“Medical” and “surgical” abortion: rethinking the modifiers

Later Gestational Age Abortion in Canada: A Scoping Review

Since the decriminalization of abortion in Canada in 1988, there have been no legal restrictions on when in pregnancy an abortion can take place. However, abortion care is only consistently available in Canada up to 23 weeks and 6 days; women, transgender men, and gender non-binary individuals who need abortion care after 24 weeks typically obtain services in the United States. Furthermore, abortion care beyond 16 weeks is unavailable in some regions of the country. The authors undertook this scoping review to explore what is currently known about later gestational age abortion in Canada. Using a six-stage framework, they identified 32 relevant sources that were published in the last 30 years, and they consulted with seven topic experts to validate the findings from our document synthesis. The limited body of literature on abortion after 16 weeks in Canada sheds light on the safety of both medical and instrumentation procedures, the type and training of abortion-providing clinicians, the characteristics of those obtaining abortion care after the first trimester, and geographic disparities in service availability. These topic experts emphasized the need for future research on patient experiences and developing and implementing strategies to help provinces and territories expand abortion care to later gestational ages and improve comprehensive reproductive health services.

Abortion rights beyond the medico-legal paradigm

Abortion rights in international law have historically been framed within a medico-legal paradigm, the belief that regulated systems of legal and medical control guarantee safe abortion. However, a growing worldwide practice of self-managed abortion (SMA) supported by feminist activism challenges key precepts of this paradigm. SMA activism has shown that more than medical service delivery matters to safe abortion and has called into question the legal regulation of abortion beyond criminal prohibitions. This article explores how abortion rights have begun to depart from the medico-legal paradigm and to support the novel norms and practices of SMA activism in a transformation of the abortion field. Abortion rights as reimagined in SMA activism increasingly feature in human rights agendas related to structural violence and inequality, collective organising and international solidarity, and democratic engagement.

Perceived Access to Abortion Among Women in the United States in 2018: Variation by State Abortion Policy Context

Objectives. To describe perceptions of access to abortion among women of reproductive age and their associations with state abortion policy contexts.Methods. We used data from the 2018 Survey of Family Planning and Women's Lives, a probability-based sample of 2115 adult women aged 18 to 44 years in US households.Results. We found that 27.6% of women (95% confidence interval [CI] = 23.3%, 32.7%) believed that access to medical abortion was difficult and 30.1% of women (95% CI = 25.6%, 35.1%) believed that access to surgical abortion was difficult. Adjusted for covariates, women were significantly more likely to perceive access to both surgical and medical abortions as difficult when they lived in states with 4 or more restrictive abortion policies compared with states with fewer restrictions (surgical adjusted odds ratio [AOR_surgical] = 1.60, 95% CI = 1.15, 2.21; AOR_medical = 1.65, 95% CI = 1.04, 1.95). Specific restrictive abortion policies (e.g., public funding restrictions, mandatory counseling or waiting periods, and targeted regulation of abortion providers) were also associated with greater perceived difficulty accessing both surgical and medical abortions.Conclusions. State policies restricting abortion access are associated with perceptions of reduced access to both medical and surgical abortions among women of reproductive age.

The changing landscape of abortion care: Embodied experiences of structural stigma in the Republic of Ireland and Northern Ireland

The private use of abortion medication outside of the formal healthcare setting is an international phenomenon. Despite new and expanding pathways to abortion access, we know little about how women's perceptions and experiences of abortion may also be changing. This study examines the embodied experience of 68 women who sought abortion services in Northern Ireland and the Republic of Ireland. Social stigma and restrictive abortion laws were major barriers to care at the time of study, providing the opportunity to explore the ways biological, social, and structural factors shape embodiment. Those who obtained an abortion either traveled abroad for clinical care or self-managed a medication abortion at home. Participant's perceptions of pain, the fetus, the method (medication vs. surgical), and environment in which they sought abortion care (at home vs. in a clinic) were shaped by structural stigma. Women gained greater experiential knowledge through medication self-management, allowing them to relate abortion to other natural bodily processes and redefine their beliefs about pregnancy and the fetus. Preferences and attitudes about the environment of abortion care were informed by stigma and differential perceptions of risk. Those who traveled most often emphasized legal and medical risks of abortion at home, while those who self-managed emphasized social, financial, and emotional risks of pursuing clinical abortion care abroad. Given the increase in reproductive self-care alternatives, these findings situate self-managed abortion in the literature of (de)medicalization and reveal the ways technology and structural factors shape perceptions and beliefs about pain, the fetus, method, and environment. For some, self-managed medication abortion may be a preferred pathway to care. Policies that consider medication self-management as part of a spectrum of legitimate options can improve abortion access for marginalized groups while also offering an improved abortion experience for those who prefer medication abortion and an out-of-clinic environment.

Promoting or Undermining Quality Decision Making? A Qualitative Content Analysis of Patient Decision Aids Comparing Surgical and Medication Abortion

OBJECTIVES

To understand, describe, and compare the content of patient decision aids on surgical and medication abortion, including 1) attributes used to describe each method, 2) approaches to clarify patients' values, 3) language used to describe each method, and 4) language used to frame women's decision-making role.

STUDY DESIGN

We analyzed 49 decision aids identified through a previous systematic review and environmental scan. We used summative content analysis for objectives 1 and 2 and directed content analysis for objectives 3 and 4.

RESULTS

We identified 37 method attributes. Overall, the attributes privileged medical over practical and emotional information. One decision aid included an explicit values clarification approach, and others included implicit approaches, which varied in length, information consistency, and organization. We identified four themes-information consistency, subjective claims, emotive or ambiguous descriptions, and medication abortion as not a real abortion-related to the methods' descriptions. We identified three themes-agency in choice, unclear emphasis on women's preferences, and endorsement of clinic services-related to women's decision-making role. Of the nine tools that listed factors influencing women's decision making, patient preferences was often listed last.

CONCLUSIONS

Early abortion method decision aids presented a broad range of information and typically framed the method choice as the woman's. However, their emphasis on medical attributes, use of inconsistent information, and, at times, biased presentation of methods may undermine quality decision making. We recommend adapting an existing decision aid or designing a novel tool based on the content and language that women find most acceptable.

Admitting privileges and hospital-based care after presenting for abortion: A retrospective case series

Objective

To examine the pathways of care for abortion patients transferred or referred to emergency departments (EDs) or hospitals before and after abortion‐providing physicians obtained hospital admitting privileges.

Data Sources

This case series was based on retrospective chart review at three abortion clinics in which physicians had obtained admitting privileges in the previous 5 years.

Study Design

We identified patients who were transferred or referred to a hospital or ED. Patients were grouped according to the pathway by which their care was transferred or referred to the ED/hospital.

Principal Findings

Both before and after admitting privileges, the majority of patients were referred to a hospital before the abortion was attempted and most were for suspected ectopic pregnancy or to perform the abortion in a hospital. Direct ambulance transfer from the facility to the ED/hospital was the least common pathway. We observed few changes in practice from before to after admitting privileges. Preexisting mechanisms of coordination and communication facilitated care that was tailored for the specific patient.

Conclusions

We did not find evidence that physician admitting privileges influenced the pathways through which abortion patients obtain hospital‐based care, as existing mechanisms of collaboration between hospitals and abortion facilities allowed for management of patients who sought hospital‐based care.

Sociodemographic Characteristics of Women Able to Obtain Medication Abortion Before and After Ohio's Law Requiring Use of the Food and Drug Administration Protocol

Purpose: In 2011, a law went into effect in Ohio that regulates how abortion care providers can offer medication abortion to their patients. We sought to evaluate changes in sociodemographic characteristics of Ohio medication abortion patients before and after the implementation of this law. Methods: We used a retrospective cohort design, comparing characteristics of women obtaining a medication abortion at four abortion facilities before and after the law. We used chart data from January 2010 to January 2011 and February 2011 to October 2014. For any significant changes in sociodemographics found before and after the law, we used stratified cross-tabulations to disentangle whether they were likely related to the restricted gestational limit imposed by the law (lowered from 9 to 7 weeks gestation), or whether they were likely related to other burdens brought on by the law, such as increased costs and visits. Results: Women obtaining a medication abortion after the law were more likely to be older (p=0.01), have higher levels of education (p<0.001), be of white race (p<0.001), have private insurance (p=0.001), have no children (p=0.002), and reside in a higher income zip code (p=0.03). Both the reduced gestational limit and the increased costs and visits likely contributed to declines among black women and women with lower levels of education. The reduced gestational limit for medication abortion likely contributed to a decline among younger women and Medicaid recipient groups. The increased costs and visits imposed by the law likely contributed to the decline in medication abortion among women with no insurance and women with children. Conclusion: The lower gestational limit, higher cost, and time and travel burdens exacted by Ohio's medication abortion law were associated with disproportionate reductions in medication abortion among the most disadvantaged groups. The law was associated with reduced access among women who were younger, of black race, less educated, and in lower socioeconomic groups.

'Abortion' or 'termination of pregnancy'? Views from abortion care providers in Scotland, UK

BACKGROUND

The phrase 'termination of pregnancy' has recently been adopted by a number of British medical institutions as a preferred descriptor of induced abortion. How it is used by abortion care providers is unclear, although the ongoing stigmatisation of abortion may play a role.

METHODS

A mixed methods study of the views of abortion care providers in Scotland, UK. Self-administered anonymous questionnaires were distributed to abortion care providers at a national conference (Scottish Abortion Care Providers). The main outcomes measured were the proportion of respondents reporting that they found the terms 'abortion' and 'termination of pregnancy' to be distressing, and their preferred terminology for use in consultations with women. In-depth interviews were conducted with 19 providers from a single clinic in Scotland to contextualise use of the terminology.

RESULTS

The questionnaire was completed by 90/118 delegates (76%). More respondents indicated they found the term 'abortion' distressing (28%), compared with those who found 'termination of pregnancy' distressing (6%; P<0.0001). Interview participants reported that 'termination of pregnancy' was the default phrase used in consultations. Some respondents stated that they occasionally purposely used 'abortion' in consultations to emphasise the seriousness of the procedure (morally, physically and/or emotionally).

CONCLUSIONS

'Termination of pregnancy' is the most commonly used term to describe induced abortion in patient consultations in Scotland. This and the term 'abortion' appear to play different roles, with the former being used euphemistically, and the latter as a more emphatic term. Further research is warranted to investigate how this interacts with patient care, service provision, and abortion stigma.

Unintended pregnancy: a framework for prevention and options for midlife women in the US

Recently unintended pregnancies have been described as "a new kind of mid-life crisis." Given the high prevalence of unwanted or mistimed pregnancy in the US, we examined the sexual and reproductive health patterns of sexually active midlife women. An examination of the prevalence of unintended pregnancy among midlife women revealed a gap in data indicating unmet sexual and reproductive health needs of midlife women. The application of a framework for primary, secondary and tertiary prevention for unintended pregnancy may assist with guiding care for women and identifying implications for reproductive health policy and potential political interference as they relate to sexual and reproductive health in midlife women.

Comparison of Outcomes before and after Ohio's Law Mandating Use of the FDA-Approved Protocol for Medication Abortion: A Retrospective Cohort Study

BACKGROUND

In February 2011, an Ohio law took effect mandating use of the United States Food and Drug Administration (FDA)-approved protocol for mifepristone, which is used with misoprostol for medication abortion. Other state legislatures have passed or enacted similar laws requiring use of the FDA-approved protocol for medication abortion. The objective of this study is to examine the association of this legal change with medication abortion outcomes and utilization.

METHODS AND FINDINGS

We used a retrospective cohort design, comparing outcomes of medication abortion patients in the prelaw period to those in the postlaw period. Sociodemographic and clinical chart data were abstracted from all medication abortion patients from 1 y prior to the law's implementation (January 2010-January 2011) to 3 y post implementation (February 2011-October 2014) at four abortion-providing health care facilities in Ohio. Outcome data were analyzed for all women undergoing abortion at ≤49 d gestation during the study period. The main outcomes were as follows: need for additional intervention following medication abortion (such as aspiration, repeat misoprostol, and blood transfusion), frequency of continuing pregnancy, reports of side effects, and the proportion of abortions that were medication abortions (versus other abortion procedures). Among the 2,783 medication abortions ≤49 d gestation, 4.9% (95% CI: 3.7%-6.2%) in the prelaw and 14.3% (95% CI: 12.6%-16.0%) in the postlaw period required one or more additional interventions. Women obtaining a medication abortion in the postlaw period had three times the odds of requiring an additional intervention as women in the prelaw period (adjusted odds ratio [AOR] = 3.11, 95% CI: 2.27-4.27). In a mixed effects multivariable model that uses facility-months as the unit of analysis to account for lack of independence by site, we found that the law change was associated with a 9.4% (95% CI: 4.0%-18.4%) absolute increase in the rate of requiring an additional intervention. The most common subsequent intervention in both periods was an additional misoprostol dose and was most commonly administered to treat incomplete abortion. The percentage of women requiring two or more follow-up visits increased from 4.2% (95% CI: 3.0%-5.3%) in the prelaw period to 6.2% (95% CI: 5.5%-8.0%) in the postlaw period (p = 0.003). Continuing pregnancy was rare (0.3%). Overall, 12.6% of women reported at least one side effect during their medication abortion: 8.4% (95% CI: 6.8%-10.0%) in the prelaw period and 15.6% (95% CI: 13.8%-17.3%) in the postlaw period (p < 0.001). Medication abortions fell from 22% (95% CI: 20.8%-22.3%) of all abortions the year before the law went into effect (2010) to 5% (95% CI: 4.8%-5.6%) 3 y after (2014) (p < 0.001). The average patient charge increased from US$426 in 2010 to US$551 in 2014, representing a 16% increase after adjusting for inflation in medical prices. The primary limitation to the study is that it was a pre/post-observational study with no control group that was not exposed to the law.

CONCLUSIONS

Ohio law required use of a medication abortion protocol that is associated with a greater need for additional intervention, more visits, more side effects, and higher costs for women relative to the evidence-based protocol. There is no evidence that the change in law led to improved abortion outcomes. Indeed, our findings suggest the opposite. In March 2016, the FDA-protocol was updated, so Ohio providers may now legally provide current evidence-based protocols. However, this law is still in place and bans physicians from using mifepristone based on any new developments in clinical research as best practices continue to be updated.

How to Escape the Doctor's Dilemma? De-Medicalize Reproductive Technologies

Kara Swanson details the professional evolution of Alan Guttmacher, and the quandary he faced when the law interfered with prerogatives he wished to exercise in his practice of reproductive medicine. This response focuses on how decoupling reproductive technologies from a regime requiring medical licensure could lead to more complete reproductive autonomy for women.

How clinicians develop confidence in their competence in performing aspiration abortion

In this article we explore how nurse practitioners, physician assistants, and nurse midwives in California (collectively referred to as clinicians) developed confidence while learning to provide vacuum aspiration abortion. We interviewed clinicians (n = 30) who worked in reproductive health care settings and had participated in a large abortion-training study. Although the training had moral and political significance for the trainees, in this article we focus on their experience of skill development and how they gained confidence and competence in aspiration abortion, a procedure typically performed by physicians. We argue that confidence is not one dimensional. Understanding the diverse ways in which clinicians arrive at confidence might inform health care training and education generally. By examining attained competency from the clinicians' perspectives, we continue the discussion within the social science of health care and medicine about how clinicians know what they know and what expertise feels like to them.

Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver

OBJECTIVES

We examined the impact on patient safety if nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs) were permitted to provide aspiration abortions in California.

METHODS

In a prospective, observational study, we evaluated the outcomes of 11 487 early aspiration abortions completed by physicians (n = 5812) and newly trained NPs, CNMs, and PAs (n = 5675) from 4 Planned Parenthood affiliates and Kaiser Permanente of Northern California, by using a noninferiority design with a predetermined acceptable risk difference of 2%. All complications up to 4 weeks after the abortion were included.

RESULTS

Of the 11 487 aspiration abortions analyzed, 1.3% (n = 152) resulted in a complication: 1.8% for NP-, CNM-, and PA-performed aspirations and 0.9% for physician-performed aspirations. The unadjusted risk difference for total complications between NP-CNM-PA and physician groups was 0.87 (95% confidence interval [CI] = 0.45, 1.29) and 0.83 (95% CI = 0.33, 1.33) in a propensity score-matched sample.

CONCLUSIONS

Abortion complications were clinically equivalent between newly trained NPs, CNMs, and PAs and physicians, supporting the adoption of policies to allow these providers to perform early aspirations to expand access to abortion care.

Early abortion in family medicine: clinical outcomes

PURPOSE

Clinical innovations have made it more feasible to incorporate early abortion into family medicine, yet the outcomes of early abortion procedures in this setting have not been well studied. We wished to assess the outcomes of first-trimester medication and aspiration abortion procedures by family physicians.

METHODS

Prospective observational cohort study conducted from August 2001 to February 2005 of 2,550 women who sought pregnancy termination in 4 clinical practices of family medicine departments and 1 private office/training site.

RESULTS

The rate of successful uncomplicated procedures for medication was 96.5% (95.5%-97.1% [corrected] confidence interval [CI], 95.5%-97.0%) and for aspiration was 99.9% (CI, 99.3%-1). Adverse events and complications of medication abortions were failed procedure (ongoing pregnancy; n = 19, 1.45%); incomplete abortion (n = 16, 1.22%); hemorrhage (n = 9, 0.69%); and patient request for aspiration (n = 1, 0.08%). One (0.08%) missed ectopic pregnancy was seen among patients receiving medication. Four types of adverse outcomes were encountered with aspiration: incomplete abortion requiring re-aspiration (n = 21, 1.83%); hemorrhage during the procedure (n = 4, 0.35%); missed ectopic pregnancy (n = 3, 0.26%); and minor endometritis (n = 1, 0.09%). Missed ectopic pregnancies were successfully treated in the inpatient setting without mortality (overall hospitalization rate of 0.16 of 100). All other complications were managed within outpatient family medicine sites. Rates of complication did not vary by experience of physician or by site of care (residency vs private practice).

CONCLUSIONS

Complications of medication and aspiration procedures occurred at a low rate, and most were minor and managed without incident.

Providing medication abortion information to diverse communities: use patterns of a multilingual web site

OBJECTIVE

This study analyzes the use patterns of , an English-, Spanish-, Arabic- and French-language web site dedicated to three methods of early pregnancy termination: mifepristone/misoprostol, methotrexate/misoprostol and misoprostol alone.

METHODS

This study examines both the overall and language-specific use patterns of the web site from October 1, 2004, through September 30, 2005. Data were recorded using Wusage 8.0, a web site statistics program.

RESULTS

Over the 12-month study period, received more than 78,000 visits and nearly 240,000 page requests. The English version is the most popular version of the web site (accessed in 46.1% of all visits), followed by the Spanish (35.0%), Arabic (10.4%) and French (8.8%) versions. Spanish-language visits are nearly three times as likely to access the misoprostol-only section of the web site when compared with the other language versions (p<.001).

CONCLUSION

This study confirms that multilingual, medically accurate online resources have the potential to expand information about medication abortion to both providers and women considering the option of abortion in diverse communities. Analysis of the language-specific use patterns highlights the different priorities of various types of web site visitors and suggests future priorities for educational outreach, collaboration and research.

Abortion education in nurse practitioner, physician assistant and certified nurse–midwifery programs: a national survey

OBJECTIVE

This study was undertaken to examine the inclusion and extent of abortion education in accredited nurse practitioner (NP), physician assistant (PA) and certified nurse-midwifery (CNM) programs in the United States.

METHODS

In January 2000, a confidential survey requesting information about the curricular inclusion of eight reproductive health topics was mailed to program directors at all 486 accredited NP, PA and CNM programs in the United States.

RESULTS

Two hundred two surveys were returned, with a response rate of 42%. Overall, 53% of programs reported didactic instruction on surgical abortion, manual vacuum aspiration or medication abortion and 21% reported including at least one of these three procedures in their routine clinical curriculum.

CONCLUSION

Abortion education is deficient in NP, PA and CNM programs in the United States. As integral components of women's health care, abortion, pregnancy options counseling and family planning merit incorporation into routine didactic and clinical education.

Patient costs for medication abortion: Results from a study of five clinical practices

PURPOSE

In 2000, the FDA approved mifepristone as a medication abortion alternative. There is limited understanding of the patient costs associated with use of this method. Our objective was to determine total patient costs for medication abortion. This information may be useful for improving counseling and patient decision making.

METHODS

We surveyed 212 women who received a medication abortion from a convenience sample of 5 health care practices. Patient costs including direct medical costs (pregnancy test costs, charges), direct nonmedical costs (child care, travel, lodging), and productivity losses (value of time away from work or other activities) were determined.

RESULTS

The mean total cost for medication abortion was 351 dollars (0-1,140 dollars). The average charge paid by women themselves for the procedure itself was 306 dollars. Three quarters of total costs were direct medical costs and almost one quarter was time away from work and other activities. Although nearly three quarters of the women were insured, only 1% used insurance to cover their abortion--many (44%) did not know if their insurance covered abortion.

CONCLUSIONS

This study provides descriptive information on patient costs associated with medication abortion that may be integrated into patient counseling to enhance informed decision making by women. The study raises questions about why women who report having insurance are not aware of whether their insurance will cover abortion and suggests that we are unclear about women's and providers' preferences for using insurance. We should continue to develop our knowledge of the clinical and nonclinical trade-offs for women choosing between abortion methods to benefit patient decision making.

Physicians' knowledge and opinions about medication abortion in four Latin American and Caribbean region countries

To examine physicians' knowledge and attitudes in regard to medication abortion, we conducted focus-group discussions with general practice physicians and obstetrician-gynecologists in Honduras, Mexico, Nicaragua and Puerto Rico. Physicians were familiar with the practice of several types of medication and surgical abortion methods. Medication abortion with misoprostol is most common among women of higher socioeconomic status and is prescribed by physicians, pharmacists or self-administered. Conflicting opinions regarding safety, efficacy, cost, potential for self-medication and acceptability emerged; some participants expressed hope that medical abortion would reduce the risks associated with unsafe abortion, while others contended that drug distribution and self-medication without proper counseling could be problematic. Participants noted a lack of reliable sources of information for both providers and women, and expressed interest in strategic dissemination of information.