The Growing Importance of Self-Managed and Telemedicine Abortion in the United States: Medically Safe, but Legal Risk Remains.

The salience of the study has grown as the proportion of Americans who use medications to end their pregnancies has increased and as state-level legal barriers to abortion access have proliferated, with outright bans expected within months.3 The ongoing COVID-19 pandemic has also increased demand for at-home medication abortion because of concerns about the risk of contracting COVID-19 in a clinic or in transit;this has added to long-standing barriers to access for clinic-based abortion care, including long distances to the nearest clinic, arranging care for dependents, and more.4 Aiken et al. note the effect of abortion restrictions on increasing demand for at-home medication abortion and offer a preview into the future of abortion seeking for the growing number of Americans who will be legally unable to obtain abortion in a clinical setting. Questions remain about the challenging legal issues that will arise with actions that cross borders of states with differing laws.3 Self-managed abortion may place the person having the abortion or people who help them at risk for criminal and civil penalties8;indeed, people who self-managed their abortion and individuals who helped them have been arrested and prosecuted in the United States.9 The laws of some states specifically criminalize self-managed abortion, whereas laws unrelated to abortion (e.g., fetal harm laws, homicide laws) may also be used to prosecute people who self-manage.9 The distinction between self-managed abortion and telemedicine is also pertinent to the study of the safety and effectiveness of telemedicine abortion, which is well-established as on par with clinic-based medication abortion.4,10 Research on self-managed medication abortion has similarly found levels of effectiveness and safety comparable to clinical care.6,11 Because of the ambiguous legality and decentralized nature of self-managed abortion, however, research on this experience faces unique challenges, such as difficulty identifying a representative sample of people who self-manage and difficulty gaining their trust in the face of privacy and legal concerns-challenges that are less likely when researching telemedicine abortion.12 The model that Aiken et al. studied is somewhat of a hybrid, with the recordkeeping end more closely mirroring telemedicine models and the experience of the person seeking abortion more closely mirroring that ofselfmanaged models. Ten states have six-week bans, and two have enacted total abortion bans.13 Viewing the study results of Aiken et al. through the lens of the future abortion landscape in the United States would predict an increase in demand for out-of-clinic abortion, as state law becomes more restrictive with the weakening of federal constitutional protections. [...]the development of causal models for the operation of laws can set the stage for accurately measuring the relationship between policy and demand for and incidence of self-managed abortion among specific populations.15 NEW RESEARCH The study authors appropriately noted the growing evidence of the safety and efficacy of self-managed medication abortion through online telemedicine and highlighted that the primary risk associated with self-managed abortion may be legal risk. Since the study was published, new research has further established the high levels of safety and effectiveness of self-managed medication abortion across a range of out-of-clinic models-ranging from 94% to 100% abortion completion without surgical intervention.11,16 One recent study in particular-the SAFE (Studying Accompaniment model Feasibility and Effectiveness) study- evaluated the safety and effectiveness of self-managed medication abortion with support from accompaniment groups, whereby non-clinically trained counselors provide information and support over the telephone as needed to people self-managing their abortions.11 The SAFE study further established the effectiveness and safety of self-managed medication abortion and, importantly, concluded that effectiveness in the self-managed setting is not inferior to the clinical setting.