by Aliza Adler, M Antonia Biggs, Shelly Kaller, Rosalyn Schroeder, Ndola Prata, Karen Scott, Lauren Ralph
Contraception. January 2025. Vol. 141, Article No.110697.
Abstract
Objective
To assess the prevalence of ever considering self-managing an abortion (SMA) and its associations with experiences of medical mistrust and mistreatment in a nationally representative sample.
Study design
In 2021–22, we conducted a national, cross-sectional, online probability-based survey of US people assigned female at birth ages 15–49. Among those who had ever been pregnant, we ran weighted multivariable logistic regressions to examine whether having had difficulty trusting medical providers and/or experiencing medical mistreatment was associated with SMA consideration.
Results
Of 4,260 participants who had ever been pregnant, 5.2% (95% CI, 4.3%−6.3%) ever considered SMA. Additionally, 38.8% (95% CI, 36.8%−40.9%) reported prior moderate medical mistrust; 17.0% (15.4%−18.6%) experienced neglect of symptoms only, and 22.2% (20.6%−24.0%) experienced ridicule or humiliation in a previous healthcare encounter. In multivariable analyses, those who reported prior high medical mistrust had increased odds of considering SMA (aOR = 5.2, [95% CI, 2.9–9.2]), compared to those who had no prior medical mistrust. Those who had experienced ridicule or humiliation by healthcare providers had increased odds of considering SMA (aOR = 3.8, [95% CI, 2.3–6.1]), compared to those without such experiences. Participants who believed others perceived them as Black or Arab/Middle Eastern, were poor in their youth, or identified as Lesbian, Gay, Bisexual, Transgender, Queer, and other had higher proportions of considering SMA (p-values <0.01).
Conclusions
Experiences of medical mistrust and mistreatment are common and are associated with increased likelihood of considering SMA. Those who identified with a structurally minoritized group were more likely to consider SMA, and those whose “street race” was Arab/Middle Eastern had the highest likelihood.
Implications
If restrictions on abortion continue to increase, individuals may further consider SMA. Our findings suggest a need to create healthcare environments that foster trust and respect, as well as to ensure people have access to safe options for SMA.
Introduction
Since the United States (US) Supreme Court overturned the constitutional right to abortion, state-based abortion restrictions have expanded. Evidence suggests that individuals are increasingly self-managing abortions (SMA) – defined as seeking to end a pregnancy outside of the formal healthcare system. While the self-sourcing of medication abortion pills (mifepristone and/or misoprostol) for SMA has been shown to be safe and effective, people also frequently use other methods, such as ingesting herbs or using physical methods, with less well studied efficacy and safety profiles. With the ever-shifting abortion access landscape in the US, it is important to understand to what extent pregnant people consider SMA, to better design and target outreach efforts that ensures access to effective and safe models of abortion.
Prior research demonstrates that barriers to facility-based abortion care and/or living in places “hostile” to abortion are strongly associated with attempting SMA, as are living below 100% of the Federal Poverty Level, being born outside of the US, being uninsured, or lower educational attainment. Further, several studies have shown higher prevalence of SMA among non-Hispanic Black and Hispanic participants, which may be due to amplified barriers to reproductive healthcare and experiences of medical racism among these populations. Additionally, seeking abortion due to physical or mental health reasons and experiencing barriers to abortion care have been associated with considering SMA. However, few studies have examined how negative healthcare experiences in general (i.e., beyond reproductive healthcare) may impact SMA consideration and prevalence.
Medical mistrust can exist both on a systemic and interpersonal level, with individuals experiencing varying degrees of mistrust across both levels; however, experiencing either level may result in decreased interactions with the healthcare system. Previous studies indicate that people who lack trust in the healthcare system or have been mistreated may prefer to limit interactions within the medical system and may delay reproductive healthcare or seek this care only when necessary. Prior evidence indicates that racial discrimination in healthcare can create and perpetuate medical mistrust and mistreatment. One study found that participants who experienced racism in healthcare settings reported a strong desire to manage their own reproductive healthcare and sought to reduce medical interventions as existing systems did not meet their needs. Additionally, provider mistrust or dissatisfaction can be predictors for low adherence to reproductive healthcare, such as HIV treatments. Early evidence after the overturning of the constitutional right to abortion shows that criminalization of abortion may be contributing to greater mistrust between patients and clinicians. Consequently, individuals who face mistreatment or mistrust healthcare providers in general may be more likely to prefer seeking abortion care outside of the medical system.
To our knowledge, few quantitative studies have explored how often pregnant people consider SMA or how negative healthcare encounter experiences may influence abortion and SMA decision-making. Among these studies, most have focused on obtaining pills online or focused on trans and gender expansive participants only (gender expansive is defined as gender indentities that are not limited to man or woman).
Using nationally representative survey data, we examine the prevalence of consideration of SMA among ever pregnant people and its associations with experiences of medical mistrust or mistreatment. We hypothesize that individuals who experienced mistrust or mistreatment in the healthcare setting may prefer to seek health services outside of the formal medical system, and thus would be more likely to consider SMA.
[Editor’s comment: This study took place before Roe v. Wade was brought down, when most abortions in the US took place in clinics. Use of medical abortion pills increased rapidly once they became known and available, and this study took place on the cusp of the changes. The findings reported here should not be misread to imply that only, or even mostly, those who mistrusted the clinics or had less access to the clinics’ services (e.g. due to cost), sought self-managed abortions. It took time for large numbers of women and providers to learn about and trust the fact that SMA was safe and to start providing/using MA pills without clinical oversight. There was also initially concern that SMA threatened the financial viability of many clinics. Lastly and importantly, the main body of this paper is behind a paywall and we don’t know whether or how it addresses these aspects of this subject. So I urge caution in thinking that mistrust or lack of support from “the system” were the main reasons for women moving to using SMA in large numbers. SMA is and has been recognised by WHO on down as a positive choice and a major step forward for women’s autonomy in and of itself.]