com
www.rhmjournal.org.uk
Abstract: Recent media coverage and case reports have highlighted women's attempts to end their
pregnancies by self-inducing abortions in the United States. This study explored women's
motivations for attempting self-induction of abortion. We surveyed women in clinic waiting rooms
in Boston, San Francisco, New York, and a city in Texas to identify women who had attempted
self-induction. We conducted 30 in-depth interviews and inductively analyzed the data. Median
age at time of self-induction attempt was 19 years. Between 1979 and 2008, the women used
a variety of methods, including medications, malta beverage, herbs, physical manipulation and,
increasingly, misoprostol. Reasons to self-induce included a desire to avoid abortion clinics, obstacles
to accessing clinical services, especially due to young age and financial barriers, and a preference
for self-induction. The methods used were generally readily accessible but mostly ineffective and
occasionally unsafe. Of the 23 with confirmed pregnancies, three reported a successful abortion
not requiring clinical care. Only one reported medical complications in the United States. Most
would not self-induce again and recommended clinic-based services. Efforts should be made to
inform women about and improve access to clinic-based abortion services, particularly for medical
abortion, which may appeal to women who are drawn to self-induction because it is natural,
non-invasive and private. 2010 Reproductive Health Matters. All rights reserved.
Keywords: self-induced abortion, medical abortion, adolescents and young people,
misoprostol, United States
136
a woman in Massachusetts who used misoprostol9 and another in Washington who inserted
a metal coat hanger into her uterus and presented with sepsis.10 There have also been reports
in the media of women using various selfinduction methods.11,12 Yet the assumption has
been that women would no longer be driven to
self-induce after abortion was legalized in the
US in 1973, when complications from unsafe
abortion decreased.13
A recent national survey of US abortion
patients found that 1.2% reported ever using
misoprostol, and 1.4% reported using other substances to self-induce an abortion.14 In another
study, among mostly Dominican women in New
York City obstetrics and gynecology (ob/gyn)
clinics, 37% knew about misoprostol and 5%
had used it themselves, although the study did
not specify whether the women had done so in
the US.15
The purpose of this qualitative study was to
explore experiences of abortion self-induction
by women living in the US, to better understand
women's motivations and suggest practice and
policy recommendations to improve access to
safe abortion care.
Methods
Participants were recruited as part of a larger
study examining knowledge and experience
with abortion among women in San Francisco,
Boston, New York City and a city in Texas adjacent to the US-Mexico border. The sites were
selected to oversample Latinas and low-income
women, since prior reports have documented selfinduction with misoprostol among these populations in the US.11,15 We received ethical approval
from all relevant institutional review boards.
Between June 2008 and February 2009, we
recruited a convenience sample of 1,425 women
aged 1545 speaking English or Spanish at primary care or ob/gyn clinics (and an abortion clinic
in Texas) to participate in a survey (in Texas, the
minimum age was 18). In the survey, the women
were asked if they had ever attempted to selfinduce an abortion, and if so, were invited to participate in an in-depth interview on their most
recent experience.
The number of survey participants was: San
Francisco (448); Boston (402); New York City
(412); Texas (163). Fifty-six women who com-
Findings
Participants
At the time of their last self-induction attempt,
three participants were living in countries where
abortion was legally restricted: Uganda, Nigeria
and the Dominican Republic. Two women were
living in Puerto Rico, where they incorrectly
believed abortion was illegal. We felt it was
important to include them in our analysis as
their perceptions and beliefs at the time of selfinduction may still be current.
137
Methods of self-induction
Table 1 provides information about the women,
their self-induction experiences and the methods
they used. We grouped the methods into six categories; 13 of the women used multiple methods
from different categories. The most commonly
reported methods were medications (n=12),
including vitamin C, aspirin, laxatives, oral contraceptives, hormonal injections, and unspecified
pills or injections (but not misoprostol). Among
those who used hormonal medications to selfinduce, several believed that high doses of contraceptives could cause a miscarriage.
The pills was my idea if you get pregnant on
birth control, they say to stop, cause it can cause
miscarriages. (Boston 1, age 16)*
138
A few women sought information from a physician when they suspected they were pregnant
but were not told where they could obtain an
abortion. One found out she was pregnant at her
doctor's surgery and when she became upset,
he told her to do whatever [she] could within
reach because he wasn't going to get involved.
(New York 3, age 31)
A third of women described financial barriers
as a motivating factor. This is not surprising
given that the average cost of a non-hospital,
first trimester abortion in the US in 2005 was
US$413.18 Only 17 states pay for abortion services for Medicaid patients (the national health
care plan for low-income individuals), while
four states restrict coverage of abortion by private insurance plans.20 Some women said they
went to a clinic and were discouraged when
they were told the price, while others never went
because they believed it was too expensive. A
few were concerned their insurance would not
cover abortion or that a parent would find out
if they used their insurance. The participant
who haemorrhaged, requiring a D&C and blood
transfusion, lived in Texas where Medicaid does
not pay for abortion. Cost was a factor that prevented her from using the clinic. She had used
misoprostol and an injection at 13 weeks' gestation. When asked if she would do the same again
if she could go back in time, she said:
141
Only four women thought they would try something on their own again in the future if they
wanted to end a pregnancy. Three of them said it
was something they would do early in pregnancy,
and all still had negative views of clinic abortions.
Discussion
Only 4.6% of ever-pregnant women participating
in our survey reported a history of attempting
self-induction, and several of these cases occurred
outside the US. Our study did not measure the
prevalence of abortion self-induction, but these
findings are consistent with a recent survey that
found that less than 3% of abortion patients
reported attempting self-induction, suggesting
that this phenomenon is uncommon in the US.14
Medical complications were rare in this sample,
although another recent case report of a woman
using intravaginal trauma highlights that major
complications still occur with unsafe abortion in
the US.10 Women may also face legal prosecution
for self-inducing their abortion, which has occurred
in several cases.11,21
The media have focused on Latinas self-inducing
abortion in the US.11,21,22 In the national survey
of abortion patients, being foreign-born, but not
race or ethnicity, was significantly associated
with a history of ever attempting self-induction.14
While self-medication with pain medicine, antibiotics and other drugs obtained at pharmacies
without a prescription for a variety of conditions
has been documented in several countries in Latin
America,23 this may be more related to barriers to
access or concerns about quality of care than any
cultural preference. A third of the women that we
interviewed did not identify as Hispanic or Latina.
Despite facing barriers to clinical services and
often failing in their self-induction attempts,
women in this study were generally resolute to
end the pregnancy. Although many tried easily
accessible methods unlikely to terminate a pregnancy, this did not usually reflect ambivalence
about abortion. Two-thirds of participants with a
failed self-induction attempt went for a clinical
abortion, and many of those who continued with
their pregnancies did so because they felt they
had no other option.
Our study has several limitations. Women
were recruited from clinic settings and therefore
had knowledge of and access to clinic-based
health services. The study was also conducted
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Resumen
En recientes reportajes e informes de casos se
han destacado los intentos de interrupcin del
embarazo mediante la autoinduccin del aborto
en Estados Unidos. Este estudio explor las
motivaciones de las mujeres para intentar la
autoinduccin del aborto. Encuestamos mujeres
en las salas de espera de clnicas en Boston, San
Francisco, Nueva York y una ciudad en Texas
para identificar a las que haban intentado la
autoinduccin. Realizamos 30 entrevistas a
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