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B1 Self Managed Abortion B1- Ensuring Support for and Access to Self-Managed Abortion 1 I. Title: Ensuring Support for and Access to Self-Managed Abortion 2 3 II. Author Identification 4 • Monique Baumont, Center for Reproductive Rights, 199 Water St, 22nd Floor, New York, NY 5 10038, [email protected], Member #10432693, Sexual and Reproductive Health 6 Section 7 • Bonnie K Epstein, unaffiliated, 4403 Riverview Ave, Englewood, NJ 07631, 8 [email protected]. Member #9855820, Sexual and Reproductive Health Section. 9 • Caitlin Phelps, American College of Obstetricians and Gynecologists, 409 12th Street, SW 10 Washington, DC 20024-2188, [email protected], Member #9847505, Sexual and Reproductive 11 Health Section 12 • Silpa Srinivasulu, Reproductive Health Access Project, P.O. Box 21191, New York, NY 10025, 13 [email protected], Member #10338166, Sexual and Reproductive Health Section 14 15 III. Co-Sponsorship: Sexual and Reproductive Health Section 16 17 IV. Collaborating Units: N/A 18 19 V. Endorsement: International Health Section 20 21 VI. Summary 22 Access to abortion care is essential to the health, well-being, and bodily autonomy of pregnant 23 people and their families. While the right to abortion is constitutionally protected in the U.S., restrictive 24 state and federal legislation and regulations have eroded this right. These policies have exacerbated 25 structural inequities to undermine and impede access to care, disproportionately affecting Black, 26 Indigenous, and people of color, those with lower incomes, immigrants, and people in rural areas. Due to 27 logistical and financial barriers to accessing abortion care, and some people’s personal preferences and 28 experiences of stigma and structural racism with respect to the medical system, there has been 29 considerable growth in demand for self-managed abortion in the U.S. Yet, some police and prosecutors 30 continue to misuse state laws to criminalize people who end their pregnancies outside of a medical 31 context or people who support them. Moreover, unnecessary restrictions and regulations prevent people 32 from having full access to safe and effective medications to self-manage their abortions. The desire to 33 stay at home throughout the COVID-19 pandemic and avoid potential virus exposure has heightened 34 interest in this care, making it particularly important to establish and strengthen the public health 1 B1- Ensuring Support for and Access to Self-Managed Abortion 1 community’s support for self-managed abortion. This policy statement recommends that APHA members, 2 public health professionals, clinicians, and elected officials denounce the criminalization of self-managed 3 abortion, including the criminalization of those who provide support, and work toward guaranteeing safe 4 and equitable access to the full-range of safe abortion care options, including self-managed abortion. 5 6 Relationship to Existing APHA Policy Statements 7 ● #20152: Restricted Access to Abortion Violates Human Rights, Precludes Reproductive Justice, 8 and Demands Public Health Intervention 9 ● #20083: Need for State Legislation Protecting and Enhancing Women’s Ability to Obtain Safe, 10 Legal Abortion Services Without Delay or Government Interference 11 ● #20112: Provision of Abortion Care by Advanced Practice Nurses and Physician Assistants 12 ● #201113: Call to Action to Reduce Global Maternal, Neonatal, and Child Morbidity and 13 Mortality 14 ● #20139: Renouncing the Adoption or Misapplication of Laws to Recognize Fetuses as 15 Independent of Pregnant Women 16 ● #20199: Preventing and Reducing the Harm of the Protecting Life in Global Health Assistance 17 Policy in Global Health 18 ● #200314: Support for Sexual and Reproductive Health and Rights in the United States and 19 Abroad 20 ● #20153: Universal Access to Contraception 21 22 VII. Rationale for Consideration 23 This is a new policy statement about public health and medical professionals’ responsibility to 24 support people’s rights to access the full-range of safe abortion care options free from criminalization or 25 unnecessary restrictions, including self-managed abortion. This policy statement does not replace or 26 update an existing one. APHA has identified the need to address self-managed abortion as demand for 27 this option came to the forefront during the COVID-19 pandemic. Self-managed abortion with medication 28 for those who prefer it is safe, effective, and enhances bodily autonomy. Over the last five years we have 29 witnessed increasingly restrictive state mandates on abortion leading to clinic closures, delays in care, and 30 logistical and financial barriers. Self-managed abortion would address these issues. Given accurate 31 information, self-managed abortion is as safe as clinic-based care. APHA has a long history of 32 recognizing access to safe abortion care as a public health issue and has demonstrated support for 33 reproductive justice, particularly pregnant people’s bodily autonomy. APHA has several abortion-related 34 policies, but none that specifically address self-managed abortion. 2 B1- Ensuring Support for and Access to Self-Managed Abortion 1 VIII. Problem Statement 2 In the past decade, abortion access has become increasingly restricted in the U.S. Since 2011, 3 nearly 500 abortion restrictions have been enacted, including laws banning abortion in certain 4 circumstances and laws that impose medically unnecessary requirements on abortion care (1). Studies of 5 multiple states, like Texas, Georgia, and Ohio, have demonstrated adverse impacts of restrictive state- 6 level laws on access to abortion care, including delays in accessing care due to increased travel distance; 7 economic burdens from lost wages, childcare, and travel costs; increased stigma; and reduced abortion 8 rates (2-5). These barriers disproportionately impact Black, Indigenous, and people of color, low-income 9 people, immigrants, people with disabilities, members of the LGBTQ community, and people living in 10 rural and medically underserved areas (4). Despite the constitutional right to abortion, for many, state 11 restrictions interact with structural inequities to place abortion care entirely out of reach. 12 Self-managed abortion represents an alternative to clinical care for individuals facing barriers due 13 to abortion restrictions or who prefer this method. Self-managed abortion occurs when an individual 14 performs their own abortion outside of a formal medical setting or without clinical supervision and can 15 include ingesting herbs, using mifepristone and misoprostol or misoprostol only (known as medication 16 abortion), inserting objects into the vagina, or other methods (6). 17 Researchers have documented considerable demand for self-managed abortion in the U.S. 18 Approximately 7% of U.S. women will self-manage abortion at some point in their lives, using a variety 19 of methods (7). A study of requests from U.S. residents for self-managed medication abortion through the 20 online telemedicine abortion service Women on Web from October 15, 2017 to August 15, 2018 21 identified 6,022 requests, three-quarters of which were from individuals living in states hostile to abortion 22 (8). Barriers to accessing abortion care during the COVID-19 pandemic have led to further increases in 23 demand. Based on data from the online medication abortion service Aid Access, there was a statistically 24 significant increase of 27% in the rate of requests for self-managed medication abortion from March 20, 25 2020 to April 11, 2020 compared to before the pandemic (8). Since these studies only measured a single 26 pathway to self-managed abortion, actual demand is likely much higher. 27 In exploring reasons for self-management, qualitative research identified that some individuals 28 seek self-managed abortion due to financial and logistical barriers to accessing clinical care, while others 29 prefer the privacy, comfort, and convenience offered by self-managed abortion (9). Subsequent 30 quantitative research similarly found that the majority of people report seeking self-managed abortion due 31 to both barriers and preferences, with cost, distance, inability to locate a clinic, and legal restrictions all 32 cited as barriers to clinical care, particularly in states hostile to abortion (7, 8). A nationally representative 33 study found that the prevalence of self-managed abortion was nearly three times higher among Black 34 women than White women and elevated among Hispanic individuals, indicating that they may face 3 B1- Ensuring Support for and Access to Self-Managed Abortion 1 heightened barriers to accessing clinical care or have a stronger preference for self-managed abortion due 2 to experiences of stigma, discrimination, and structural racism (7). 3 Despite considerable demand for self-managed abortion among pregnant people who prefer this 4 method or are unable to access clinical care due to state restrictions, numerous barriers, including threat of 5 criminalization and restrictions on the availability of medication, prevent people from self-managing their 6 abortion safely and with support. 7 Risk of Prosecution 8 State laws have been misapplied by police and prosecutors to punish people for self-managing 9 their abortion or for supporting those who self-manage, creating stigma and fear. As of 2020, five states 10 had antiquated laws criminalizing self-managed abortion despite the constitutionally protected right to 11 abortion (10). Due to stigma and anti-abortion political motivations, police and prosecutors
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