Surge in self-managed abortions reported post-Dobbs decision

The loss of federal abortion protection led to an increase in self-managed abortion (SMA) rates, especially among marginalized groups, according to a recent study published in JAMA Network Open.¹

In June 2022, the Supreme Court overturned federal protections on abortion in the Dobbs vs Jackson Women’s Health Organization decision. Between June 2022 and June 2024, abortion bans or severe restrictions have been implemented in 21 states, with data indicating a significant rise in travel to states with protections for abortion.

In 1 study, an increase in out-of-state abortion care was reported in Washington, with an increase in the number of weekly abortion of 6.35 observed after Dobbs.2 Additionally, the time to appointment increased by 1.6 days among Black patients and 1.5 days among White patients.

Concerns have arisen about an increase in SMA among patients unable to travel for abortion care.¹ Before Dobbs, SMA was estimated in 2% to 7% of patients seeking abortion care, but emerging data has indicated a rise in self-sourcing medication abortion pills since the Dobbs decision.

Investigators conducted a survey study to determine the impact of the Dobbs decision on SMA. Data was obtained from surveys administered from December 10, 2021, to January 11, 2022, and from June 14 to July 7, 2023.

Participants included panel members aged 18 to 49 years assigned a female sex at birth. Participants with adolescent female household members aged 15 to 17 years were also offered to invite them to take the survey.

SMA was evaluated as the primary outcome of the analysis. This outcome was determined by asking participants if they had ever taken or done something to end a pregnancy without medical assistance. Those who selected no or skipped this question were given a list of SMA methods and asked to select any they had used by themselves to attempt pregnancy termination.

If a participant gave a positive response to either question, they were asked follow-up questions about the method used, number of SMA attempts, age at first and most recent attempts, pregnancy testing before SMA attempt and result, reason for suspecting pregnancy, residence at most recent attempt, complication type, actions if SMA attempt failed, and whether they sought follow-up care.

The final question asked participants their reason for attempting SMA. Covariates included race and ethnicity, household size and income, state of residence, marital status, and lesbian, gay, bisexual, transgender, queer, or nonbinary/gender nonconforming (LGBTQ) identity.

There were 7016 participants in the 2021 to 2022 period and 7148 in the 2023 period, aged a mean 32.5 years and 32 years, respectively. Of participants, 14% were non-Hispanic Black, 21% Hispanic, and 54% non-Hispanic White.

A past-year abortion was reported in 0.62% of participants in 2021 and 0.88% in 2023. Based on national estimates of past-year abortion, an underreporting of 47% was estimated.

The overall prevalence of past-year SMA attempts was 2.4% in 2021 and 3.4% in 2023, indicating a significant increase of 1%. When restricting the analysis to cases with confirmed pregnancy, rates were 1.4% and 1.8%, respectively, which did not indicate a significant change.

When accounting for the underreporting of abortion, the prevalence of attempting SMA was 5% in 2021 and 7.1% in 2023. Additionally, the projected lifetime prevalence of SMA increased from 5.1% to 10.7%.

The rise in SMA attempts remained significant in the multivariable analysis, from 2.4% in 2021 to 3.3% to 2023. Compared to other race and ethnicity groups, non-Hispanic Black patients had the highest rate at 5.1%. Other factors increasing SMA risk included poor socioeconomic status during adolescence and LGBTQ status, at 4.4% and 5.8%, respectively.

Patients attempting SMA were aged a mean 20.7 years at first attempt in 2021 and 21.2 years in 2023. A first SMA attempt before the age of 20 years was reported by approximately 1 in 4 patients and more than 1 attempt in their lifetime by approximately 1 in 5.

These results indicated a significant increase in SMA attempts after the Supreme Court overturned federal protections on abortion. Investigators concluded SMA attempts will likely continue to increase as further restrictions are placed on abortion access.

References

1. Ralph L, Schroeder R, Kaller S, Grossman D, Biggs MA. Self-managed abortion attempts before vs after changes in federal abortion protections in the US. JAMA Netw Open. 2024;7(7):e2424310. doi:10.1001/jamanetworkopen.2024.24310
2. Krewson C. Out-of-state abortion travel and care delays increased in Washington post-Dobbs. Contemporary OB/GYN. June 3, 2024. Accessed July 31, 2024. https://www.contemporaryobgyn.net/view/out-of-state-abortion-travel-and-care-delays-increased-in-washington-post-dobbs