When there is nowhere left to turn: a qualitative study on people who could not access safe abortion care after 20 weeks’ gestation

The World Health Organization recommends abortion after 12 weeks of pregnancy to take place under clinical supervision. This is, however, unavailable in most settings. Women on Web (WoW) currently facilitates online access to abortion pills up to 13 weeks and 6 days of pregnancy and provides information on abortion pill use at any stage of pregnancy. Until 2024, people were provided with information on the use of abortion pills only for pregnancies under 20 weeks due to the limited knowledge and acceptance of self-managed abortion (SMA) at the time. This study examines the care seeking experiences and outcomes of individuals who sought information on abortion at 20 or more weeks’ gestation through WoW while this policy was in place. We performed a combined qualitative content and thematic analysis of the email correspondence of people who contacted WoW and/or reported using abortion pills at or after 20 weeks’ gestation between January 2020 and December 2023. We identified 244 people contacting WoW at or after 20 weeks of pregnancy between January 2020 and December 2023. Of these, 189 (77%) reported gestational lengths of 20–24 weeks, 41 (17%) of 25–29 weeks, and 14 (6%) 30 weeks or more. Almost half of care-seekers came from four countries with restrictive settings: Brazil, Indonesia, Morocco, and the Philippines. Documented outcomes were scarce after the requested pills or information was not provided. We generated three themes to describe care seeking experiences: (1) mental health problems related to the inability to safely terminate an unwanted pregnancy, including suicide attempts; (2) circumstances surrounding their requests for help, such as the detection of fetal malformations, rape, violent relationships or family situations, fear of criminalization, and the inability to travel for care; and finally, (3) (previous) abortion attempts during the current pregnancy. Within this theme, people described having tried multiple times to abort, either with misoprostol, usually with inadequate doses or application routes, or with unsafe methods. This study highlights the need for abortion care at and beyond 20 weeks. It also supports a recent (2024) change in WoW´s policy on providing information on abortion pill use at or after 20 weeks pregnancy as the results reaffirm the importance of information provision on SMA at any gestational length as a harm-reduction strategy, allowing people to make informed decisions over their own bodies. The World Health Organization recommends abortion after 12 weeks under clinical supervision. This is often unavailable. Nowadays, Women on Web (WoW) provides online access to abortion pills up to 13 weeks and 6 days and information on how to use them througout pregnancy. Until 2024, people got information on abortion pills only until 20 weeks, due to limited knowledge and acceptance of self-managed abortion (SMA) at the time. This study examines the experiences and outcomes of people who asked WoW about an abortion at or after 20 weeks when this policy was in place. We analyzed emails sent to WoW about abortion at or after 20 weeks, from January 2020 to December 2023. We identified 244 people; 189 (77%) had a pregnancy of 20-24 weeks, 41 (17%) 25-29 weeks, and 14 (6%) 30 weeks or more. Almost half came from four countries with strict laws: Brazil, Indonesia, Morocco, and the Philippines. We identified three main themes: 1. Mental health issues from not being able to have a safe abortion. This included suicide attempts; 2. Circumstances such as fetal malformations, rape, violence, fear of criminalization, and travel barriers; 3. (Previous) abortion attempts. Many reported attempting abortion multiple times. They often used misoprostol, but with wrong doses, or unsafe methods. They often mentioned having abortion pills and needing guidance on their use. We know little about how people were after contacting WoW. This study highlights the need for abortion care at all points during pregnancy. It also supports WoW's 2024 decision to provide information on abortion pills at or after 20 weeks. This helps individuals make informed choices about their bodies.