Society of Family Planning interim clinical recommendations: Self-managed abortion

“While the medical risks of SMA [self-managed] may be few, the legal risks for people attempting SMA may be significant. Although only three states currently have laws explicitly criminalizing SMA, almost half of U.S. states have at least one law in place that could be used to prosecute people attempting or assisting with SMA. These policies include legislation explicitly banning SMA, criminalizing harm to the fetus, and criminalizing abortion. For those who have been targeted with criminalization for SMA, many came into contact with law enforcement following interactions with healthcare professionals. However, to date, legal experts are unaware of any laws requiring a healthcare provider to report a self-managed abortion or a patient’s intention to self-manage an abortion to law enforcement authorities. In fact, reporting suspicions of SMA can cause harm, violate patients’ rights to privacy, and keep people from seeking care that they need. In addition, widespread implicit and explicit biases among clinicians and within the criminal legal system result in disproportionate reporting and prosecution of people of color and people with lower financial means, among others. Therefore, in addition to understanding the clinical aspects of care, clinicians must recognize the legal risks of SMA to best support their patients. While clinicians may have a range of opinions and perspectives on SMA, including feeling that SMA is safe, feeling that SMA is too risky, and feeling that people do or do not have a right to self-manage if desired, all clinicians have an obligation to provide compassionate, non-judgmental care to their patients. These interim clinical recommendations provide guidance to help clinicians understand methods and components of SMA, as well as best practices when caring for people interacting with the healthcare system before, during, and after self-managing their abortion.

What are the components of self-managing a medication abortion in the first trimester?
Three components of the self-managed medication abortion process are

  1. Self-assessment of eligibility, including estimating pregnancy duration and ruling out contraindications to use,
  2. Self-administration of abortion medications and management of the abortion process, and
  3. Self-assessment of abortion completion.

In addition to these three components, people undergoing SMA should have access to accurate information about how to use abortion medications, the ability to obtain quality abortion medications and medications to manage side effects, and the support of trained health workers and a healthcare facility if they need or desire it. [..]

What resources exist to help individuals find medications and to support them during self-management of their abortion?

Unlike in some other countries like Mexico, where misoprostol can be purchased from pharmacies without a prescription, people in the U.S. are usually unable to access misoprostol within the healthcare system without clinician involvement. However, organizations and resources functioning outside of the healthcare system can help individuals access the medications they need to self-manage. The Plan C website provides reliable up-to-date information on how to obtain abortion pills online for those in the U.S. They list groups that provide medications and clinical services outside of the formal healthcare system, as well as online pharmacies without clinical support. Aid Access is a global service that aims to support all people seeking safe and effective medication management of an abortion or miscarriage. Aid Access consists of a team of doctors, activists, and advocates working outside of the formal healthcare system who provide information and send medications to those in need of a safe abortion after evaluating people for eligibility.

There are several other resources available to support people who are self-managing their abortions.
For clinical questions:

For emotional support:

  • All-Options – This is a peer-based talkline (888-493-0092) to discuss pregnancy options or talk about past/current experiences with abortion, adoption, parenting, infertility, or pregnancy loss. At the time of publication of this document, they are open Monday-Friday 10-1a EST; Saturday/Sunday 10-6p EST.
  • Connect & Breathe – This is a peer-based talkline (866-647-1764) for nonjudgmental support after abortion. At the time of publication of this document, they are open Mon 7-10p EST; Tuesday-Thursday 6-9p EST; Saturday 12-3p EST.
  • Exhale – This is a peer-based phone/text hotline (617-749-2948) for emotional support around abortion. At the time of publication of this document, they are open weekdays 3p-9p PST, Saturdays 1p-9p PST, and Sundays 3p-7p PST.
  • Reprocare Healthline – This is an anonymous healthline (833-266-7821) providing peer-based emotional support, medical information, and referrals to those having an abortion at home with pills. At the time of publication of this document, the hotline is open 9a-9p PST, 7 days a week.

For legal questions: If/When/How – If/When/How runs a legal helpline to answer questions about legal rights and self-managed abortion. The helpline can be accessed by leaving a phone message at 844-868-2812 or filling out a secure online form any time of day. Interpreter services are available.

What medication regimens can be used for self-managed abortion?

[..] Currently, the U.S. Food and Drug Administration (FDA)-approved label for mifepristone includes a regimen for medication abortion that is a combination of mifepristone 200 mg orally followed by misoprostol 800 µg buccally 24 to 48 hours later. The WHO recommends the same dose and route of administration of mifepristone with use of misoprostol 800 µg either vaginally, sublingually, or buccally 24 to 48 hours later. Shortening the interval between mifepristone and vaginal misoprostol to 0 to 8 hours has been shown to be very highly, but slightly less effective than a 24 to 48 hour interval and may be statistically non-inferior. The effectiveness of a combined mifepristone and misoprostol regimen is approximately 98% at ≤49 days gestation and slightly decreases with advancing gestational duration to approximately 93-95% at 64-70 days. Addition of a second dose of misoprostol 800 µg four hours after the first increases effectiveness of medication abortion to 97-99% in gestations between 64-77 days. The WHO recommends, for individuals self-managing their abortions with mifepristone and misoprostol, to consider this regimen up to 12 weeks of gestation. Another recommended regimen >10-12 weeks’ gestation involves mifepristone 200 mg orally, followed 24-48 hours later with misoprostol 800 µg used vaginally, sublingually, or buccally and then misoprostol 400-800 µg every 3 hours until expulsion of pregnancy tissue. Oral misoprostol should be avoided since it is less effective than the alternate routes. People may be advised to avoid vaginal administration of misoprostol for abortion or miscarriage management to eliminate the risk of detection based on residue in the vagina if they present to a clinic or hospital. [..]

How can people self-assess completeness of a self-managed abortion with medications?

[..] Symptom checklists to self-assess abortion completion include questions about cramping, bleeding, passing of blood clots, and abatement of pregnancy symptoms such as nausea and breast tenderness after taking medication abortion pills. People experiencing no bleeding within 24 hours of taking misoprostol, bleeding less than 4 days, bleeding lighter than a typical menses, or ongoing pregnancy symptoms are instructed to seek care from a trained health professional. Few studies have examined the effectiveness of symptom checklists alone in self-assessed completion of abortion. These studies suggest that such checklists either require further refinement or may not add to the accuracy of diagnosing ongoing pregnancy over follow-up urine pregnancy tests.

The different types of urine pregnancy tests used in studies evaluating patient assessment of SMA completion include high-sensitivity pregnancy tests (HSPT) which detect urine human chorionic gonadotropin (hCG) levels as low as 25 mIU/mL (milliinternational units/milliliter), low-sensitivity pregnancy tests (LSPT) which are positive at urine hCG levels of 1000-2000 mIU/mL, and multilevel pregnancy tests (MLPT) which currently have very limited availability worldwide. Using a home pregnancy test self-assessment strategy, a person is instructed to take the first test on the day of mifepristone use and a repeat test approximately 7-30 days later. A negative LSPT, negative HSPT, or declining MLPT by at least one bracket level is consistent with a complete abortion. [..]

Urine hCG levels naturally decline toward the end of the first trimester, thus calling into question the effectiveness of home urine pregnancy tests to self-assess abortion completion beyond 63 days gestation. Whitehouse et al. compared the effectiveness of a LSPT and symptom checklist performed approximately 14 days after mifepristone use to ultrasound follow-up among patients using medication abortion at 64 to 70 days gestation. Among 558 patients, 2.3% had an ongoing pregnancy. An LSPT correctly identified all ongoing pregnancies (100% sensitivity) and the symptom checklist alone had a sensitivity of 76.9%. Using a combined symptom checklist and LSPT self-assessment strategy did not improve diagnostic accuracy of detecting an ongoing pregnancy over LSPT alone. [..]

How should clinicians approach caring for a patient who presents with complications during or after self-managing an abortion?

[..] In most cases, clinical management of patients who have attempted SMA is identical to the care of those with spontaneous pregnancy loss, and there is no need to ask or document in the medical record whether the person intentionally did something to try to end the pregnancy. Asking patients about whether they had a prior ultrasound during the pregnancy may be helpful to rule out ectopic pregnancy. If a patient has signs concerning for possible physical trauma, asking about what was used may be clinically relevant, but care should be taken to avoid documentation that may put the patient at legal risk. In some states, abortion restrictions may complicate clinicians’ ability to appropriately care for a patient after an SMA attempt when fetal cardiac activity is still present. For example, if a patient attempted SMA and presents with light bleeding and a continuing pregnancy, the clinician may not be able to intervene. If a patient attempted SMA and presents with ruptured membranes and a fetus with cardiac activity but has signs of uterine infection, the clinician may be able intervene. It is important for clinicians to work with their clinic and hospital staff to create policies to help facilitate evidence-based, compassionate care in these situations.

Clinicians should be sensitive to the fact that patients may be concerned about the potential legal risks of SMA. Patients should be given information about If/When/How’s Repro Legal Helpline (see above) for legal support. Clinicians should recognize that some patients may intentionally choose to withhold information relevant to their clinical presentation, and this decision should be respected and supported. Rarely does such withholding of information affect the care provided.

What privacy and confidentiality considerations should clinicians address when caring for a patient who is self-managing or has self-managed an abortion?

[..] Criminalization of SMA disproportionally harms those from marginalized communities and those who are more likely to experience surveillance from the criminal legal system. It is therefore essential that clinicians understand how to protect patient privacy and confidentiality when caring for a patient who is self-managing or has self-managed an abortion. As such, clinicians should be intentional about the information they request from patients. For example, given that complications of a spontaneous abortion and self-managed abortion with medications present similarly, clinicians often do not need to differentiate between the two scenarios to appropriately treat a patient. Similarly, some patients may present to the hospital or clinic with fetal tissue that they passed at home, or may pass tissue while presenting to the hospital or clinic for bleeding, pain, or other concerns. In these situations, it is often not relevant to the patient’s care whether they have had a miscarriage or self-managed an abortion, and clinicians can put patients at risk by asking about or documenting SMA. Clinicians can protect patients by only gathering and documenting information that is relevant to their current and future medical care. For example, a clinician can chart that a patient believes she was pregnant and is now bleeding, without specifying additional details.

To help clinicians understand their mandatory reporting obligations while also protecting patient agency and confidentiality, If/When/How produced “Patient Confidentiality and Self-Managed Abortion: A Guide to Protecting Your Patients and Yourself.” Here, legal advocates review common situations where healthcare professionals may feel they need to report SMA. As a guiding principle, If/When/How urges clinicians to ensure patients are aware of what healthcare professionals may have to report prior to requesting information that could result in criminalization. The following provides a brief overview of the common situations they highlight, and more detail can be found in their guide.

  1. Child and vulnerable adult abuse: Healthcare professionals are considered mandatory reporters for suspected child abuse and neglect in every state, and for vulnerable adult abuse in most states. However, a minor or vulnerable adult self-managing an abortion is usually not reportable as abuse.
  2. Statutory rape: Some states require clinicians to report statutory rape. However, the fact that a patient attempted SMA does not need to be reported.
  3. Certain traumas and injuries: Many states require clinicians to report certain violent injuries, such as gunshot or stab wounds, to law enforcement. However, SMA is typically not a reportable injury.
  4. Abortion: Most states have a system in place for clinicians to report abortion for vital statistics purposes. Commonly, clinicians only have to report abortions that they perform themselves, and do not need to report a patient’s self-managed abortion.
  5. Self-harm: Some states require clinicians to report concerns that a patient is at imminent risk of self-harm. Patients who are planning on SMA are not ordinarily considered at risk of self-harm. If a patient does disclose that they are considering serious self-injury to end a pregnancy, clinicians should practice harm reduction techniques. In some cases, they may need to report intention to cause self-injury, but do not need to report the reason behind the intention.
  6. Overdoses and drug use during pregnancy: While some states mandate reporting in the event of a drug overdose, clinicians are not required to report the intent behind the overdose. Therefore, clinicians do not need to document or report that a patient overdosed in order to end a pregnancy.”

Full article, N Verma, V Goyal, D Grossman et al., 2022.6.15