July 9, 2018 Liz Borkowski, MPH 0Comment

With Justice Anthony Kennedy having announced his retirement from the Supreme Court and President Trump having demonstrated his commitment to nominating justices who will vote to overturn Roe v. Wade, the threat against abortion rights has intensified. Although two-thirds of the public oppose overturning the 1973 Supreme Court decision that established the constitutional right to abortion, and the rule Senate Majority Leader Mitch McConnell invented in order to deny Obama SCOTUS nominee Merrick Garland a vote dictates waiting until after the next election before confirming a Trump nominee, we’re soon likely to see a Supreme Court majority that opposes women’s rights to control their own bodies and family size.

A very helpful New York Times article by Pam Belluck and Jan Hoffman considers what conditions were like in the U.S. before Roe v. Wade, how they’ve been changing, and how they’re likely to change in the coming years. The article is well worth a read, and it’s also a good opportunity to highlight some of the recent evidence that we should keep in mind as abortion takes center stage in political discussions.

Belluck and Hoffman begin by invoking the era of “back-alley, coat-hanger abortions” that preceded Roe, but posit that scientific advances in contraception and abortion will preventing a wholesale return to that kind of scenario. With long-acting reversible contraception and emergency contraception being more widely available and accessible, abortion rates have fallen. Medication abortion allows for abortions outside healthcare settings, and women in countries where most abortion is illegal routinely order abortion drugs online. However, access to these interventions is uneven, and those with the fewest resources often face the greatest barriers.

Simultaneous threats to contraception
Don’t make the mistake of thinking that Republicans’ efforts to limit access to reproductive healthcare stop at abortion. The successful Title X family planning program has a four-decade track record of helping people with low incomes and insufficient insurance access high-quality, culturally sensitive reproductive healthcare, but the Trump administration has issued a funding announcement and domestic gag order that would result in federal funding being shifted away from providers that offer comprehensive family-planning care and toward those that focus on natural family planning and don’t offer a full range of contraceptive options. “It appears that the Trump administration aims to transform the very intent of the Title X program by reshaping the scope of services and the network of entities supported by Title X funds,” Guttmacher Institute’s Kinsey Hasstedt writes at the Health Affairs blog.

A hostile administration isn’t the only threat to Title X. House Republicans have tried to zero out Title X funding in the past, and the draft bill from the relevant House appropriations subcommittee for fiscal year 2019 also eliminates it. The constant struggle to maintain even level funding hasn’t helped the program keep up with rising costs. What might the U.S. unintended pregnancy rate look like if we invested more in equipping people to achieve the families they want on the timetables they desire? Belluck and Hoffman write:

Johanna Schoen, a professor at Rutgers University in New Brunswick, N.J., who specializes in the history of women’s reproductive health, said the fate and rate of abortion will be intertwined with the availability of contraception, and whether anti-abortion political forces also take aim at birth control.

Professor Schoen said many European countries have low abortion rates because birth control and sex education are widely available. “But in the United States, the same people who are trying to restrict abortions have tried to restrict contraception, too.”

And it’s not just abortion and contraception: Comprehensive sex education and teen pregnancy prevention programs are also under attack.

Uneven access
Advances in contraceptive and abortion care and a dropping uninsurance rate have indeed improved reproductive health in the U.S., but the gains have become less evenly distributed as some states have adopted multiple restrictions on abortion. Today, access to abortion is far more limited in the Midwest and South than in the Northeast and West. Researchers from Advancing New Standards in Reproductive Health identified 27 U.S. cities where those seeking abortions must travel more than 100 miles to reach an abortion facility. Travel distances for abortion have increased in recent years, Guttmacher Institute researchers found, as states have enacted more abortion restrictions that lead to clinic closures. Belluck and Hoffman report on the increase in abortion restrictions and their disparate impacts:

A report this year by a committee of the National Academies of Sciences, Engineering and Medicine found that three-quarters of women who have abortions are poor or low-income, and 61 percent are women of color. Such women bear the brunt of state laws that restrict abortion, including those requiring multiple appointments or waiting periods or that limit which providers can perform abortions.

Such hurdles and delays could eventually threaten the consistently high level of safety in abortion procedures, experts said. “We found that more and more regulations on abortion and abortion procedures reduced the quality of care,” said the committee’s co-chairwoman, Dr. Helene Gayle, president and chief executive of the Chicago Community Trust.

That National Academies report is The Safety and Quality of Abortion Care in the United States, and I highlighted some of its findings here. My colleagues and I also recently published a white paper on the impacts of state-level abortion restrictions: restrictions on insurance coverage, gestational limits, waiting periods, state-mandated information, restrictions on medication abortion, and requirements on abortion facilities and providers that are far more burdensome than necessary to ensure patient safety. We found that the recent wave of regulations reducing access to abortion care isn’t based on compelling evidence that they’ll improve public health — in fact, a growing body of research shows that public health suffers when laws reduce abortion access.

Recently, states have been adopting legislation that bans abortions at earlier points in pregnancy, including 15 weeks in Mississippi and as soon as a fetal heartbeat is detected in Iowa — which can be as early as six weeks, before many women even realize they’re pregnant. Earlier gestational limits are most burdensome to those who face delays in accessing abortion care, which can be due to not recognizing the pregnancy, struggling to afford the procedure or associated costs (such as transportation or childcare), and not having easy access to a provider. In a study that compared characteristics of women who received abortions at six weeks or earlier (when they would still be allowed under Iowa’s law) to those of women who received second-trimester procedures, the Guttmacher Institute’s Rachel Jones and Jenna Jerman found:

Among first-trimester abortion patients, characteristics that decreased the likelihood of obtaining a very early abortion include being under the age of 20, relying on financial assistance to pay for the procedure, recent exposure to two or more disruptive events and living in a state that requires in-person counseling 24–72 hours prior to the procedure. Having a college degree and early recognition of pregnancy increased the likelihood of obtaining a very early abortion. Characteristics that increased the likelihood of obtaining a second-trimester abortion include being Black, having less than a high school degree, relying on financial assistance to pay for the procedure, living 25 or more miles from the facility and late recognition of pregnancy.

For the moment, judges have blocked the Iowa and Mississippi laws, but one of those legal challenges could be the case that lets the Trump-era Supreme Court take away the right to an abortion. The Center for Reproductive Rights warns that if Roe v. Wade is overturned, 23 states could ban abortion outright. So, the disparities in abortion access that have been growing over the past several years could get substantially worse.

Self-managed abortion
What happens if abortion becomes effectively illegal in several states or the country as a whole? Belluck and Hoffman note that in many countries that ban abortions in most or all circumstances, “women have managed to get [abortion] drugs from websites and abortion rights organizations that ship them.” For instance, the nonprofit Women on Web mails abortion drugs — a combination of mifepristone and misoprostol — to women who seek abortions in countries that ban it, and provides online medical consultations. Abigail Aiken and colleagues studied outcomes in 1,000 women from the Republic of Ireland and Northern Ireland who managed their own abortions after receiving medications online from Women on Web and provided follow-up information. The authors conclude, “Self sourced medical abortion using online telemedicine can be highly effective, and outcomes compare favorably with in clinic protocols.”

The combination of the drugs mifepristone and misoprostol is more effective than misoprostol alone, but the World Health Organization advises that misoprostol can be safely used alone to end a pregnancy in circumstances when mifepristone is not available. Misoprostol is also a treatment for gastric ulcers; U.S. residents who cross the border can obtain it from pharmacies in Mexico. Purchased this way, though, it does not come with instructions for use as an abortifacient. If users don’t take the correct dosage, they may not realize an abortion has failed until the pregnancy is too far advanced for a medication abortion. Extensive research supports the use of medications for abortion for pregnancies of up to 70 days; beyond that, research is more limited, but suggests that efficacy declines as the pregnancy advances. Another concern about not consulting a healthcare provider is that medication abortion is not effective for ectopic pregnancies, a rare but serious condition.

Researchers from the Texas Policy Evaluation Project surveyed Texas women about whether they had tried to end a pregnancy on their own, or whether they knew or suspected a best friend had done so. Participants reported that such attempts had included taking misoprostol, using herbs or homeopathic remedies, or getting hit in the abdomen. Based on those responses, the authors estimate that 100,000–240,000 Texas women have tried to end a pregnancy on their own without medical assistance.

Self-managing an abortion, or receiving a procedure from someone who is not part of the formal medical system, may be appealing to those who’ve had negative experiences with healthcare providers, find it financially or logistically difficult to access care in a clinic, want to preserve their privacy, or prefer to receive care in their own homes or communities. While health advocates call for elimination of barriers to abortion care from licensed providers, some also promote dissemination of information about how to safely self-manage abortion and streamlined access to abortion drugs. In the U.S., the sites Plan C and Women Help Women do not directly supply medications, but do offer support and information about recommended use of medications for abortion.

To obtain the drugs, one option is for U.S. residents is to order mifepristone and misoprostol online, and hope the pills that arrive are what the sellers claim. For the New York Times, Patrick Adams reported on researchers investigating online abortion-drug purchases:

The F.D.A. warns against purchasing the drugs from online vendors, but women in the United States are doing it anyway. Increasingly, advocates of access to the drugs say, women are turning to the internet to procure the pills for use in their homes. [Francine] Coeytaux and her colleague, Elisa Wells, who lives in Portland, Ore., were curious: Who are these vendors? Will they steal your credit card information? Will the pills get held up in customs? Will the police come knocking on your door? Are the drugs real?

“And guess what?” Ms. Coeytaux said, then paused, eyebrows arching. “It worked.” Within two weeks, she said, the pills had arrived on her doorstep. The cost, including shipping, came to just over $200, but the question remained: Was this the real thing? Ms. Coeytaux passed the envelope around the table. Inside was a blister pack bearing the names of the medicines.

… “The fact is, women in the U.S. are already doing this, and the reproductive health community needs to catch up,” Ms. Wells said. “We started Plan C because we believe it’s time for bold action. We have to make sure women have the information they need, that they know their rights” — for example, that they are not obligated to report to the police or providers that they have taken abortion pills; that the drugs can’t be detected in their blood; and that knowing that a woman has used the pills has no bearing on follow-up care, which is the same as for a natural miscarriage.

The team has since published their results. They ordered mifepristone and misoprostol from online vendors and analyzed the pills they received (18 mifepristone-misoprostol combinations and two misoprostol products from 16 different websites). All mifepristone tablets contained 92 – 102% of the labeled quantity; most misoprostol tablets contained lower amounts than labeled, though the authors note that lower amounts are not necessarily ineffective for terminating pregnancy. There were also some worrisome findings, the authors (Chloe Murtagh et al.) report:

Nearly half of the products did not arrive until after the anticipated date. The products received rarely appeared to be the same brand as those ordered, and none came with instructions for use. Some websites disappeared shortly after the order was placed. The security of the information provided to vendors, including financial information, was questionable; indeed, we received fraud alerts and a notification from a vendor suggesting that an active investigation was ongoing. This potential lack of security may be a concern to some buyers given that people in the United States have been prosecuted for using abortion pills they procured online.

Facing prosecution for attempting to end one’s own pregnancy is not a purely hypothetical scenario. Irin Carmon writes in the Washington Post:

If states regain unfettered control of abortion law, will they punish women for trying to end their pregnancies? In fact, they already do. According to data gathered by Berkeley Law’s Self-Induced Abortion Legal Team, part of the school’s Center on Reproductive Rights and Justice, 17 women are known to have been arrested since 2005 after being accused of self-inducing abortions. Even if it isn’t explicitly illegal in their states, prosecutors have brought charges like feticide or violating laws requiring that an abortion be provided by a physician. “The danger of people being arrested, being jailed, being separated from their families, being potentially detained and deported,” says Jill Adams, executive director of the center, “these are the real dangers of self-induced abortion in 2017.”

Just ask Purvi Patel. Doctors at the Indiana hospital where she showed up in 2013, bleeding after taking pills to end her pregnancy (which, she maintained, she thought was far less advanced than the 25-plus weeks she’d already notched), called the police. Abortion is legal in Indiana, and the state’s feticide law was passed to protect pregnant women from violence. Yet she was convicted of feticide and neglecting a dependent, and was given a 20-year prison sentence. Her sentence was reduced on appeal, and she went free last September after 525 days. In March, authorities in Chesterfield County, Va., arrested Michelle Roberts on felony charges of “producing abortion or miscarriage,” The Washington Post reported, after police found fetal remains buried on her property.

The National Institute for Reproductive Health notes that criminalizing self-managed abortions means that women seeking care for miscarriages can be interrogated by police and prosecuted. Their recent report points out that low-income women and women of color are particularly vulnerable to prosecution for self-abortion, as they face more barriers to affordable legal abortion and are more likely to be targets of law enforcement.

The bottom line
Those who want to see fewer abortions should support universal access to comprehensive sex education and high-quality family planning care — including all FDA-approved forms of contraception. Abortion restrictions don’t lead to fewer abortions; they just exacerbate existing disparities. “The people most impacted are the immigrant women already under siege, low-income women, women of color, transgender and queer women,” Jessica González-Rojas, executive director of the National Latina Institute for Reproductive Health told Belluck and Hoffman.

As abortion restrictions tighten further, we will almost certainly see more women try to end their pregnancies without the involvement of licensed healthcare providers. Thanks to increased availability of abortion drugs and high-quality online information, many of these self-managed abortions will be safe and effective. However, some of those with the fewest resources — such as women whose abusive partners monitor their search histories and mail — will still turn to the same kinds of risky measures, like corrosive liquids and sharp objects, that were common before Roe v. Wade. Medical science may have had important breakthroughs, but in the United States, attitudes about reproductive autonomy haven’t advanced nearly enough.

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