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

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.