Decriminalization of and Support for Self-Managed Abortion

  • Date: Oct 26 2021
  • Policy Number: 20217

Key Words: Abortion, Sexual Health, Contraception

Abstract
Access to abortion care is essential to the health, well-being, and bodily autonomy of pregnant people and their families. While the right to abortion is constitutionally protected in the United States, restrictive state and federal legislation and regulations have eroded this right. These policies have exacerbated structural inequities, which undermine and impede access to care, disproportionately affecting Black, indigenous, and people of color; those with lower incomes; immigrants; and people in rural areas. Due to logistical and financial barriers to accessing abortion care and some people’s personal preferences and experiences of stigma and structural racism with respect to the medical system, there has been considerable growth in demand for self-managed abortion in the United States. Yet, some police personnel and prosecutors continue to misuse state laws to criminalize people who end their pregnancies outside of a medical context, as well as people who support them. Moreover, unnecessary restrictions and regulations prevent people from having full access to safe and effective medications to self-manage their abortions. The desire to stay at home throughout the COVID-19 pandemic and avoid potential virus exposure has heightened interest in this care, making it particularly important to establish and strengthen the public health community’s support for self-managed abortion. This policy statement recommends that APHA members, public health professionals, clinicians, and elected officials denounce the criminalization of self-managed abortion, including the criminalization of those who provide support, and work toward guaranteeing safe and equitable access to the full range of safe abortion care options, including self-managed abortion.

Relationship to Existing APHA Policy Statements

  • APHA Policy Statement 20152: Restricted Access to Abortion Violates Human Rights, Precludes Reproductive Justice, and Demands Public Health Intervention

Problem Statement In the past decade, U.S. abortion access has become increasingly restricted. Since 2011, nearly 500 abortion restrictions have been enacted, including laws banning abortion in certain circumstances and laws that impose medically unnecessary requirements on abortion care.[1] Studies of multiple states have demonstrated adverse impacts of restrictive state laws, including delays in accessing care due to increased travel distance; economic burdens from lost wages, child care, and travel costs; increased stigma; and reduced abortion rates.[2–5] These barriers disproportionately impact racial/ethnic minority individuals, people with lower incomes, immigrants, people with disabilities, LGBTQ (lesbian, gay, bisexual, transgender, queer or questioning) communities, and people living in rural and medically underserved areas.[4]

Despite the constitutional right to abortion, state restrictions interact with structural inequities to place abortion care out of reach for populations that are marginalized. The Turnaway Study, a prospective longitudinal investigation comparing outcomes among those receiving a wanted abortion with those denied an abortion, showed that women denied an abortion had elevated levels of anxiety, stress, and low self-esteem soon after the abortion denial; were more likely to report worse health years after; and were four times as likely to have a household income below the federal poverty level.[6] Self-managed abortion represents an alternative to clinical care for individuals who face barriers due to abortion restrictions or who prefer this method. Self-managed abortion occurs when an individual experiences an abortion outside of a formal medical setting or without clinical supervision and can include using mifepristone and misoprostol or misoprostol only (known as medication abortion), ingesting herbs, inserting objects into the vagina, and other methods.[7]

Researchers have documented considerable demand for self-managed abortion in the United States. Approximately 7% of U.S. women reported having attempted to self-manage abortion in their lifetime.[8] A cross-sectional study of requests from U.S. residents for self-managed medication abortion through the online service Aid Access between March 2018 and March 2020 identified 57,506 requests from individuals in all 50 states.[9] Barriers to accessing abortion during the COVID-19 pandemic have led to further increases in demand. Aid Access reported a statistically significant increase of 27% in the rate of requests for self-managed medication abortion from March 20 to April 11, 2020, relative to before the pandemic.[10] Since these studies measured only a single pathway to self-managed abortion, demand is likely much higher. 

Qualitative research has shown that some individuals seek self-managed abortion due to financial and logistical barriers to accessing clinical care, while others prefer the privacy, comfort, and convenience offered by self-managed abortion.[11] Quantitative studies have similarly revealed that the majority of women report seeking self-managed abortion due to both barriers and preferences, with cost, distance, inability to locate a clinic, and legal restrictions all cited as barriers to clinical care.[8–10] A nationally representative cross-sectional survey of 7,022 women showed that the prevalence of self-managed abortion was nearly three times higher among Black women than White women and elevated among Hispanic women, indicating that they may face heightened barriers to accessing clinical care or prefer self-managed abortion due to experiences of stigma, discrimination, and structural racism.[8] 

Despite considerable demand for self-managed abortion, numerous barriers, highlighted below, prevent people from self-managing their abortion safely and with support. This policy statement (1) opposes all criminalization of self-managed abortion, regardless of method, and (2) supports broader access to mifepristone and misoprostol, which are known to be safe and effective.[12–14]

Risk of prosecution: In addition to the nearly 500 abortion restrictions passed since 2011, other state laws, some not specific to pregnancy, have been misapplied by the police and prosecutors to punish people for self-managing abortion or for supporting those who self-manage, creating stigma and fear. As of 2020, five states had antiquated laws criminalizing self-managed abortion.[15] Due to stigma and anti-abortion political motivations, police personnel and prosecutors in other states misapply laws that criminalize harm to fetuses, as well as other laws, to target people who self-manage their abortion and/or those who support them.[16] In 2020, 13 states had criminal abortion laws that could be misapplied to people who self-manage, and nine states had laws criminalizing harm to fetuses.[15] As a result of these harmful laws, at least 21 people in the United States have been arrested for ending their pregnancies or helping others do so since 2000.[15]

If/When/How: Lawyering for Reproductive Justice has found that laws indirectly or directly criminalizing self-managed abortion are likely to be disproportionately used against immigrants, people of color, and other communities at the margins, who already experience overpolicing and disproportionate state surveillance and punishment.[15] From 1973 to 2005, more than 400 women were arrested or received forced interventions due to their pregnancy, of whom 52% were African American and 71% were economically disadvantaged. In South Carolina and Florida, approximately 75% of cases were brought against Black women, indicating substantial racial targeting.[17]

The threat of prosecution, including the risk of being reported by one’s doctor, impedes the public health priority of maintaining trust in the health care system and ensuring access to information and medical care for people who self-manage. As noted by the American College of Obstetricians and Gynecologists (ACOG), this may prevent people from using their preferred method of care due to fear of prosecution and increase the risk of negative health outcomes by deterring those who self-manage from seeking care for complications.[18] The threat of criminalization may also prevent people and organizations from assisting individuals with the self-managed abortion process. 

Self-managed medication abortion: The mifepristone and misoprostol or misoprostol-only regimens for medication abortion are supported by U.S. and international medical organizations, including the World Health Organization (WHO).[12,13] The medication abortion regimen, approved by the U.S. Food and Drug Administration (FDA), is 200 mg of mifepristone taken orally, followed by 800 mcg of misoprostol taken buccally or vaginally 24 to 48 hours later.[19] Most pregnant people who desire medication abortion are eligible and have no contraindication.[12] ACOG Committee Opinion 788 details the strong body of literature demonstrating that reproductive-age women can self-screen for hormonal contraception and suggests that similar self-screening for medication abortion could be accomplished without a provider.[20]  

Mifepristone and misoprostol are safe and effective for terminating a pregnancy. U.S. trials of 16,794 pregnant women showed that the regimen was 97.4% effective through 70 days of gestation.[19] Complications are very rare and occur in only a fraction of a percentage of patients.[21] The FDA confirms that medication abortion’s “efficacy and safety have become well-established by both researchers and experience, and serious complications have proven to be extremely rare.”[22] The misoprostol-only regimen is a safe, effective alternative to mifepristone with misoprostol; a systematic scoping review of 13,000 evaluable women revealed that this regimen was about 78% effective without additional intervention.[12,14] 

While stigma and restrictive legal contexts inhibit extensive research on self-managed medication abortion, research has shown that, with accurate information, it is safe and effective. A study of more than 1,000 Women on Web clients from the Republic of Ireland and Northern Ireland revealed that outcomes compared favorably with in-clinic medication abortion, rates of adverse events were low, and clients were able to self-identify symptoms of potentially serious complications and seek medical attention.[23] In a three-country prospective pilot study of people self-managing medication abortion with support from an online counselor, 94% of participants reported a complete abortion without surgical intervention, no adverse events were reported, and participants sought care after noticing potential complications.[24] Based on safety and effectiveness data, WHO states that medication abortion can be self-managed for pregnancies less than 12 weeks of gestation when people have access to a source of accurate information and to a health care provider should they want or need one during the process.[13] 

Restrictions imposed by the FDA: Despite the safety, effectiveness, and widespread use of mifepristone and misoprostol, the FDA has imposed a series of drug safety restrictions on medication abortion, known as risk evaluation and mitigation strategies (REMSs).[25] REMSs are applied in rare cases: when a drug is beneficial but carries the risk of serious side effects. As of 2017, only 74 of approximately 1,750 FDA-approved prescription drugs and therapeutic biological active ingredients had REMS programs.[22] Since mifepristone’s approval in 2000, data have shown an estimated mortality rate of 0.00063% and a rate of nonfatal serious adverse events ranging from 0.01% to 0.7%.[25] 

The mifepristone REMS requires distribution in clinics, hospitals, and medical offices by registered providers. Instead of receiving mifepristone in a pharmacy or by mail, individuals must travel, sometimes incredibly long distances, to a clinic or medical office that has a registered provider to pick up the medication in-person. Rather than improving safety, the REMS impedes access for people who wish to self-manage this way by creating medically unnecessary barriers to obtaining mifepristone, including having to arrange transportation and child care. Lawsuits challenging mifepristone’s REMS classification have noted that it disproportionately affects pregnant individuals with lower incomes and racial/ethnic minority populations and exacerbates geographic barriers to accessing health care.[26] According to ACOG, the mifepristone REMS is “outdated and substantially limit[s] access to this safe, effective medication.”[27] The FDA allows patients to self-administer mifepristone at home, making the required in-person trip to obtain the medication burdensome and unnecessary.[22] For self-managed abortion support services, this has created legal challenges or, in some cases, entirely prevented them from operating in the United States.[28] 

Self-managed abortion and human rights: Administrative and policy barriers to self-managed abortion violate international human rights law. The Committee on Economic, Social, and Cultural Rights asserts that abortion must be decriminalized, medicines for abortion must be made available, and states must ensure that abortion care is available, accessible, affordable, acceptable, and of good quality.[29] Furthermore, the committee recommends that states liberalize abortion laws to improve access to safe abortion, including medication for abortion, and remove barriers that infringe upon the right to bodily autonomy, integrity, equality, and nondiscrimination in relation to the right to sexual and reproductive health.[29,30] 

Moreover, applying a reproductive justice lens to abortion illuminates that access to abortion care is a critical aspect of a person’s life, autonomy, and dignity. The term “reproductive justice,” coined by a group of U.S. Black women human rights activists and organizers in 1994, refers to the interconnected human rights “to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.”[31] Putting the tools for safe abortion care into the hands of those who want and need them facilitates the realization of one’s right to bodily autonomy, to control one’s own health care, and to self-determination. 

A human rights and public health harm reduction approach requires efforts to ensure that individuals do not face legal risks from self-managing abortion and can self-manage abortion with access to accurate information, quality medicines, and support. As clinical care for abortion becomes increasingly restricted and stigmatized in the United States, more individuals may turn to self-managed abortion. For some, the combination of state abortion restrictions and the FDA REMS has placed both clinical care and self-managed medication abortion out of reach. These individuals face increased health risks from unsafe techniques for self-managing abortion or from being forced to carry their pregnancy to term.

Evidence-Based Strategies to Address the Problem 
Creating an enabling environment for people to receive abortion care how they need and prefer—without stigma or fear—will require decriminalizing all forms of self-managed abortion, exploring and expanding models for self-managed abortion information and support, demedicalizing in-clinic medication abortion, and funding research to generate further evidence to support this care.

Decriminalizing self-managed abortion at the state level: If/When/How has developed a three-level approach to state advocacy to enable pregnant people to self-manage and seek medical care without fear of prosecution: repeal, reform, reinforce. The group works with state-based advocates to urge state policymakers to repeal criminal, pre-Roe laws targeting people who self-manage abortion; reform laws to prevent misuse by prosecutors; and reinforce existing abortion rights protections to include freedom from criminalization. Clinicians, law enforcement, and prosecutors must also understand actual legal requirements to prevent improper applications of the law. While no mandatory rules exist to report people who self-manage their abortion, administrative policies may be misinterpreted to permit or require clinicians to report self-managed abortion, compromising patient trust and undermining ethical and legal requirements to protect patient privacy and health.[18] 

Models for delivering self-managed abortion information, support, and care safely and effectively: WHO recommends that individuals have accurate information and access to a health care provider should they need or want them at any stage of self-managed abortion.[13] In response, many initiatives support self-managed medication abortion while promoting human rights and autonomy.[32] In countries where abortion is heavily restricted, organizations led by lay community experts—community health workers (CHWs), doulas, or trained volunteers—have effectively implemented safe abortion hotlines providing information on how to use misoprostol.[32] Accompaniment models for self-managed abortion, in which trained grassroots networks provide pregnant people with evidence-based counseling and support, have expanded to communities where the legal right to abortion exists but barriers impede access to care. Retrospective chart reviews and prospective studies have shown that these models are effective in supporting clients to obtain the necessary medications and complete their abortion without complications or clinic-based care.[24,33] Similarly, doulas have long provided information, patient advocacy, navigation, and emotional and physical support to those trying to make ends meet and racial/ethnic minorities in the United States, including for abortion.[34] While at present there is not a widespread movement of doulas providing self-managed abortion accompaniment (likely due to stigma and risks of criminalization), doulas are well positioned to implement community-based accompaniment to support clients in self-managing abortion safely and effectively. Furthermore, a retrospective chart review of women who received abortion care from trained CHWs in three Latin American countries revealed that CHWs are able to provide misoprostol-only abortion care safely and effectively. The study showed that 94% of cases were completed without further intervention, and there was timely follow-up for uterine aspiration in all other cases.[35] Qualitative studies and the aforementioned models show that trained laypeople are capable of providing evidence-based and culturally affirming support and information to clients in their communities.[36] 

In the United States, many reputable national organizations provide evidence-based information online about self-managed abortion. Plan C provides up-to-date, local information on where to obtain pills. The Reproductive Health Access Project published “Sam’s Medication Abortion,” a zine in English and Spanish that illustrates medication abortion experiences. Through the M+A hotline, physicians take questions, direct clients to resources, and support them through the process without directly providing pills. If/When/How’s free confidential helpline answers legal questions about self-managed abortion. These services, too, face the threat of criminalization as a result of misapplied laws and anti-abortion sentiment, making it more difficult to provide support. Legal protections for those who self-manage and who provide support services are crucial to enable positive, safe, and dignified self-managed abortion experiences. 

Amending the FDA mifepristone REMS: Due to a large body of evidence demonstrating their safety, effectiveness, and acceptability, expanding access to mifepristone and misoprostol outside of the clinic setting is an essential first step in strengthening access to safe self-managed abortion.[21] However, the FDA REMS requirements regarding mifepristone are inconsistent with its safety profile and create barriers to health care not imposed on other medications with documented higher levels of risk.[25] For example, treatment for erectile dysfunction (phosphodiesterase type 5 inhibitors) has a mortality rate of 0.004% (versus 0.00063% for mifepristone), yet this medication is not subject to REMS restrictions.[25] Antibiotics and insulin are both associated with serious, potentially fatal adverse reactions, and neither are limited by REMSs.[25] 

Public health researchers and advocacy organizations have been working for decades to generate high-quality evidence on the safety of mifepristone and the burdens of its REMS and to urge the FDA to review the evidence. The American Civil Liberties Union filed two lawsuits on the REMS: Chelius v. Becerra and ACOG v. FDA. The former seeks to remove mifepristone from the REMS entirely and the latter, in response to the COVID-19 pandemic, sought a temporary suspension of the in-person dispensing requirements.[37] In July 2020, a federal court ruled for the FDA to temporarily suspend this requirement, allowing clinicians to provide telemedicine abortion and to mail the pills to patients in 31 states, where telemedicine abortion is legal. While the Supreme Court overturned the temporary injunction in January 2021, the FDA decided to no longer enforce the in-person dispensing requirement as of April 12, 2021, until the end of the COVID-19 public health emergency. In addition, on May 7, 2021, the FDA announced its initiation of a comprehensive evaluation of the mifepristone REMS. 

Revoking the REMS classification would allow mifepristone to be provided via prescription in retail and online pharmacies without unnecessary clinician certification and additional logistical and financial burdens on clinics and patients. A prospective cohort study has already shown pharmacist-dispensing models to be safe and acceptable to U.S patients.[38] Experts concur that the mifepristone REMS is inconsistent with the express rules governing how the FDA determines REMS classification and creates unnecessary burdens rather than enhancing patient safety.[25,37,39] 

Telemedicine for self-managed abortion care: Telemedicine medication abortion has grown since the COVID-19 pandemic compelled health facilities to provide care with minimal contact and travel. Even before the pandemic, clinician-staffed organizations such as Women on Web and Aid Access were providing clients with telemedicine medication abortion and/or online consultations and sending medications by mail.[9,23] Quantitative and qualitative data demonstrate that women find their services acceptable and satisfactory.[40] Their safety and effectiveness outcomes are comparable with those of in-clinic medication abortion care.[23] In response to the COVID-19 pandemic, abortion care experts have developed a “no-test” protocol for providing medication abortion and minimizing virus exposure that limits in-person tests.[40] Throughout the pandemic, many clinic-based abortion providers began providing (and Aid Access continued to provide) completely virtual, at-home medication abortion, including sending medications by mail. Studies examining outcomes among patients receiving this care demonstrated its safety, effectiveness, and acceptability, contradicting the idea that the REMS increases medication abortion safety.[41–43] Despite this innovation, 19 states ban telemedicine for abortion. National legislation supportive of abortion access overall could dismantle these medically unnecessary laws and improve access to compassionate, equitable health care. 

While mifepristone and misoprostol together are the safest, most effective regimen for medication abortion, surveys suggest that this is not the most common self-management method.[8] Expanding the accessibility of this protocol has the potential to make self-managed abortion in the United States safe and more effective. Finally, further research would provide evidence to enable full support for and access to self-managed abortion in the United States, yet few funding opportunities exist to support researchers. Having federal government funding agencies support work exploring self-managed abortion would allow policy, public health, and research communities to collaborate on self-managed abortion research priorities.[44] 

Opposing Arguments/Evidence
Opponents of self-managed abortion argue that moving abortion outside of the medical setting would be unsafe for pregnant people. They highlight arguments about the safety of self-managed abortion and whether patients are capable of fulfilling requirements to self-manage with medications. 

Safety of self-managed abortion: Before Roe v. Wade legalized abortion in the United States, pregnant people were often compelled to pursue dangerous methods to terminate a pregnancy.[16] Although the harms of “pre-Roe” clandestine abortions were of great public health concern, applying past experiences to 2021 and beyond ignores the highly safe and effective models for self-managed abortion that exist today.[13,21] Some people worry that pills obtained online may not work or may include harmful ingredients. However, in a study evaluating the quality of mifepristone and misoprostol obtained from 18 different online vendors without a prescription, chemical assays showed that all of the pills were of high quality and contained an appropriate and expected amount of the active ingredients.[45] Reputable organizations such as Ipas offer evidence-based information to help people determine whether the pills they buy online are safe and accurate. There have been no significant reports of harmful experiences with obtaining pills online, although finding trusted online pharmacies can be challenging.[11]

Opponents may argue that some people use less efficacious self-managed abortion methods, such as objects and herbs, that could cause the pregnant person more harm and delay care. However, decriminalizing all forms of self-managed abortion would ensure that those with complications or incomplete abortions could access care without fear of legal repercussions. Pairing decriminalization with the aforementioned evidence-based strategies to expand mifepristone/misoprostol availability, information, and support could increase the uptake of safer methods and improve access to follow-up care if needed. 

Criminalization and prosecution threats are the biggest risk to the safety of people self-managing their abortion. As noted by ACOG, such threats may result in negative health outcomes by eroding trust in the medical system and deterring people from seeking care when needed.[18] If/When/How has found that pregnant women of color, immigrants, and/or those with lower incomes are more likely to be reported for suspected self-managed abortions than patients who are White and/or affluent.[15] This reporting happens in spite of possible violations of state and federal medical privacy laws.[46] 

Ability to fulfill requirements regarding self-managing abortion with medications: Arguments against self-managed abortion also question pregnant people’s ability to self-assess eligibility, take the pills, and self-assess abortion completion. Assessing eligibility means determining gestational age and contraindications. Last menstrual period can be used instead of ultrasound to determine gestational age, as concluded in systematic reviews examining diagnostic accuracy studies and secondary data analyses.[47,48] Online and mobile applications can help patients and clinicians calculate gestational age by entering patients’ last menstrual period. Some argue that Rhesus factor (Rh) testing is necessary due to sensitization risk after early abortion if the fetus is Rh positive and the pregnant person is Rh negative. Evidence shows that this risk is negligible; the National Abortion Federation and ACOG state that Rh testing is not required and should not be a barrier to receiving mifepristone and/or misoprostol.[12,49] During the COVID-19 pandemic, many U.S. abortion providers did not require these tests to minimize interpersonal contact and unnecessary travel while still having safety and effectiveness outcomes comparable to in-clinic care.[40,41] Patients can easily determine mifepristone and misoprostol contraindications on their own through low-literacy drug labels and checklists.[50,51] Researchers have shown that women with some literacy who have never had or assisted someone with medication abortion are able to read a sample label and comprehend when the drugs are indicated and situations to consult a clinician before use.[51] 

Some are concerned with the risk of ectopic pregnancies, which occur when a fertilized ovum implants outside of the uterus. They occur in 1% to 2% of pregnant women in the general population but in less than 1% of those seeking abortion care.[52,53] An undiagnosed ectopic can rupture and cause life-threatening bleeding. Mifepristone and/or misoprostol will not terminate an ectopic, allowing it to potentially go undiagnosed. Clinicians screen for ectopic pregnancy pre-abortion by asking about lower abdominal pain, vaginal bleeding, history of ectopic, or risk factors.[12] According to ACOG, ultrasound is not necessary for those without risk factors.[12] Low-literacy drug labels, checklists, and education from self-managed abortion groups on ectopic pregnancy risk and symptoms can enhance safety and ensure that those at risk receive the care they need.[50,51] 

Taking the medication correctly without clinician supervision has precedent from the FDA-approved regimen, which allows at-home administration. Numerous studies have shown that home administration is as safe, effective, and acceptable to patients as in-clinic administration.[54–58] Just as patients follow their clinician’s instructions regarding dosage, intake, and timing, they are able to follow directions by reading evidence-based instructions, labels, and other educational resources.[51] 

Opponents may argue that in-clinic follow-up is necessary to determine whether the abortion was completed or to manage potential negative effects. However, patients are able to self-assess abortion completion and determine whether or not they need follow-up or emergency care by using symptom evaluation and urine pregnancy tests found in drug stores.[23,59,60] Urine pregnancy tests are a highly accurate and inexpensive way to assess complete abortion at home.[61] Evidence-based, online patient education and hotlines can support people in accessing follow-up or emergency care. 

Impact on abortion clinics: Some proponents of abortion are concerned with self-managed abortion reducing in-clinic demand, impacting clinics financially and thus affecting the availability of clinic-based abortion. This concern has been expressed during the COVID-19 pandemic, when many new services began providing telemedicine abortion. Abortion clinics, too, began providing telemedicine abortion to meet demand and can continue to do so. New services such as Hey Jane and Abortion on Demand have seen many patients during the pandemic who typically may have sought in-clinic abortion care. While these changes may have resulted in reduced in-clinic demand or financial pressure, some patients will always prefer to see a clinician or may need or prefer surgical abortion. Researchers have found that state restrictions, as opposed to personal preference alone, largely drive people away from abortion clinics.[11]

Alternative Strategies
There are no evidence-based counterpoints to our knowledge.

Action Steps

  1. APHA calls on elected officials to repeal all laws that criminalize any form of self-managed abortion and pregnancy loss, including laws criminalizing feticide, improper disposal of fetal remains, and concealing a birth. Lawmakers must reform any laws criminalizing harm to fetuses and ensure that they do not apply to acts or omissions with respect to pregnancies. Attorneys general must reinforce existing protections for abortion rights, eliminate prosecutions based on pregnancy loss through self-managed abortion or otherwise, and prevent misapplications of criminal laws by prosecutors. 
  2. APHA calls on professional medical organizations, medical schools, residency programs, and nursing schools to provide pre-service education on how to care for patients experiencing abortion or miscarriage complications in ways that are compassionate, are trauma informed, and will not lead to punishment. 
  3. APHA calls on public health agencies, medical professional organizations, and clinic staff to engage in continuous education, training, and dialogue about medical, ethical, and legal obligations to provide supportive counseling and emergency post-abortion care with compassion, dignity, and respect and to uphold patients’ privacy as asserted in state and federal medical privacy laws. This must include situations in which it is unclear that the patient attempted to self-manage abortion, such as fetal demise, having ingested a substance while pregnant, or other situations. 
  4. APHA encourages public health professionals to study, develop, and expand models of providing self-managed abortion support, information, accompaniment, and care.
  5. APHA calls on public health organizations, foundations, and government funding agencies to fund organizations led by Black, indigenous, and people of color and community-based organizations that employ CHWs, doulas, and other trained laypeople to better integrate accompaniment, hotlines, and other support models for self-managed abortion in communities with the greatest abortion access barriers.
  6. APHA calls on the FDA to continue its comprehensive, evidence-based review of its REMS restrictions on mifepristone and to remove medically unnecessary, harmful restrictions.
  7. APHA calls on federal and state legislators to propose and pass laws to protect and expand access to abortion care to ensure that individuals have true choice between self-managed and clinic-based care.
  8. APHA calls on federal funding bodies to fund research related to self-managed abortion to generate evidence enabling full support for and access to self-managed abortion in the United States.

References 
1. Nash E. Unprecedented wave of abortion bans is an urgent call to action. Available at: guttmacher.org/article/2019/05/unprecedented-wave-abortion-bans-urgent-call-action. Accessed January 26, 2021.
2. Hall KS, Redd S, Narasimhan S, et al. Abortion trends in Georgia following enactment of the 22-week gestational age limit, 2007–2017. Am J Public Health. 2020;110:1034–1038. 
3. Norris AH, Chakraborty P, Lang K, et al. Abortion access in Ohio’s changing legislative context, 2010–2018. Am J Public Health. 2020;110:1228–1234. 
4. American College of Obstetricians and Gynecology. Increasing access to abortion: committee opinion number 815. Available at: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/12/increasing-access-to-abortion. Accessed January 26, 2021.
5. White K, Baum SE, Hopkins K, Potter JS, Grossman D. Change in second-trimester abortion after implementation of a restrictive state law. Obstet Gynecol. 2019;133(4):771–779.
6. Greene Foster D. The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having―or Being Denied―an Abortion. New York, NY: Scribner; 2020.
7. Moseson H, Herold S, Filippa S, Barr-Walker J, Baum SE, Gerdts C. Self-managed abortion: a systematic scoping review. Best Pract Res Clin Obstet Gynaecol. 2020;63:87–110.
8. Ralph L, Foster DG, Raifman S. Prevalence of self-managed abortion among women of reproductive age in the United States. JAMA Netw Open. 2020;3(12):e2029245.
9. Aiken A, Starling J, Gomperts R. Factors associated with use of an online telemedicine service to access self-managed medical abortion in the US. JAMA Netw Open. 2021;4(5):e2111852. 
10. Aiken ARA, Starling JE, Gomperts R, Tec M, Scott JG, Aiken CE. Demand for self-managed online telemedicine abortion in the United States during the coronavirus disease 2019 (COVID-19) pandemic. Obstet Gynecol. 2020;136(4):835–837.
11. Aiken ARA, Broussard K, Johnson DM, Padron E. Motivations and experiences of people seeking medication abortion online in the United States. Perspect Sex Reprod Health. 2018;50(4):157–163.
12. American College of Obstetricians and Gynecologists. Medication abortion up to 70 days of gestation. Obstet Gynecol. 2020;136:e31–e47.
13. World Health Organization. Medical management of abortion. Available at:  https://apps.who.int/iris/bitstream/handle/10665/278968/9789241550406-eng.pdf?ua=1. Accessed January 26, 2021. 
14. Raymond EG, Harrison MS, Weaver MA. Efficacy of misoprostol alone for first-trimester medical abortion: a systematic review. Obstet Gynecol. 2019;133(1):137–147.
15. If/When/How. Supporting people who end pregnancies: necessary for reproductive justice. Available at: https://www.ifwhenhow.org/wp-content/uploads/2020/04/FINAL-Fact-Sheet-Self-Managed-Abortion-.pdf. Accessed February 11, 2021.  
16. Donovan MK. Self-managed medication abortion: expanding the available options for U.S. abortion care. Guttmacher Policy Rev. 2018;21:41–47.
17. Paltrow L, Flavin J. Arrests of and forced interventions on pregnant women in the United States, 1973–2005: implications for women’s legal status and public health. J Health Polit Policy Law. 2013;38(2):299–343. 
18. American College of Obstetricians and Gynecologists. Decriminalization of self-induced abortion: position statement. Available at: https://www.acog.org/clinical-information/policy-and-position-statements/position-statements/2017/decriminalization-of-self-induced-abortion. Accessed January 26, 2021.
19. U.S. Food and Drug Administration. Mifeprex label. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/020687s022lbl.pdf. Accessed February 11, 2021. 
20. American College of Obstetricians and Gynecologists. Over-the-counter access to hormonal contraception. Obstet Gynecol. 2019;134:e96–e105.
21. National Academies of Science, Engineering and Medicine. The Safety and Quality of Abortion Care in the United States. Washington, DC: National Academies Press; 2018. 
22. U.S. Food and Drug Administration. Mifeprex medical review. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/nda/2016/020687Orig1s020MedR.pdf. Published 2021. Accessed February 4, 2021.
23. Aiken ARA, Digol I, Trussell J, Gomperts R. Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland. BMJ. 2017;357:j2011. 
24. Moseson H, Jayaweera R, Raifman S, et al. Self-managed medication abortion outcomes: results from a prospective pilot study. Reprod Health. 2020;17:164.
25. Mifeprex REMS Study Group. Sixteen years of overregulation: time to unburden Mifeprex. N Engl J Med. 2017;376:790–794. 
26. Courthouse News. American College of Obstetricians and Gynecologists, Council of University Chairs of Obstetrics and Gynecology, New York State Academy of Family Physicians, SisterSong Women of Color Reproductive Justice Collective, and Honor MacNaughton, MD, v United States Food and Drug Administration; Stephen M. Hahn, MD, in his official capacity as Commissioner of Food and Drugs; United States Department of Health and Human Services; and Alex Azar, JD, in his official capacity as Secretary, United States Department of Health and Human Services. Available at: www.courthousenews.com/wp-content/uploads/2020/05/Abortion.pdf. Accessed February 4, 2021. 
27. American College of Obstetricians and Gynecologists. Improving access to mifepristone for reproductive health indications. Available at: https://www.acog.org/clinical-information/policy-and-position-statements/position-statements/2018/improving-access-to-mifepristone-for-reproductive-health-indications. Accessed February 4, 2021.
28. Aiken ARA, Starling JE, van der Wal A, et al. Demand for self-managed medication abortion through an online telemedicine service in the United States. Am J Public Health. 2020;110:90–97.
29. United Nations Economic and Social Council. General comment no. 22 (2016) on the right to sexual and reproductive health (article 12 of the International Covenant on Economic, Social and Cultural Rights). Available at: https://digitallibrary.un.org/record/832961?ln=en 2016. Accessed February 4, 2021.
30. United Nations Economic and Social Council. General comment No. 25 (2020) on science and economic, social and cultural rights (article 15 (1) (b), (2), (3) and (4) of the International Covenant on Economic, Social and Cultural Rights). Available at: https://digitallibrary.un.org/record/3899847?ln=en. Accessed February 4, 2021. 
31. Sister Song. Reproductive justice. Available at: https://www.sistersong.net/reproductive-justice/. Accessed February 4, 2021.
32. Drovetta RI. Safe abortion information hotlines: an effective strategy for increasing women’s access to safe abortions in Latin America. Reprod Health Matters. 2015;23(45):47–57. 
33. Moseson H, Bullard K, Cisternas C, Grosso B, Vera V, Gerdts C. Effectiveness of self-managed medication abortion between 13 and 24 weeks gestation: a retrospective review of case records from accompaniment groups in Argentina, Chile, and Ecuador. Contraception. 2020;102(2):91–98.
34. Chor J, Goyal V, Roston A, Keith L, Patel A. Doulas as facilitators: the expanded role of doulas into abortion care. J Fam Plann Reprod Health Care. 2012;38(2):123–124. 
35. Tebbets C, Santana D, Ros Silvestre J, Redwine D. Building bridges: a case for community health worker provision of misoprostol-only abortion in the first trimester. J Womens Health. 2018;27(3):311–316. 
36. Zurbriggen R, Keefe-Oates B, Gerdts C. Accompaniment of second-trimester abortions: the model of the feminist Socorrista network of Argentina. Contraception. 2018;97(2):108–115. 
37. Kaye J, Reeves R, Chaiten L. The mifepristone REMS: a needless and unlawful barrier to care. Contraception. 2021;104(1):12–15. 
38. Grossman D, Baba FC, Kaller S, et al. Medication abortion with pharmacist dispensing of mifepristone. Obstet Gynecol. 2021;137:613–622.
39. Brown BL, Wood SF, Sarpatwari A. Ensuring safe access to mifepristone during the pandemic and beyond. Ann Intern Med. 2021;174(1):105–106. 
40. Raymond EG, Grossman D, Mark A, et al. No-test medication abortion: a sample protocol for increasing access during a pandemic and beyond. Contraception. 2020;101(6):361–366. 
41. Kerestes C, Murayama S, Tyson J, et al. Provision of medication abortion in Hawai’i during COVID-19: practical experience with multiple care delivery models. Contraception. 2021;104(1):49–53. 
42. Chong E, Shochet T, Raymond E, et al. Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic. Contraception. 2021;104(1):43–48. 
43. Godfrey EM, Thayer EK, Fiastro AE, Aiken ARA, Gomperts R. Family medicine provision of online medication abortion in three US states during COVID-19. Contraception. 2021;104(1):54–60. 
44. Advancing New Standards in Reproductive Health, Gynuity Health Projects, Ibis Reproductive Health. A roadmap for research on self-managed abortion in the United States. Available at: https://www.ibisreproductivehealth.org/publications/roadmap-research-self-managed-abortion-united-states. Accessed July 23, 2021.
45. Murtagh C, Wells E, Raymond E, Coeytaux F, Winikoff B. Exploring the feasibility of obtaining mifepristone and misoprostol from the internet. Contraception. 2018;97(4):287–291. 
46. If/When/How. Self-managed abortion, the law, and COVID-19 fact sheet. Available at: https://www.ifwhenhow.org/wp-content/uploads/2020/04/20_04_Final_SMA_TheLaw_COVID-19_FactSheet_PDF.pdf. Accessed January 26, 2021.
47. Raymond EG, Bracken H. Early medical abortion without prior ultrasound. Contraception. 2015;92(3):212–214. 
48. Schonberg D, Wang LF, Bennett AH, Gold M, Jackson E. The accuracy of using last menstrual period to determine gestational age for first trimester medication abortion: a systematic review. Contraception. 2014;90(5):480–487. 
49. Mark A, Foster AM, Grossman D. Foregoing Rh testing and anti-D immunoglobulin for women presenting for early abortion: a recommendation from the National Abortion Federation’s Clinical Policies Committee. Contraception. 2019;99:265–266.
50. Health Worker Roles in Providing Safe Abortion Care and Post-Abortion Contraception. Geneva: World Health Organization; 2015. 
51. Kapp N, Methazia J, Eckersberger E, Griffin R, Bessenaar T. Label comprehension of a combined mifepristone and misoprostol product for medical abortion: a pilot study in South Africa. Contraception. 2020;101(1):46–52. 
52. Marion LL, Meeks GR. Ectopic pregnancy: history, incidence, epidemiology, and risk factors. Clin Obstet Gynecol. 2012;55(2):376–386.
53. Edwards J, Creinin MD. Surgical abortion for gestations of less than 6 weeks. Curr Probl Obstet Gynecol Fertil. 1997;20:11–19.
54. Ngo TD, Park MH, Shakur H, Free C. Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review. Bull World Health Organ. 2011;89(5):360–370. 
55. Newhall EP, Winikoff B. Abortion with mifepristone and misoprostol: regimens, efficacy, acceptability and future directions. Am J Obstet Gynecol. 2000;183(suppl):S44–S53. 
56. Gambir K, Kim C, Necastro KA, Ganatra B, Ngo TD. Self-administered versus provider-administered medical abortion. Cochrane Database Syst Rev. 2020;3(3):CD013181. 
57. Foster AM, Arnott G, Hobstetter M. Community-based distribution of misoprostol for early abortion: evaluation of a program along the Thailand Burma border. Contraception. 2017;96(4):242–247.
58. Foster A. Exploring Polish women’s experiences using a medication abortion telemedicine service: a qualitative study. Eur J Contracept Reprod Health Care. 2018;23:59–60.
59. Raymond EG, Tan YL, Grant M, et al. Self-assessment of medical abortion outcome using symptoms and home pregnancy testing. Contraception. 2018;97(4):324–328. 
60. Raymond EG, Shochet T, Bracken H. Low-sensitivity urine pregnancy testing to assess medical abortion outcome: a systematic review. Contraception. 2018;98(1):30–35. 
61. Raymond EG, Shochet T, Blum J, et al. Serial multilevel urine pregnancy testing to assess medical abortion outcome: a meta-analysis. Contraception. 2017;95:442–448.