A Post-Roe World Demands New Ways of Preserving Reproductive Autonomy

Commentary /

Woman looking at a reflective surface with pills on top
Photo by Matteo Badini on Unsplash

Contributors: Klaira Lerma, Laura Frye, Elizabeth Raymond, Beverly Winikoff

In July of 2022, we celebrated 246 years of American independence. For American women*, however, there wasn’t much to celebrate. For the first time in our history, the liberty and independence of a significant portion of the public was reduced, curtailed or, in modern parlance, canceled.

The overturning of Roe v. Wade by the Supreme Court of the United States (SCOTUS) reversed almost 50 years of progress towards reproductive liberty and independence. As a result, access to safe, reliable abortion in 30 states is jeopardized. Those in need are left looking for alternatives. We know that some of those alternatives—like medication abortion—are safe and effective. Our Reproductive Equity and Autonomy Lab (REAL) is a team of researchers and health clinic and policy experts that has support from Stanford Impact Labs’ start-up funding. We’re working together to generate rigorous research and practical insights to understand better how new strategies of providing facility-based medication abortion can preserve and even enhance people’s reproductive autonomy.

Medication Abortion with Autonomous Self-Assessment Project

Proliferating state-level legal restrictions result in closing of abortion clinics; those that remain are increasingly overburdened. Many people must travel hundreds of miles to visit an abortion provider, and some clinics have no available appointments for weeks. 

Through our partnership with Gynuity Health Projects and close collaboration with Planned Parenthood of the Rocky Mountains and Planned Parenthood North Central States, our team has initiated a new project, the Medication Abortion with Autonomous Self-Assessment Project (MA-ASAP), to address this crisis. 

Gynuity’s prior work was pivotal in showing medication abortion can be safely provided without an in-person clinic visit or facility-based tests: clinical screening can be accomplished by telehealth (videoconference or phone) and medications can be delivered by mail. Our project aims to test two additional ways to simplify the process and provide access: 

  1. Real-time clinical interactions should not be required for every patient - screening can instead be accomplished using asynchronous communication methods like email, texting, and online forms.
  2. Screening evaluation can be facilitated using a computerized tool that assesses medical eligibility for standard early abortion medication regimens.

These two modifications, together and separately, could streamline and expand safe abortion service delivery. Indirect communication methods have several advantages, allowing the abortion-seeker and the clinician to interact on their own schedules, offering convenience and flexibility, improved efficiency at clinics, reduced costs, and fewer delay in care. 

A computerized eligibility screening tool could save time for busy clinicians and could be especially useful in promoting and expediting the addition of abortion services into medical practices not currently providing this care. We envision this tool could enable advanced practice clinicians and other health professionals, such as pharmacists or nurse practitioners, to provide abortion. Indeed, the tool could be adapted for use by pregnant people on their own, without a clinician, which could help to improve the safety of self-sourced abortion. 

"Anything we can do to streamline the abortion care process can help to ensure better access for people who need it." — Laura Frye

We developed an informational website about abortion with a linked screening tool. We are collaborating with two Planned Parenthood affiliates in Colorado and Minnesota to conduct a pilot study that will obtain preliminary data on the safety, feasibility, and acceptability of this medication abortion model.

More data from a variety of settings will be needed for health providers, policy makers, and prospective users to change policy and practice. We hope to scale up the project and conduct a much larger multicenter demonstration project. In this demonstration project, we would hope to include other abortion provider types, in addition to Planned Parenthood sites, such as independent facilities, academic medical centers, and online-only service providers.

Medication Abortion Advance Provision Survey

Until relatively recently (2006), emergency contraception, also known colloquially by the brand name Plan B, was not available without a prescription in the United States. People had to consult a health care provider to obtain a prescription before they could acquire emergency contraception.

Many wrongly believed that if people had unrestricted access to emergency contraception, they wouldn’t use a reliable form of contraception, would engage in riskier sexual behavior, and be more likely to contract sexually transmitted infections.

Researchers combatted this misguided belief with science—large clinical trials were conducted, resulting in debunked myths and misconceptions. The advance provision of emergency contraception was also explored; these studies found people could safely and effectively self-direct emergency contraception use. As a result, today, one can walk into commercial outlets and purchase emergency contraception without a prescription. Medication abortion pills are just as safe or safer than other medications we keep at home for other forms of self-treatment, including Tylenol.

Thus, we believe this strategy may be generalizable to medication abortion. Before conducting a large, expensive, rigorous clinical trial exploring this strategy, we identified the value of first asking potential users—reproductive-aged people capable of pregnancy—about their interest in having advance provision of medication abortion pills. In a nationwide internet-based survey, administered between January and February 2022, we assessed interest in, and acceptability of, procuring abortion medications from a health care provider before an unwanted pregnancy. The survey included 649 respondents aged 18-45 from 48 states.

Analysis is underway. Our survey will uncover hidden attitudes and misconceptions and will inform efforts to address them.

"The arc of reproductive health history, and all medicine, bends towards self-care or putting essential care into the hands of people." — Paul Blumenthal

Whether eliminating unnecessary clinical requirements to determine medication abortion eligibility, simplifying follow-up without sacrificing safety, or allowing people to have pills in their hands ahead of need, all our work follows a historical trend toward self-care in medicine and could achieve the de-medicalization of abortion.

Our initiative to explore the acceptability of “advance provision” of the medication abortion regimen is aligned with historical trends and the overall goals of our lab: timely and unhindered access to medication abortion. In the same way we encourage those in need to keep emergency contraceptive pills at home and not have to seek them “after the fact” of unprotected intercourse, people capable of pregnancy could keep medication abortion pills at home in the event of an undesired or untenable pregnancy. In this way, an undesired pregnancy could be terminated using these already in-stock-at-home pills, obviating the need to seek a provider for services.

Because of the timing of the SCOTUS decision and our ongoing partnership in the REAL lab, we are also able to assess potential users’ attitudes towards medication abortion in a “before and after” fashion. We fielded a nationwide survey before the Roe reversal (and before the “leaked” version of the majority opinion). Because of our flexible funding from Stanford Impact Labs, we are able to respond quickly to new realities of reproductive healthcare, and are now repeating the survey to assess any attitudinal changes surrounding “advance provision” after the SCOTUS decision.

Our team is the first to field such a “before and after” survey on this topic. Insights and evidence from our rigorously conducted survey could, we hope, result in real impact by informing guidelines and practices to increase access to abortion care.

Looking Ahead

For nearly 20 years, the Stanford team and Gynuity have collaborated on a wide variety of projects, resulting in over 15 co-authored publications in peer-reviewed journals. Importantly, many of these projects and publications have led to changes in practice both domestically and internationally. Gynuity has a highly capable staff with extensive experience in project conceptualization, study design, and implementation and the Stanford team has broad clinical technical capacity with strengths in idea generation, training, and translation of results to the clinical community. Gynuity has a track record of translating science into policy and protecting access to abortion through coalition-building and drug registration in multiple countries. The Stanford team has experience incorporating clinical evidence into guidelines and programs and measuring the impact. We continue this work within the Reproductive Equity and Autonomy Lab.

Our team identified the importance of these research priorities as early as the summer of 2019 when the handwriting regarding Roe reversal was already on the wall (at least in pencil). Driving towards de-medicalization, simplification, and self-care is a foundational hope of all the investigators on our team. We remain passionate about making this happen and reestablishing reproductive equity and autonomy of those who have been disenfranchised.

 

Paul Blumenthal is a professor emeritus of obstetrics and gynecology at Stanford University and principal investigator of the Reproductive Equity and Autonomy Lab

Klaira Lerma is a co-investigator of the Reproductive Equity and Autonomy Lab and public health researcher based at the University of Texas at Austin

Laura Frye is a co-investigator of the Reproductive Equity and Autonomy Lab and Director at Gynuity Health Projects

Elizabeth Raymond is a co-investigator of the Reproductive Equity and Autonomy Lab and Senior Medical Associate at Gynuity Health Projects

Beverly Winikoff is a co-investigator of the Reproductive Equity and Autonomy Lab and President at Gynuity Health Projects

*The Reproductive Equity and Autonomy Lab recognizes there are those with the capacity for pregnancy with other gender identities who need abortion and are also impacted by the SCOTUS decision.