# Acceptability of misoprostol-only medication abortion dispensed by mail-order or retail pharmacy: a qualitative study based on in-depth interviews in the United States

## TL;DR

This study explores how acceptable misoprostol-only abortions are in the US, focusing on people's experiences with medication delivery and overall care.

## Contribution

The study provides new insights into the acceptability of misoprostol-only medication abortion in the US context, particularly regarding service delivery models.

## Key findings

- Participants who picked up misoprostol from a retail pharmacy felt a sense of familiarity and legitimacy due to having a prescription.
- Mail-order delivery of misoprostol met preferences for privacy and anonymity among participants.
- Adolescents reported a distinct need for emotional support compared to older participants.

## Abstract

The WHO recommends two medication abortion regimens, either misoprostol used with mifepristone or misoprostol-only. Both regimens are recognised as safe and effective, but in the United States (US) most abortions are completed using mifepristone and misoprostol. Given current political hostility to abortion, restrictions on mifepristone, and the long-term legal strategy to restrict nationwide access to the combined mifepristone and misoprostol regimen, more people in the US may use misoprostol-only regimens. Globally research has documented experiences with misoprostol-only abortions, but what are the experiences among people living in the US? We conducted a thematic analysis of 31 in-depth interviews with people who self-managed their abortion using misoprostol acquired from a mail-order or retail pharmacy between May and June 2020. We examine the acceptability of using misoprostol for medication abortion across three domains: the medication regimen, the mode of delivery of medications, and the overall model of care. We find that individual perceptions of misoprostol were shaped by both prior and informed knowledge. Picking up misoprostol from a retail pharmacy fostered familiarity, and having a prescription legitimised the service as an authentic medication provider. Receiving medications from the mail-order delivery model met preferences for privacy and anonymity. In reflections on the overall model, satisfaction was high across participants, but those who were adolescents at the time of their abortion had a distinct unmet need for emotional support compared to older participants. These results contribute to a growing evidence base on the acceptability of misoprostol-only regimens and mail-order and retail pharmacy service delivery models.

There are two commonly used medication abortion options. They are misoprostol used with mifepristone and misoprostol used by itself. Both regimens are safe and effective. In the United States, most medication abortions are done using misoprostol with mifepristone. Accessibility is an issue because mifepristone is legally restricted in the US and other countries. People throughout the world have been using misoprostol-only for abortions. Researchers would like to understand the experiences with misoprostol-only among people in the US. We conducted 31 interviews with US-based individuals who had an abortion at home using misoprostol. We find that knowledge shaped people's perceptions of misoprostol. Picking up the medications from a pharmacy felt familiar, and a prescription from a physician legitimised the process. Receiving medications from the mail-order order pharmacy met preferences for privacy and anonymity. Participants were generally satisfied with their abortion. Younger participants had a need for more emotional support. These findings inform the use of misoprostol-only regimens and innovations in abortion service delivery.