Dana M. Johnson

Background: State-level abortion bans, parental involvement laws and structural barriers to abortion care create a complicated landscape for adolescents under 18 years old seeking clinic-based abortion. Because of such obstacles, adolescents may seek medication abortion from online sources. We aimed to understand their individual motivations for obtaining medication abortion from one online telemedicine service instead of in-person clinic-based care. Methods: We conducted a mixed-methods study among adolescents who requested medication abortion between 1 July and 30 November 2022 from a service providing asynchronous clinician consultation and medication dispensed by mail to people in all 50 United States (US) states. We examined demographic characteristics, reasons for request, and conducted a content analysis of a subsample of anonymised email communications. Results: Over a 5-month period, 558 adolescents requested medication. The most frequently selected motivations were: I would rather keep my abortion private (66%); I would be more comfortable at home (64%); I need to keep my treatment a secret from my partner/family (64%); Pills at home are more affordable (47%); I prefer to take care of my own treatment (47%); and I want to have my partner/friend with me (45%). In email communications, adolescents expressed an urgent need for abortion and articulated additional barriers including the high cost of the service and lack of access to credit cards or digital payment methods. Conclusions: Our results provide insights into why adolescents in the US pursue online medication abortion services and raise the need to address cost and payment barriers to telehealth abortion.

The WHO recommends two medication abortion regimens, either misoprostol used with mifepristone, or misoprostol-only. Both regimens are recognised as safe and effective, but in the United States (US) most abortions are completed using mifepristone and misoprostol. Given current political hostility to abortion, restrictions on mifepristone, and the long-term legal strategy to restrict nationwide access to the combined mifepristone and misoprostol regimen, more people in the US may use misoprostol-only regimens. Globally research has documented experiences with misoprostol-only abortions, but what are the experiences among people living in the US? We conducted a thematic analysis of 31 in-depth interviews with people who self-managed their abortion using misoprostol acquired from a mail-order or retail pharmacy between May and June 2020. We examine the acceptability of using misoprostol for medication abortion across three domains: the medication regimen, the mode of delivery of medications, and the overall model of care. We find that individual perceptions of misoprostol were shaped by both prior and informed knowledge. Picking up misoprostol from a retail pharmacy fostered familiarity, and having a prescription legitimised the service as an authentic medication provider. Receiving medications from the mail-order delivery model met preferences for privacy and anonymity. In reflections on the overall model, satisfaction was high across participants, but those who were adolescents at the time of their abortion had a distinct unmet need for emotional support compared to older participants. These results contribute to a growing evidence base on the acceptability of misoprostol-only regimens and mail-order and retail pharmacy service delivery models.

Background: Advance provision of medication abortion, or the prescription of mifepristone and misoprostol before pregnancy occurs, is an unexplored care model aimed at expanding abortion access. We examine motivations for obtaining advance provision from the online telemedicine service, Aid Access, which supports people in the United States. Methods: Between May and November 2023, we conducted semi-structured, in-depth interviews with 39 people who obtained advance provision between January 2022 and April 2023. Interviews were transcribed and we conducted a thematic analysis to assess individual motivations. Results: Participants were motivated to obtain medications because of the Dobbs v Jackson Women’s Health Organization (Dobbs ) draft opinion leak and eventual decision. Participants expressed concerns about access to abortion under current and future abortion restrictions. Concerns about restrictions prompted people to make a backup plan for themselves and loved ones, and participants compared advance provision to other emergency medications and practices. Some participants were motivated to have medications on hand because pregnancy would be either unsafe or difficult. Others were trying to become pregnant, but because of their health histories they were cognisant of the health risks of a desired pregnancy. Overall, participants were motivated to take back control of their reproductive autonomy in the face of inevitable abortion bans. Conclusions: The need for autonomy, resistance and reassurance were woven throughout participant’s motivations for obtaining advance provision. The Dobbs decision acted as a catalyst for action to take back reproductive autonomy and prepare for a lack of access to abortion care.

Introduction: Telehealth medication abortion (teleMAB) is an option for expanding abortion access in the USA. In this study, we compared the accessibility of two no-test, direct-to-patient teleMAB regimens: mifepristone and misoprostol, and misoprostol-only.Research design and methods: Over a 5-month period, we conducted an exploratory study surveying clients who received teleMAB services from an abortion clinic offering teleMAB. We calculated descriptive statistics focusing on the healthcare access dimensions of acceptability and accommodation. We conducted a content analysis of open-response comments focusing on convenience.Results: Of the 218 clients in the study: 195 (89%) selected the mifepristone and misoprostol regimen and 23 (11%) selected the misoprostol-only regimen. Across all respondents, 88% reported they would use the service again if they needed an abortion in the future. Half of the respondents (52%) connected to the service using a smartphone, 99% owned the device that they used, 98% could easily hear and 99% could easily talk to the prescribing provider, and only 7% had a problem connecting to the service. Respondents felt that teleMAB was convenient because they had quality and trustworthy communications. It also accommodated their childcare needs, travel, and scheduling, felt private and comfortable, and facilitated a sense of reproductive autonomy.Conclusions: Respondents found both teleMAB regimens to be acceptable, technologically accommodating and convenient. These results have promising implications for states positioned to expand insurance coverage and reimbursement for teleMAB, including misoprostol-only regimens. Results also inform a need to focus on policies that expand access to teleMAB through nationwide internet connectivity.