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Primary Submission Category: Reproductive health
Key Informant Perspectives on the US Abortion Care Ecosystem, Abortion Seeker Holistic Needs, and Considerations for Over the Counter Medication Abortion
Authors: Laura Jacobson, Samantha Ruggiero, Leah Scott, Ruvani Jayaweera, Caitlin Gerdts,
Presenting Author: Laura Jacobson*
Background
Abortion access in the United States is shaped by an ecosystem of clinical, community, legal, policy, and funding actors. Many people rely on self‑managed medication abortion (SMA) supported by helplines, pill‑by‑mail initiatives, doulas, abortion funds, and wrap‑around practices. As formal over‑the‑counter (OTC) medication abortion is explored, little is known about ecosystem‑level facilitators, social supports, and implementation challenges. We describe the current abortion ecosystem; characterize perceptions of abortion‑seekers’ holistic needs; examine how the ecosystem meets or fails to meet those needs; and identify equitable pathways to OTC medication abortion to inform policy and practice.
Methods
We conducted a qualitative study using semi‑structured key‑informant interviews. We recruited 23 experts from sexual and reproductive health, rights, and justice organizations across the United States via purposive sampling, drawing on professional networks to capture diverse perspectives and roles across the ecosystem. We included clinicians (clinic-based and wrap‑around practices), pill‑by‑mail programs, full‑spectrum doulas, abortion funds, national hotlines, reproductive‑justice organizations, and legal and policy advocates. Participants worked nationally and in 28 states, with many based in restrictive Southern and Midwestern regions. Interviews explored the abortion landscape, holistic needs, perceived facilitators, barriers, and equity safeguards for OTC medication abortion. Interviews were recorded when permitted, transcribed, de‑identified, and analyzed using thematic analysis with a combined deductive (ecosystem domains) and inductive approach.
Results
Interviewees described a strained but resilient abortion ecosystem delivering clinical care, information, logistical, legal, and financial support across the access continuum. Roles included traveling clinicians and wrap‑around practices, pill‑by‑mail initiatives, full‑spectrum doulas, hotlines, abortion funds, and advocacy groups working in concert to guide people before, during, and after abortion. We identified layered, intersecting holistic needs that shape decision‑making and delays: practical information, cost and lost wages, transportation and childcare, legal risk and criminalization fears, immigration enforcement, emotional care, intimate‑partner violence, follow‑up access, stigma, and needs such as housing and food. Parents, Black and Latinx communities, LGBTQ+ people (including trans‑masculine clients), immigrants, youth, rural residents, people with disabilities, and those living in poverty faced amplified barriers. The ecosystem meets needs through curated information tools, shield‑law virtual care, practical and financial support, peer accompaniment, provider legal protocols, and policy advocacy. Yet capacity limits, chilling effects of information‑sharing, judgmental spaces, harmful media narratives, clinic rules that exclude children, and clinic deserts persist. OTC medication abortion was widely viewed as a “game‑changer” that could shrink logistical burdens if paired with plain‑language instructions, multilingual hotlines, accompaniment, and clear guidance on follow‑up and legal rights. Concerns about OTC centered on patchwork legality, pharmacy harassment, age/ID verification, coercion, and clinic financing.
Conclusion
Abortion seekers need straightforward, multilingual information on options and legality; affordable care and practical help (funding, travel, childcare, time off); follow‑up support; accessible clinical/legal advice; digital privacy; protection from criminalization and immigration enforcement; non‑judgmental emotional and peer support; and accessible, culturally affirming services for parents, youth, rural residents, disabled and LGBTQ+ people. Sustainable funding is needed to expand ecosystem capacity. OTC medication abortion may ease burdens in a supportive legal environment that is embedded within these supports.