their own abortion. Medication abortion, first approved by the FDA in 2000, consists of the medications mifepristone and misoprostol. Taking these medications while not under the direct supervision of a medical provider is considered self-managed abortion.
There are many, currently-existing barriers to a fully supported, self-managed model of care. Barriers to medication abortion generally include risk evaluation and mitigation strategies, (REMS) which are a set of restrictions imposed on mifepristone by the FDA. REMS are a tool used by the FDA to ensure that the benefits of taking a drug outweigh the risks. Given its extensive safety profile, mifepristone don’t belong alongside drugs typically subject to REMS. There are also state-level restrictions on medication abortion, as well. 34 states limit the provision of medication abortion to physicians, despite recommendations from WHO and NAF that other practitioners can safely administer medication abortion. 19 states require those providing the medication abortion to be physically present.
There are also a number of barriers to achieving the environment in which self-managed abortion is fully supported, accessible, and available to everyone. Stigma and fear often prevent people from accessing medication abortion. Providing education and information on medication abortion can de-mystify and create new options for those seeking care. Going one step farther and making medication abortion available over-the-counter would allow people to access the medication they need directly, rather than needing a provider to write a prescription. Over-the-counter status wouldn’t come without its own barriers, though, including affordability and the possibility of religious refusals.
No one should be punished for seeking to terminate a pregnancy, but there are a variety of state laws that have been used to punish people who have been suspected of seeking to self-manage their own abortion. Seeking to education legislators and defy harmful state laws could help lower trends of criminalization.
Facilitating access to self-managed medication abortion is really about ensuring that people have access to a full range of safe and effective methods of abortion care. Self-managed abortion provides another option for people as we increasingly face restrictions against abortion care.
Jennie Wetter: Welcome to rePROs Fight Back a podcast on all things repro. I'm your host Jennie Wetter. In each episode, I'll be taking you to the front lines of the escalating fight over our sexual and reproductive health and rights at home and abroad. Each episode, I will be speaking with leaders who are fighting to protect our reproductive health and rights to ensure that no one's reproductive health depends on where they live. It's time for repros to fight back.
Jennie Wetter: Welcome to rePROs Fight Back. Today we're going to tackle another listener request, which is always fun. Um, and this one actually came together perfectly cause I had just read an amazing article covering it. Um, so today we're going to talk about self-managed medication abortion. I'm like super excited to have Megan Donovan with the Guttmacher Institute and the author of the article I just read here with me today to talk about this important topic. Hi Megan. Thank you for being here.
Megan Donovan: Hi, thank you so much for being here. I'm really excited.
Jennie Wetter: So why are we talking about self managed abortion?
Megan Donovan: Any conversation about abortion and reproductive health freedom or autonomy should include discussion of all of the available options for how a person can access abortion. And that includes self managed care. You know, self managed abortion is not new, but there's a lot of fear and misunderstanding out there, really stemming from an earlier era in which the options were generally sought in secret and often unsafe, especially now as we contemplate a changing Supreme Court, and the unfortunate reality that we may see abortion rights seriously undermined, uh, in the coming years. People are understandably eager to talk about and picture what that might look like. Um, but they sometimes fall back on ideas and images that do stem from that earlier era and really harped our understanding of what it might look like. And so they fall back on concepts like the coat hanger or the back alley abortion. But the world around us is changing. Peo ple access healthcare in all kinds of new ways. Um, you know, they use technology on their phones and consult doctors and order birth control, uh, from apps on their phones. And so as we continue to update our notion about what health care is and how people access reproductive health care, including abortion in the 21st century, I think it's really exciting and even comforting to know that that how we access abortion has come a long way since Roe v Wade was decided in 1973.
Jennie Wetter: Yeah, I think you're right. Like I think often if you hear about not having an abortion in the clinics, you really just do hear the ubiquitous coathanger everywhere. Um, and that's kind of the end of the conversation. There isn't the kind of the fuller like what would it look like.
Megan Donovan: Safe and legal abortion in the United States is really associated in our minds with a sort of medicalized setting and clinic based or provider based care. That's what people think of and where, you know, many people feel comfortable and so, uh, challenging that or, or talking about abortion not in that setting can be uncomfortable for people.
Jennie Wetter: Um, what is self managed abortion?
Megan Donovan: Yeah. So there are a variety of ways in which people you know, may seek to self manage their, uh, own abortion. Medication abortion in particular, uh, holds great promise for the future of, uh, abortion care in the US and that's what I, you know, really like to focus on today. That's what the article was about. As you mentioned at the beginning of this conversation, just to, you know, make sure that, you know, listeners are, are with us as we think about what this looks like, medication abortion was first approved, uh, in the US into by the FDA in 2000 and, uh, you know, consists of two medications, mifepristone followed by misoprostol. And so when, you know, we're talking about, uh, self managing a medication abortion, we're talking about the process of administering that medication and completing an abortion without the direct supervision of a provider. It's important though to, um, understand that we're really thinking about this as a model in which people should always have access to complete and accurate information in order to self manage their abortion safely and effectively. And should also always have access to a provider should they, you know, want or need one at any stage of the process,
Jennie Wetter: You know, there are a number of barriers to making that a reality in the US and that's definitely something your article addresses. So there's kind of, I think you broke it into two types of barriers. So maybe let's focus on the first one, um, which, um, is accessing medication abortion in the US in general.
Megan Donovan: That's right. I think that that is a helpful way of thinking about this. There are kind of a number of barriers to realizing a kind, fully supported self-managed model of care. And you can start by thinking about some of the primary barriers to medication abortion generally. So, um, one of the biggest barriers that inhibits access currently to medication abortion are the REMS. Now that is a very, a wonky acronym that stands for risk evaluation and mitigation strategy. The REMS uh, are a set of restrictions imposed by the FDA on mifepristone. The first drug I mentioned, that's part of the true drug protocol. REMS are a sort of a tool that the FDA has a available to it that are really supposed to be used for drugs with high risk profiles to ensure that the benefits of using that drug outweigh the risks to the consumer. But given it's extensive safety profile, mifepristone and medication abortion don't belong, um, alongside drugs typically subject to REMS. So we have what are really a set of ideological, um, restrictions stemming from, uh, anti abortion sentiment that limit the distribution of mifepristone and what that really means at the end of the day for someone seeking medication abortion is, uh, that they can only access it by finding a registered provider in, um, a few specific settings such as an abortion clinic or medical office or hospital. They cannot access the medication, um, through pharmacy pharmacies for example, like you can with, you know, most prescription drugs. So someone needs to find a provider who is able both to prescribe the medication to them, but then actually also has it stocked and ready to be given over, um, on site to the person. It is completely different to sort of your typical, um, experience where you might get a prescription from a provider and then be able to access the medication you need, uh, at a retail pharmacy or these days, you know, online, um, through any type, any number of online pharmacies or options. And so getting rid of the REMS to begin with, could really expand access to medication abortion in general in the US by, uh, opening up and expanding the pool of providers that are willing and able to offer medication abortion and making the, um, options that people have for how and when they, you know, purchase and access the medication a lot more convenient.
Jennie Wetter: Um, so beyond the REMS, there's also other state restrictions that impact how people can access abortion.
Megan Donovan: Sure. And so, um, just to make sure it's clear, the, the REMS are a federal level set of restrictions imposed by the FDA. Um, and so, you know, that's at the federal, at the national level, um, that we're dealing with them. And then when you get down to the state level, there are a number of other types of restrictions that states have imposed on, uh, medication abortion over the years. Uh, two really primary ones are that 34 states limit the provision of medication abortion to physicians despite a recommendations from, you know, bodies such as the World Health Organization and the National Abortion Federation that, you know, a number of other clinicians, mid level clinicians, the advanced practice practitioners can uh, you know, safely and effectively administer medication abortion and 19 states require the clinician who is providing medication abortion to be physically present, which essentially bans, um, telemedicine for medication abortion. So these are a couple of the other types of restrictions that you know, we can work to remove. That would just start to open up the ways in which people are able to access medication abortion as one way of, you know, getting us closer to a world in which self managed care is accessible, more fully accessible and supported.
Jennie Wetter: Maybe we just want to touch a little bit on, um, what we cause saying that, um, physicians need to, um, be the ones to prescribe medication abortion sound, I think to a lot of people, sounds like common sense. Some of you want to flush out a little bit, but what by what you mean by mid level people can do it so that people are understanding what we're talking about.
Megan Donovan: So there are recommendations from bodies such as the World Health Organization on the National Abortion Federation that, um, when it comes to prescribing the medication and uh, and explaining to people, um, providing the information people need to use medication abortion that, you know, that can be done, you know, competently, safely, effectively by, um, you know, nurse midwives or um, uh, you know, other classes of nurses, for example. These are clinicians who, you know, actually, um, do, do a lot of medical care that perhaps in a past era we associated primarily with physicians. But, um, in this day and age are, you know, have sort of increased authority to, you know, do, um, a lot of the clinical care. And it's been shown that, um, they can facilitate and support someone through medication abortion, you know, as a physician might be able to. And so when we, um, think about how states could, uh, just at a basic level expand access to medication abortion, um, it is too, so when we talk about one of the ways that states can expand access to medication abortion, it's to, you know, make sure that, uh, all of the clinicians who are able to deliver this care have the authority to do so and it's not being sort of unnecessarily or perhaps politically, um, limited to physicians.
Jennie Wetter: Good. I think that makes sense and makes it a little bit clear for people like who we're talking about when we talk about more people can provide than what is currently allowed. Um, so the next, uh, type of barrier you, you identified are barriers to a fully self managed model do, um, you want to touch on what some of those are?
Megan Donovan: We were just talking a lot about the ways that we could increase access to, uh, to medication abortion as it's currently approved in the United States. Um, but, or, or, or even further, I should say in the absence of the, uh, REMS restrictions that are, you know, sort of unnecessarily limiting, um, it at the moment. But as we look ahead and really think about, um, a model of care in which self-managed abortion and using medication is sort of fully supported and accessible and available to people, there are also a number of barriers to kind of achieving that environment where people can access the information they need, um, and access the medication and have the support that they need or want at any stage. One of the biggest, I think is this we've already touched upon and that stigma and fear and we've talked about it already, but it's worth I think mentioning again that that um, people need more information and they need to understand that, um, you know, medication abortion is very safe and effective and over 15 years of, you know, use in the United States has shown that to be the case. And that the evidence really is there to suggest that, uh, that people, you know, may be able to self manage it without the direct supervision of a provider. And so working to kind of educate people, help people become more familiar with medication abortion firstly but then also get more comfortable with the concept of self-managed medication abortion and with the fact that we are, we are talking about a model in which people will have the information and the support they need to do this safely and effectively. Um, I think it's really, really important.
Jennie Wetter: I think it's important cause I think part of it is also just kind of demystifying abortion cause I think when so many people think of abortion, they're not thinking medication abortion and don't really understand that that's an option for a lot of people.
Megan Donovan: I think that's absolutely right. Um, I think we have a lot more work to do here in the US to talk more openly and honestly about abortion and abortion care. And you know that, that you're right, that people, um, in, you know, sort of in general, don't realize, um, that medication abortion is an option or is an option that is, you know, that is widely used in the United States. Um, since it was approved by the FDA in 2000 medication abortion really has kind of transformed, uh, the, the nature of abortion care in the US and you know, as recently as 2014 which is the most recent data we have medication abortion accounted for, um, 31% of all non-hospital abortions in the US and I think that's just something people don't, don't understand or are not fully aware of.
Jennie Wetter: Um, so one of the other barriers you talked about after a stigma and fear was over over the counter status.
Megan Donovan: Sure. So we talked a few minutes ago about, um, about the REMS, which I keep kind of referring back to this set of FDA restrictions that really kind of set mifepristone and therefore medication abortion apart from other similarly safe, um, drugs in the way that people access it. But even where you to lift the REMS and, and sort of therefore expand access to medication abortion generally in the US that would still limit, uh, what we're talking about to prescription based care. So moving, um, the medications over the counter would help ensure that, um, people can access both medications directly instead of requiring a provider to write a prescription first. And I want to keep going back to this idea and this point because I think it's worth repeating that sort of the, the, the vision here is that someone would be able to, you know, access in a way that's comfortable to them. Um, whether that's online or whether that is by sort of interfacing with and talking with a provider or someone first, but would be able to access, you know, the information that they needed, um, in order to feel supported and in order to, um, know how to self manage and abortion with medication safely and effectively, but that ultimately they would be able to access that medication without first needing, um, a prescription and therefore could conveniently and easily go into a retail pharmacy or order, order it online in order to self manage their care.
Jennie Wetter: I think one of the things I think of when I of moving it into a pharmacy is the dangers of running into religious refusals.
Megan Donovan: That's a really good point. Um, and it is a barrier that, um, you know, could potentially stand in the way we know from not even a over the counter status, but even, you know, uh, prescription based drugs, um, can sometimes, uh, be difficult to access if someone seeks them out at a pharmacy for example, where where a pharmacist, uh, refuses the care based on ideological arguments or beliefs. I think continuing to work on ensuring that, um, uh, an individual level refusal is never a barrier to care is, is one thing that you know, is a necessary step towards, um, just sort of promoting access to sexual and reproductive health care in the US in general. So ensuring that even if an individual doctor or pharmacist has an objection to providing care, there's always a seamless backup in that, you know, that office or pharmacy has to ensure that a consumer gets the care is a principle that kind of applies to, um, any type of care that we're talking about. But I think that, you know, self-managed abortion, um, also could by, by making the medication available, um, in more ways. And, you know, increasingly through online applications, for example, could also be one way that people could, you know, find routes to accessing care that are currently limited. And even beyond refusals, that could mean, um, expanding reach to, you know, rural or otherwise under-served communities.
Jennie Wetter: Another barrier would be affordable affordability.
Megan Donovan: Yeah. Affordability is a critical topic of conversation. Anytime we're talking about access to sexual and reproductive health care and, you know, including abortion. And, you know, in this world in which we're talking about, uh, medication abortion being available over the counter, you know, kind of a perverse fact that over the counter status can sometimes have the effect of making a medication less affordable. Uh, if someone's insurance company won't cover over the counter medication without a prescription. So this is one of those things that, um, we as advocates need to be very mindful of as we are promoting policies that move towards over the counter status to promote over the counter access is that we need to be working at the same time on ensuring that that over the counter status, uh, meaningfully expands options and doesn't restrict them. Um, so by and, uh, working on the sort of insurance piece of it and other kind of affordability mechanisms to make sure that, um, we don't have kind of the perverse effect of taking it out of reach of people.
Jennie Wetter: It's not more accessible if people can't afford it.
Megan Donovan: Exactly. That is the critical point. And so we need to be ensuring that, um, the people can access it, uh, in more places, but in a way that is meaningful. And a key piece of that is, uh, being able to afford it.
Jennie Wetter: And then I think the last barrier you touched on was criminalization.
Megan Donovan: No one should be punished for seeking to terminate a pregnancy. Uh, and you know, unfortunately there are a variety of state laws that have been used to punish people who have been suspected of seeking to self manage abortion. And so these are another set of kind of barriers that we need to be breaking down both in terms of seeking to change these policies where they exist, seeking to ensure, uh, excuse me, seeking to educate, uh, people including law enforcement, about, um, abortion and about self-managed abortion in order to ensure that someone who seeks to end a pregnancy is not punished for it. I think it's worth noting that both the American Medical Association and ACOG, the American American College of Obstetricians and Gynecologists, um, opposed criminalization of self-managed abortion.
Jennie Wetter: What would access if we were able to achieve affordable access to self managed abortion? What would that mean for women?
Megan Donovan: Facilitating access to self managed medication abortion is really about ensuring that people have access to the full range of safe and effective methods of abortion care. We are talking about, you know, one method among many, um, but the benefits of self-management can include, you know, enhanced privacy, um, and enhanced autonomy. I think something that may be really helpful for people is to think about and not underestimate the, the benefits of being able to end a pregnancy in the setting of one's choosing and surrounded by the community or not, you know, that one chooses. So, uh, you know, involving the, involving the people that one chooses to involve in that or, or, um, enhancing, you know, the privacy that someone wants for, for that care that they receive.
Jennie Wetter: Yeah. And I also think about we're clinics, being forced to close for restriction reasons and being able, if we were to live in a world where all of a sudden we could have access to self managed abortion care, women in rural areas, that could be a real game changer for them to be able to access it via telemedicine and then be able to go to a pharmacy or get it online would make things a lot easier for them.
Megan Donovan: That's right. I think there's a couple of important points kind of embedded in what you said and it takes me in a few different directions. But um, you know, your main point I think is a critical one is that this is a, you know, way of hopefully expanding the options available to people, including the way people in rural or otherwise underserved communities could access care. Um, and absolutely has a lot of potential for, you know, a telemedicine model is not necessarily a self managed model, but it's something, it's something close to it. You know, it's something that could more robustly develop if we, for example, got rid of the REMS, um, where people could use technology to, uh, you know, access a provider remotely, um, and get that information and care that they want. I think it's very important to acknowledge that self-managed abortion can provide another option for people as we face ongoing, you know, restrictions against abortion and, and sort of, you know, we look ahead to a world in which the Supreme Court may take action to even further limit access to abortion. But I do want to sort of be careful to caution folks not to think about self-managed abortion only as a work around to reduced access or to therefore start thinking about it as like a worst case scenario or last sort of chance that someone has. I think there's a danger when we talk about it as a response to restrictions to kind of present it as a something for the desperate. And I think self managed abortion can be, um, something so much more positive than that. So some something that gives someone, allows someone the um, the autonomy and the freedom and the privacy to, uh, manage their own experience. Um, whether that is in part because of restrictions or for other reasons. And I also think we really need to, as we work towards fully supporting self managed care, we need to make sure that the piece of that is making sure that people actually still have access to a provider if they decide at some point while during the process that they want or they need one, um, or they, you know, they self assess that they may need one. And so we don't want to lose sight of the importance of complete and accurate information and you know, access to a provider if someone wants or needs it.
Jennie Wetter: Um, yeah, no, and it's definitely important because self managed abortion is only, especially if it's medication abortion, there's only effective up to a certain point in which case you would definitely need to go to a clinic and you need the clinics to be available, uh, for women to be able to access safe care.
Megan Donovan: So medication abortion is currently approved in the US for up to 70 days after a woman's last menstrual period. Um, and so if we're thinking about it in that framework, you know, part of the process of self managing and abortion involves, you know, being able to self assess if you're, if you're eligible and then, you know, um, being able to access other care if you're not.
Jennie Wetter: We always kind of end the podcast focusing on what can people do to take action. So what can people do to, uh, what steps can they take to make self managed care more accessible in the US?
Megan Donovan: The first and foremost, most important thing is to do exactly what you and I have just been doing for this past little while, which is talk about it and keep talking about it and ask questions and share information and help break down that barrier of stigma and fear that we have identified a couple of times during this, uh, this conversation. Um, and that'll happen by promoting access to information and resources and, and being open and honest about abortion, abortion and care. And you know, what we want from the experience. There are of course other ways that people can help, um, you know, facilitate access to self-managed abortion. Those, you know, include supporting organizations that are working to break down the barriers. Um, the list could go on and on there, but you know, just to, just to, um, name, uh, you know, maybe one player that is really doing a lot right now to help people overcome barriers to self-managed abortion and, um, helping sure that people are not, um, criminalized for seeking to end up pregnancy is the Sia legal team. SIA. But you know, if people are really interested in, in helping out, there are a number of organizations that, um, are working on this. And I, I think similarly, um, advocates can, you know, get involved in the work to get rid of some of the restrictions we've talked about. And you know, first and foremost, I think on that list is, um, working to lift the unnecessary and ideologically motivated, uh, federal restrictions known as REMS.
Megan Donovan: One last thing to just hit upon before we close the conversation. I, I just talked about supporting organizations that are working to promote access to self-managed abortion and to um, ensure people aren't punished for ending a pregnancy. And, and the one of the organizations that jumped immediately to mind was the Sia legal team. And I think I would be remiss if I didn't acknowledge in this conversation that even as we look ahead to this model I've been talking about of kind of a fully supported, um, you know, model of self managed care that is, you know, part of how we in our, in our laws and our policies support people's access to abortion in the US it should be noted that, um, there is evidence that, uh, that some people are already self managing their abortion care in the United States, um, including using medication people. There is evidence that people may, um, increasingly have access to both mifepriston and misoprostol, but also that people have used misoprostol alone to self manage an abortion. And I think as we think about that and, and how we support people with access to reproductive health care, we always need to remember that no one should be criminalized, as I've said, for, uh, for seeking to end a pregnancy. And we should be, you know, moving towards, um, fully supporting them with all of the information and resources that they need. So in that fight, the Sia legal team is, uh, one of the organizations that that really comes to mind, um, supporting women where there are, you know, where they're at, and looking ahead to a, um, even more supportive model of care.
Jennie Wetter: Great. Um, well Megan, thank you so much for being here. I think this was a really informative conversation. Megan Donovan: Thank you so much for having me. I had a lot of fun.
Jennie Wetter: For more information, including show notes from this episode and previous episodes, please visit our website reprosfightback.com. You can also find us on Facebook and Twitter at rePROs Fight Back. If you like our show, please help others find it by sharing it with your friends and subscribing, rating and reviewing us on iTunes. Thanks for listening.