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. 2025 Dec;33(1):2522567.
doi: 10.1080/26410397.2025.2522567. Epub 2025 Jul 25.

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

Dana M Johnson  1 , Sruthi Ramaswamy  2 , Rebecca Gomperts  3
Affiliations

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

Dana M Johnson et al. Sex Reprod Health Matters. 2025 Dec.

Abstract
in English, French, Spanish

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.

L’OMS recommande deux schémas d’avortement médicamenteux, soit le misoprostol associé à la mifépristone, soit le misoprostol seul. Ces deux schémas sont reconnus comme sûrs et efficaces, mais aux États-Unis, la plupart des avortements sont pratiqués avec de la mifépristone et du misoprostol. Compte tenu de l’hostilité politique actuelle à l’avortement, des restrictions pesant sur la mifépristone et de la stratégie juridique à long terme visant à restreindre l’accès national au schéma combiné mifépristone-misoprostol, davantage de personnes aux États-Unis pourraient recourir à des schémas à base de misoprostol seul. Les recherches menées dans le monde ont documenté les expériences avec des avortements à base de misoprostol seul, mais quelles sont les expériences des personnes vivant aux États-Unis? Nous avons réalisé une analyse thématique de 31 entretiens approfondis avec des personnes ayant pris en charge elles-mêmes leur avortement grâce au misoprostol commandé par correspondance ou acheté dans une pharmacie entre mai et juin 2020. Nous avons examiné l’acceptabilité de l’utilisation du misoprostol pour l’avortement médicamenteux dans trois domaines: le schéma thérapeutique, le mode d’administration des médicaments et le modèle global de soins. Nous avons constaté que les perceptions individuelles du misoprostol étaient façonnées par des connaissances préalables et éclairées. Se procurer du misoprostol en pharmacie a favorisé la familiarité, et la présentation d’une ordonnance a légitimisé le service en tant que prestataire de médicaments authentique. Recevoir les médicaments par le biais du modèle de commande par correspondance répondait aux préférences de confidentialité et d’anonymat. L’analyse du modèle global révèle une satisfaction élevée chez les personnes participantes, mais celles qui étaient adolescentes au moment de l’avortement présentaient un besoin de soutien psychologique non satisfait distinct par rapport à des participantes plus âgées. Ces résultats contribuent à une somme de données de plus en plus étoffée sur l’acceptabilité des schémas thérapeutiques à base de misoprostol seul et des modèles de prestation de services par correspondance et en pharmacie.

La OMS recomienda dos regímenes de aborto con medicamentos: misoprostol utilizado con mifepristona, o misoprostol solo. Ambos regímenes son reconocidos como seguros y eficaces, pero en Estados Unidos (EE. UU.) la mayoría de los abortos son realizados con mifepristona y misoprostol combinados. En vista de la actual hostilidad política hacia el aborto, las restricciones impuestas al uso de mifepristona y la estrategia legislativa a largo plazo de restringir a nivel nacional el acceso al régimen combinado de mifepristona y misoprostol, es posible que un mayor número de personas en EE. UU. utilicen el régimen de misoprostol solo. A nivel mundial, las investigaciones han documentado experiencias con abortos realizados con misoprostol solo, pero ¿cuáles son las experiencias de las personas que viven en EE. UU.? Realizamos un análisis temático de 31 entrevistas a profundidad con personas que autogestionaron su aborto utilizando misoprostol adquirido mediante un pedido por correo o en una farmacia minorista, entre mayo y junio de 2020. Examinamos la aceptabilidad de utilizar misoprostol para el aborto con medicamentos en tres dominios: el régimen de medicamentos, el modo de entrega de los medicamentos y el modelo general de atención. Encontramos que las percepciones individuales de misoprostol eran influenciadas tanto por conocimiento anterior como por conocimiento informado. Recoger el misoprostol en una farmacia minorista fomentaba familiaridad, y tener una receta médica legitimaba el servicio como proveedor auténtico de medicamentos. Recibir los medicamentos mediante el modelo de entrega de pedido por correo cumplía las preferencias de privacidad y anonimato. En las reflexiones sobre el modelo en general, la satisfacción fue alta entre las participantes, pero las que eran adolescentes cuando tuvieron su aborto tenían la necesidad insatisfecha específica de recibir apoyo emocional, comparadas con las participantes de edad más avanzada. Estos resultados contribuyen a la creciente base de evidencias sobre la aceptabilidad de los regímenes de misoprostol solo, y de los modelos de prestación de servicios mediante pedido por correo y en farmacias minoristas.

Keywords: Medication abortion; United States; mifepristone; misoprostol; pharmacy; self-managed abortion; telemedicine.

Plain language summary

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.

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Conflict of interest statement

No potential conflict of interest was reported by the author(s).

Figures

Figure 1.
Figure 1.
Tailored conceptual model of acceptability examined across three domains that encompass the process of medication abortion using misoprostol dispensed from a mail-order or retail pharmacy
See this image and copyright information in PMC

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