‘Sense of urgency’ surrounds self-managed abortions
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Key takeaways:
- Self-managed abortion can be a safer option than clinic-based care for some people.
- It is important clinicians understand legal restrictions within their individual states.
BALTIMORE — In the wake of the Dobbs decision, a new energy surrounds self-managed abortions as a choice some people may make in the face of abortion restrictions, according to panelists at the ACOG Annual Clinical & Scientific Meeting.
“Self-managed abortion refers to any action to end a pregnancy outside of the formal health care system,” said Nisha Verma, MD, MPH, an OB/GYN at Grady Health and assistant professor in the division of family planning, department of gynecology and obstetrics at Emory University.
Finding the safest option
According to Daniel Grossman, MD, professor in the department obstetrics, gynecology and reproductive sciences the University of California, San Francisco, self-managed abortions were becoming more common even before the U.S. Supreme Court overturned the federal right to abortion. Grossman discussed a national survey conducted before the Dobbs decision, which found that those who reported barriers to accessing reproductive health care were more likely to say they preferred self-managed abortion to clinic-based care.
The panel discussed how clinic-based care can be unacceptable to people who may have experienced bias or stigma when seeking health care, for example; unavailable to those who live in states that restrict legal access; or inaccessible to those with geographic or other barriers. All of these factors might steer a pregnant person toward self-management. In addition, risk of criminalization has exacerbated racial inequities in abortion care.
“We know that the criminal legal system in this country is inequitable, and decisions are made in a way that is discretionary and discretion is often grounded in bias,” said Jamila Perritt, MD, MPH, an OB/GYN and president and CEO of Physicians for Reproductive Health.
When asked about the safety and efficacy of self-managed abortion, Grossman said there are very few data in the U.S., but what data are available consistently show that the success rate for medication abortion — with mifepristone and/or misoprostol pills — is extremely high and the rate of adverse events low.
According to Grossman, the most common form of self-managed abortion in the U.S. is the use of herbs, and only about 20% of self-managed abortions are medication abortions.
Perritt said when discussing the safety of self-managed abortion, it is important to take into consideration psychological and physical safety.
“Depending on the context of what’s happening in the individual’s life, an 80% efficacy rate [for example] is good enough,” Perritt said.
Concerns for the future
Each member of the panel expressed concerns for the future of self-managed abortion and the potential legal implications for clinicians and pregnant people.
“For me practicing in Georgia right now, the biggest concerns are safety of patients from criminal and legal prosecution,” Verma said. “We are definitely in a tough legal environment in Georgia, and many of the surrounding states actually have even stricter laws than we do with a 6-week ban [on abortion].”
The panelists discussed how individuals who self-manage their abortions have historically sometimes been arrested and prosecuted for doing so.
Perritt said almost half of those arrested for attempting self-managed abortions were turned in after seeking medical care. She expressed concern that the commonality among the access points for patients seeking abortions outside the medical system is that the provider’s safety is prioritized over the patient’s safety.
Adding to Perritt’s concern, Verma said there is no state in the U.S. where clinicians are mandatory reporters for self-managed abortions.
“It should not be something that we are doing,” Verma said.
“In fact, mandatory reporting in general has a racist, classist, problematic history, and we need to take care of it,” Perritt said.
Grossman said the closure of abortion clinics may limit people’s options when seeking abortion care, leaving those who experience complications from self-management to seek care from EDs, which may not be best suited to provide abortion care.
“The people who are taking care of the patients there may overtreat the patients, increasing the cost for the patient and reducing the quality of care,” Grossman said. “I’m really worried about the lack of places where people can get care before and after self-managing.”
Navigating the legal landscape
Aiding and abetting language in some state laws may restrict clinicians from sharing much information about self-managed abortion, but one way the panelists suggested clinicians can protect their patients is by documenting minimally. For example, Verma said when she shares information about self-management with a patient she writes “options discussed” in the chart.
Perritt said information in the chart is designed to protect clinicians but can often be weaponized against patients.
“I think about every person’s chart that I document as something that will be weaponized against them should this go to court,” she said.
Perritt also said having positive documentation about a patient can be important because those arrested for suspicion of self-managing an abortion may lose custody of their other children. Positive documentation can be used to build a case to regain custody.
Grossman said the whole care team must agree about prioritizing patient safety.
“We did a study in south Texas, along the Mexican border, interviewing doctors and nurses in labor and delivery and emergency departments about self-managed abortion in cases that have been referred to the police,” Grossman said. “In many of those cases, they got social work involved and then social work got the police [involved].”
“You get to refuse to collude,” Perritt said. “You hold the power in this situation, certainly significantly more power than the person you are caring for. When the police come to your hospital and ask you to turn over your records, you can say no. You can refuse to participate in this process. In fact, I urge you to do so.”
Verma said none of the panelists could offer legal advice, but she urged clinicians to balance being careful to protect both themselves and their patients from legal consequences. She suggested clinicians should check with their lawyers because the law can vary from state to state, and policies can vary from facility to facility.
Grossman said talking to lawyers about specific restrictions is important because of how much fearmongering has been circulating in popular discourse around the topic.
“There is a lot of energy around the belief that this is or can be a solution to the abortion crisis, and while this has been going on for quite some time, it is not new,” Perritt said. “What we’re finding is that the public conversation about it has taken a different tone and a sense of urgency.”