Background

Abortion services in the United States are becoming significantly more restricted.  In the first six months of 2019, 58 state level abortion restrictions were enacted.1 As more restrictions prevent abortion access, more people are choosing to self-manage their abortion. Studies have suggested self-managed abortion rates range from 1.2% and 7% in each pregnancy.2,3  In 2015 there were more than 700,000 Google searches in the United States related to self-managed abortion.4 A similar study of those performing internet searches for “self-abortion” found the majority of those searching were themselves pregnant and did not want to be.5 People who self-manage their abortion do so for a variety of motivations and by different means including attempted surgical abortion, trauma, herbal medications, taking a high dose of medications or by taking misoprostol with or without mifepristone.6,7 The prevalence of self-managed medication abortion, that is, misoprostol alone or misoprostol plus mifepristone is currently unknown. However, we know that more than 21,000 people in the United States requested abortion medication from AidAccess.org from 2018 to 2019, the majority of whom lived in states with significant abortion restrictions.8 Women on Web received over 6022 requests for abortion medications over a 10 month period, the majority of requests coming from restrictive states.9 Although there is no easy way of identifying people who are choosing to self-manage their abortion with medication, the practice appears to be increasing, especially in restricted areas.10,11

The combination of mifepristone and misoprostol for medication abortion is highly effective and safe with rare serious complications.12,13 However, unlike people who have been prescribed medications in a clinical setting, people choosing self-managed abortion may not have an identified provider in the case of worrisome side effects or complications. These people may be more likely to access care in an emergency department.14,15 Overall, abortion-related emergency department visits are rare.16 However, patients with restricted access to abortion providers have significantly higher rates of post-abortion emergency department visits.15 Rates of emergency department visits potentially for self-managed abortion are significantly higher in states with abortion restrictions.

Seven states have laws which directly criminalize self-managed abortion, while other states have laws that have been misused  to prosecute people who have or were thought to have self-managed their abortions.17  While it may be criminalized in some states, there are no state or federal laws requiring physicians to report patients suspected of self-managing their abortions. However, a growing number of people who have self-managed their abortions have been reported from emergency department providers.18 Unpublished results from a qualitative study of emergency room providers in Texas revealed desire for more education regarding mandated reporting requirements regarding self-managed abortion.19 Research gaps exist regarding emergency department provider knowledge and attitudes around abortion, self-managed abortion and perceptions of legal restrictions on abortion related to mandated reporting.  There are currently no resources designed for emergency department providers caring for patients who have undergone self-managed abortion.