Requests for Self-Managed Medication Abortion Provided Using Online Telemedicine in 30 US States Before and After the Dobbs v Jackson Women’s Health Organization Decision

On June 24, 2022, the US Supreme Court decision in Dobbs v Jackson Women’s Health Organization overturned Roe v Wade, creating a patchwork of state abortion laws. We assessed changes in online telemedicine requests to self-manage abortions with medications before vs after this decision.

Methods

The nonprofit Aid Access is the only online telemedicine service providing self-managed medication abortion (abortion conducted outside the formal health care setting) in the US. We analyzed anonymized requests for medications to the service in 3 periods: baseline (September 1, 2021, to May 1, 2022); after the Dobbs decision was leaked but before its formal announcement (May 2 to June 23, 2022); and after Dobbs was formally announced (June 24 to August 31, 2022). We omitted requests for advance provision of medications before pregnancy occurred and requests from 20 states where Aid Access provides telemedicine abortion within the formal health care setting. We categorized the remaining states as follows: (1) 12 states that banned abortion following the decision (including 3 where bans were enjoined but then reinstated during the study period); (2) 5 states that implemented bans after 6 weeks’ gestation; (3) 10 states that did not enact bans but indicated that bans or restrictions are likely; and (4) 3 states with no current or planned legal changes. During each period, we examined the overall rate of requests and, for each state separately, the mean rate of requests per 100 000 female residents aged 15 to 44 years. All requestors shared the reasons for their request from a list of responses or using open-ended text. We examined changes in requestors’ stated reasons for accessing the service before and after the formal announcement.

P values were calculated using t tests and tests for equality of proportions with statistical significance set at P < .05 (2-sided). We used R version 4.1.1 (R Foundation) for data analysis. Requestors consented to anonymous use of their data for research when making a request. The University of Texas at Austin institutional review board approved the study.

Results

Over the study period, the telemedicine service received 42 259 requests from 30 states. Mean daily requests were 82.6 (95% CI, 80.9-85.8) during the baseline period, 137.1 (95% CI, 128.8-145.5) following the leak (P < .001), and 213.7 (95% CI, 191.5-235.8) following the formal announcement (P < .001). Every state, regardless of abortion policy, showed a higher request rate during the periods after the leak and after the formal decision announcement, with the largest increases observed in states enacting total bans. The 5 states with the largest increases per week per 100 000 female residents from baseline to after the formal decision were Louisiana (from 5.6 to 14.9), Mississippi (from 2.2 to 7.8), Arkansas (from 2.1 to 7.1), Alabama (from 1.9 to 6.2), and Oklahoma (from 1.9 to 6.0).

In states with total bans, 31.4% of requestors cited “current abortion restrictions” as a reason for accessing the service at baseline vs 62.4% after the decision (difference, 31.0%; 95% CI, 29.7%-32.4%; em>P < .001). In states with 6-week bans, 3.9% of requestors cited that 6-week ban at baseline vs 28.9% after the decision (difference, 25.0%; 95% CI, 23.3%-26.8%; em>P < .001). In states where future bans are likely, 12.5% of requestors cited “possible future legal restrictions” at baseline vs 35.5% after the decision (difference, 23.0%; 95% CI, 21.1%-25.0%; P < .001). In states with no planned changes, no statistically significant changes in the proportions of requestors citing any of these reasons were reported.

Discussion

Requests for self-managed abortion through online telemedicine increased following Dobbs. The largest increases occurred in states that implemented total bans, with requestors frequently citing these bans as their motivation for accessing the service. Increases were also observed in states where the legal status of abortion did not immediately change. Possible explanations include increased awareness of the service, confusion about state laws, and disruption to in-clinic services following increases in out-of-state patients. Findings support prior research that limiting abortion within the formal health care setting is associated with more self-managed abortions.

Study limitations include that the sample is not representative of all people who seek abortions; those who self-manage may systematically differ, for example by being more likely to live with financial hardship or in rural areas. Also, the sample may not be representative of all people who self-manage abortions, as abortions from only 30 states and 1 pathway to self-management were included.