Demand for Self-Managed Online Telemedicine Abortion in the United States During the Coronavirus Disease 2019 (COVID-19) Pandemic.

INTRODUCTION

For many in the United States, abortion care is already difficult to access,[1] and the coronavirus disease 2019 (COVID-19) pandemic has created yet more potential barriers—including infection risk at clinics and state policies limiting in-clinic services. The severity of these state policies varies, but, in the most extreme case, Texas effectively suspended all abortions for approximately 4 weeks.[2] As a result, people may increasingly be seeking self-managed abortion outside the formal health care system.

Using data from Aid Access, the sole online abortion telemedicine service in the United States, we assessed whether demand for self-managed medication abortion increased as in-clinic access became more challenging.

METHODS

Aid Access provides medication abortion up to 10 weeks of gestation for those who make a request using an online consultation form.[3] We analyzed fully de-identified data provided by the service on all 49,935 requests received between January 1, 2019, and April 11, 2020, when the service temporarily paused.

We used regression discontinuity to compare requests from each state before and after the state implemented a business-closure order to slow virus transmission.[4] We also compiled information on the scope and implementation date of any state-level COVID-19–related abortion restrictions.[2] We assessed the significance of each state's discontinuity using a likelihood-ratio test compared with a null model without a discontinuity, and we calculated the percentage difference between actual requests and expected requests under the null model in the “after” period. For each state, we examined the prevalence of COVID-19 on the day of the business-closure order.[5] We also examined median daily time spent at home by residents in each state using data from aggregated, anonymized mobile device GPS traces provided by SafeGraph.[6] See Appendices 1–6, available online at http://links.lww.com/AOG/C18, for details of all analyses. The University of Texas at Austin Institutional Review Board approved the study.

RESULTS

From March 20, 2020, to April 11, 2020 (the average “after” period across all states), there was a 27% increase in the rate of requests for self-managed medication abortion across the United States (P<.001) (Table 1).

Table 1.

Actual Compared With Expected Numbers of Requests for Self-Managed Medication Abortion in the “After” Period for the United States Overall and for Each State Included in the Study

Eleven states showed individually significant increases in requests, ranging from 22% in Ohio (P=.012) to 94% in Texas (P<.001) (Table 1). Median time spent at home was 5% higher for these states compared with states without significant changes in requests (P=.037) (Appendix 6, http://links.lww.com/AOG/C18). States with significant increases in requests either had particularly high COVID-19 rates or more severe COVID-19–related restrictions on in-clinic abortion access (Appendix 5, http://links.lww.com/AOG/C18).

DISCUSSION

Our results may reflect two distinct phenomena. First, more people may be seeking abortion through all channels, whether due to COVID-19 risks during pregnancy, reduced access to prenatal care, or the pandemic-related economic downturn.[7,8] Second, there may be shift in demand from in-clinic to self-managed abortion during the pandemic, possibly owing to fear of infection during in-person care or inability to get to a clinic because of childcare and transit disruptions. In support of these possibilities, we observed higher levels of stay-at-home behavior in states with significant increases in requests.

Among states that limited access to in-clinic abortion during the pandemic, we observed larger increases in requests in states with the most severe and longest-lasting restrictions. Texas, the state with the most restrictive measures, showed the largest increase in requests, despite a relatively low burden of COVID-19 during the study timeframe.

In terms of limitations, we could not measure all pathways to self-managed abortion in the United States, and we may have lacked power to detect changes in some states with low request numbers or where abortion restrictions were implemented toward the end of the study.

The World Health Organization recommends telemedicine and self-management abortion-care models during the pandemic, and the United Kingdom has temporarily implemented fully remote provision of abortion medications.[9,10] In the United States, such services would depend on sustained changes to the U.S. Food and Drug Administration's Risk Evaluation and Mitigation Strategy, which requires patients to collect mifepristone at a hospital or medical facility, as well as changes to state-specific laws that prohibit remote provider consultation.[11] Our findings suggest that telemedicine models for medication abortion should be a policy priority; when in-clinic abortion services are not accessible, people may seek alternative ways of accessing time-sensitive care.