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Meurice ME, Mody SK, Nodora J, Marengo A, Averbach S. Social determinants of choosing telemedicine for contraceptive care: A retrospective cohort study. Contraception 2024; 134:110414. [PMID: 38431258 DOI: 10.1016/j.contraception.2024.110414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVES Compare demographic characteristics and contraception choices among individuals seeking contraception care via telemedicine versus in-person. STUDY DESIGN Retrospective cohort study of contraception visits from June-September 2021 at Planned Parenthood of the Pacific Southwest. We assessed demographics and contraception choices. We used multivariable logistic regression to evaluate effect of language, age, income, having children, and insurance type on choosing telemedicine. RESULTS We included 16,855 patients: 2383 (14.1%) telemedicine visits and 14,472 (85.9%) in-person visits; 149/2383 (6.3%) non-English speakers used telemedicine compared to 1194/14,472 (8.3%) who used in-person care. A higher proportion of the telemedicine cohort had public insurance compared to the in-person cohort (2312/2383 [97.0%] telemedicine vs 11,646/14,472 [80.5%] in-person). Among the telemedicine cohort, a higher proportion of patients chose a barrier method (691/2363 [29.2%] telemedicine vs 1564/14,215 [11.0%] in-person) and short-acting method (1248/2363 [52.8%] telemedicine vs 5834/14,215 [41.0%] in-person) compared to in-person. A higher proportion of in-person patients chose long-acting reversible contraception (2681/14,215 [18.9%] in-person vs 179/2363 [7.6%] telemedicine) and injection (3779/14,215 [26.6%] in-person vs 115/2363 [4.9%] telemedicine) compared to telemedicine. Speaking Spanish was associated with decreased odds of choosing telemedicine after adjusting for covariates (aOR 0.53 [95% CI 0.44-0.64], p < 0.001). Older age, having children, lower income, and public insurance were associated with increased odds of choosing telemedicine. CONCLUSIONS Telemedicine for contraception visits was associated with language, age, parity, income, and insurance. Despite small absolute difference in the proportion of patients that speak Spanish, in adjusted multivariate analysis speaking Spanish was associated with lower odds of choosing telemedicine. IMPLICATIONS Increasing access for people with limited technology as well as those who prefer non-English languages is essential to promote equitable reproductive care. Prospective research that focuses on patient experience and preferences is needed to better guide access to equitable, person-centered contraception care.
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Affiliation(s)
- Marielle E Meurice
- Division of Complex Family Planning, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, La Jolla, CA, United States.
| | - Sheila K Mody
- Division of Complex Family Planning, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, La Jolla, CA, United States
| | - Jesse Nodora
- Radiation Medicine and Applied Sciences, Moores Cancer Center, University of California, San Diego, La Jolla, CA, United States
| | - Antoinette Marengo
- Planned Parenthood of the Pacific Southwest, San Diego, CA, United States
| | - Sarah Averbach
- Division of Complex Family Planning, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, La Jolla, CA, United States
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Estévanez Jiménez E, Cruz Piqueras M. [Abortion in Melilla: barriers to ocean and frontier]. GACETA SANITARIA 2024; 38:102355. [PMID: 38309253 DOI: 10.1016/j.gaceta.2024.102355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/08/2023] [Accepted: 11/16/2023] [Indexed: 02/05/2024]
Abstract
OBJECTIVE To provide insights into the challenges faced by women seeking abortion services in Melilla, Spain. It seeks to describe the journey these women undertake and to identify and analyze the barriers they encounter in accessing abortion care. METHOD A qualitative research approach was employed, involving a series of eight semi-structured interviews during 2022. Three interviews were conducted with national experts in the field of abortion, while five interviews were conducted with healthcare professionals from the Melilla Health Area who are directly involved in providing abortion services and supporting women throughout the process. The study was guided by a theoretical framework that focuses on barriers to abortion access and sexual and reproductive rights. The collected data was analyzed using content analysis and categorized based on key dimensions of the study. RESULTS The study identified several significant barriers to abortion care access in Melilla. These include conscientious objection among healthcare providers, the geographical remoteness of Melilla, the legal challenges faced by Moroccan women due to their irregular status, and the requirement of parental consent for minors aged 16 and 17. Consequently, women seeking abortion services are forced to travel to mainland Spain, continue with undesired pregnancies, or resort to unsafe clandestine abortions in Morocco, thereby endangering their lives in the worst cases. CONCLUSIONS The barriers to abortion access identified in this study represent a violation of women's reproductive rights in Melilla. Urgent action is required to review the current process, ensuring that access is improved and the right to safe abortion is guaranteed for all women residing in Melilla.
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Affiliation(s)
- Eva Estévanez Jiménez
- Departamento de Medicina Preventiva y Salud Pública, Hospital Universitario Puerta del Mar, Cádiz, España.
| | - Maite Cruz Piqueras
- Escuela Andaluza de Salud Pública, Granada, España; Red de Ética Salubrista para la Acción, Cuidados y Observación Social (ESPACyOS), España
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Lewandowska M, Carter DJ, Gasparrini A, Lohr PA, Wellings K. Impact of approval of home use of misoprostol in England on access to medical abortion: An interrupted time series analysis. Int J Gynaecol Obstet 2024; 164:286-297. [PMID: 37621171 DOI: 10.1002/ijgo.15044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/18/2023] [Accepted: 07/25/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE In 2018, the Department of Health and Social Care in England approved the use of misoprostol at home for early medical abortions, following administration of mifepristone at clinic. The objective of the present study was to assess the impact of the approval of home administration of misoprostol in England on access to medical abortion, assessed through proxy measures of the proportion of all abortions that were medical and gestational age. METHODS This study uses the clinical data from the British Pregnancy Advisory Service on abortions in England in years 2018-2019, containing demographic and procedure characteristics of patients. We conducted an interrupted time series analysis to establish the differences before and after the approval in access to medical abortion, measured by the proportion of all abortions that were medical, and gestational age. The analysis also examined whether these changes were equitable, with focus on area-level deprivation. RESULTS The analysis of the data (145 529 abortions) suggested that there was an increase in the proportion of medical abortions and decrease in gestational age of abortions after the approval. Compared with the situation if former trends had continued, the actual proportion of early medical abortions was 4.2% higher in December 2019, and the mean gestational age 3.4 days lower. We found that the acceleration of existing trends in increase in proportion of medical abortions and decrease in gestational age were larger in the most deprived quintiles and in those reporting a disability, but not equal across ethnic groups, with Black and Black British women experiencing little change in trajectories post-approval. CONCLUSION The approval of home use of misoprostol as part of an early medical abortion regimen in England was associated with material and equitable improvements in abortion access. Pre-approval trends toward greater uptake of medical abortion and declining gestational age were accelerated post-approval and were greatest in the most deprived areas of England, but not across all racial/ethnic groups. The present findings strongly support the continuation or introduction of home management of medical abortions.
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Affiliation(s)
- Maria Lewandowska
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Daniel J Carter
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Antonio Gasparrini
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Patricia A Lohr
- Centre for Reproductive Research and Communication, British Pregnancy Advisory Service, London, UK
| | - Kaye Wellings
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Acre VN, Küng SA, Arce C, Yapu A, Iriondo D, Morales M. Reach, experience, and acceptability of an abortion self-care intervention in Bolivia: a mixed-methods evaluation. Sex Reprod Health Matters 2023; 31:2139888. [PMID: 36867125 PMCID: PMC9987779 DOI: 10.1080/26410397.2022.2139888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
In 2018, Ipas Bolivia launched an abortion self-care (ASC) community intervention with the goal of increasing access to supportive, well-informed abortion support provided by community agents (CAs). Between September 2019 and July 2020, Ipas conducted a mixed-methods evaluation to assess the reach, outcomes, and acceptability of the intervention. We used logbook data maintained by CAs to capture demographic characteristics and ASC outcomes of people supported. We also conducted in-depth interviews with 25 women who had received support and 22 CAs who had provided support. 530 people accessed ASC support through the intervention, most of whom were young, single, educated women accessing abortion in the first trimester. Among the 302 people who self-managed their abortions, 99% reported having a successful abortion. No women reported adverse events. All women interviewed expressed satisfaction with the support provided by the CA and, in particular, with the information, lack of judgement, and respect they felt from CAs. CAs spoke highly about their experience and viewed their participation as a way to increase people's ability to exercise their reproductive rights. Obstacles included experiences of stigma, fears of legal repercussions, and difficulties dispelling misconceptions around abortion. Legal restrictions and abortion stigma continue to complicate access to safe abortion, and findings from this evaluation highlight important avenues for the effectiveness and expansion of ASC interventions, including legal support to people who have abortions and those who provide abortion support, building capacity of people as informed buyers, and ensuring that interventions reach rural and other often under-served people.
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Affiliation(s)
- Valerie N Acre
- Senior Research, Monitoring and Evaluation Advisor, Ipas, Chapel Hill, NC, USA. Correspondence:
| | | | | | - Adela Yapu
- Program Manager, Ipas Bolivia, La Paz, Bolivia
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Podolskyi V, Gemzell-Danielsson K, Marions L, Gomperts R. Preabortion ultrasound - a patient perspective. EUR J CONTRACEP REPR 2023; 28:268-273. [PMID: 37698511 DOI: 10.1080/13625187.2023.2249158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/14/2023] [Accepted: 08/11/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE To explore women's perception of the need for an ultrasound scan before medical abortion provided by telemedicine services. METHODS We have analysed women's requests for medical abortion through the website www.womenonweb.org from the 1st of January 2019 to the 5th of October 2020. Before receiving abortion drugs for self-managed medical abortion, women received online counselling and were asked to complete an online survey on pre-abortion ultrasound scan and the reasons for having or not having one. The initial dataset included 62641 entries from 207 countries. Each entry corresponded to a person's request for medical abortion. Women reported only one or multiple reasons for not having a pre-abortion ultrasound scan. RESULTS Among 59648 women requesting a medical abortion, 45653 (76,54%) did not have any pre-abortion ultrasound scan and specified a reason for that. The countries with the highest rates of women not having a pre-abortion ultrasound scan were Thailand, Poland, Northern Ireland, Mexico, South Korea, Japan, Chile, Indonesia, Germany, and Brazil. The main reasons for not having a pre-abortion ultrasound scan were being confident regarding pregnancy length; and thus, no need for a scan stated by 10910/34390 women (31.7%), lack of resources stated by 10589/34390 women (30.8%), and privacy issues stated by 6472/34390 women (18.8%). CONCLUSION Most women opting for medical abortion through telemedicine did not undergo a pre-abortion ultrasound scan. The main reason stated was that women did not find it necessary, lack of resources and privacy issues.
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Affiliation(s)
- Volodymyr Podolskyi
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- WHO-Centre, Karolinska University Hospital Solna, QB:84, Stockholm, Sweden
- Lukyanova Institute of Pediatrics, Obstetrics and Gynecology of NAMS of Ukraine, Kyiv, Ukraine
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- WHO-Centre, Karolinska University Hospital Solna, QB:84, Stockholm, Sweden
| | - Lena Marions
- Department Obstetrics and Gynecology, Södersjukhuset, Stockholm, Sweden
- Department Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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Ehrenreich K, Baba CF, Raifman S, Grossman D. Perspectives on Alternative Models of Medication Abortion Provision Among Abortion Patients in the United States. Womens Health Issues 2023; 33:481-488. [PMID: 37105836 DOI: 10.1016/j.whi.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 03/13/2023] [Accepted: 03/24/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE Restrictions on the availability of medication abortion are a barrier to accessing early abortion. People seeking medication abortion may be interested in obtaining the medications through alternative models. The purpose of this study was to explore patient perspectives on obtaining abortion medications in advance of pregnancy or over the counter (OTC). STUDY DESIGN Between October 2017 and August 2018, we conducted 30 in-depth interviews with abortion patients who indicated support for alternative models. We recruited patients from 10 abortion clinics in states with a range of policy environments. We analyzed interviews using inductive and deductive iterative techniques. RESULTS Participants identified logistical benefits of these alternative models, including eliminating travel to a clinic and multiple appointments, and increased privacy around decision-making. Participants were interested in advance provision for its convenience and the sense of preparedness that would come with having the pills available at home, yet some had concerns about the pills being found or stolen. Privacy was the key factor considered for OTC access, including both the privacy benefits of avoiding a clinic and the concern of having one's privacy compromised within the community if purchasing the medications in public. CONCLUSIONS People who have previously had a medication abortion are interested in alternative methods of provision for reasons concerning convenience, privacy, and avoiding burdens related to hostile policy environments, such as long travel distances to clinics and multiple appointments. Concerns around these models were primarily safety concerns for young people. Further research is needed to evaluate the safety, effectiveness, acceptability, and feasibility of these alternative models of providing medication abortion.
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Affiliation(s)
- Katherine Ehrenreich
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California.
| | - C Finley Baba
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Sarah Raifman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California
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Shahrokhi SN, Salmani H, Ahmadi M. The Role of Electronic Health Tools in Unwanted Pregnancy Prevention, Abortion and Post-Abortion Follow-Up: A Systematic Review. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2023; 28:487-503. [PMID: 37869688 PMCID: PMC10588920 DOI: 10.4103/ijnmr.ijnmr_312_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 09/14/2020] [Accepted: 11/18/2022] [Indexed: 10/24/2023]
Abstract
Background More than 30% of women experience at least one abortion. To date, there has been no comprehensive mobile health project on the impact of technology on access to abortion, contraception, and post-abortion follow-up. The purpose of this study was to review published studies on the role of electronic health in the prevention of unwanted pregnancy, abortion, and post-abortion follow-up. Materials and Methods The Web of Science, PubMed, ScienceDirect, and EMBASE databases were searched to find relevant articles published between 2008 and 2018. A systematic review study was conducted on 33 relevant articles. All studies related to the use and impact of electronic health on unwanted pregnancy prevention, abortion and post-abortion follow-up in English from January 2008 to December 2018 were included. The quality of the studies was evaluated using the PRISMA-S. Results Thirty-three studies met the inclusion criteria for the review. The Studies were divided into four main groups of women's experiences on the use of mobile health and telemedicine technologies for at-home medical abortion, unwanted pregnancy prevention, abortion, and post-abortion follow-up. The results showed the significant impact of using electronic health on unwanted pregnancy prevention, abortion, and post-abortion follow-up. Conclusions Health technologies have the potential to be used as a low-cost and accessible method to replace abortion services. They can facilitate remote care and quick access to information to complete the gaps in access to abortion. Therefore, it is necessary for health service providers to be aware of the possibility of the client's access to electronic health tools.
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Affiliation(s)
- Seyedeh Nafiseh Shahrokhi
- Department of Health Information Management, Iran University of Medical Sciences, School of Health Management and Information Sciences, Tehran, Iran
| | - Hosna Salmani
- Department of Health Information Management, Iran University of Medical Sciences, School of Health Management and Information Sciences, Tehran, Iran
| | - Maryam Ahmadi
- Department of Health Information Management, Iran University of Medical Sciences, School of Health Management and Information Sciences, Tehran, Iran
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Madera M, Johnson DM, Broussard K, Tello-Pérez LA, Ze-Noah CA, Baldwin A, Gomperts R, Aiken AR. Experiences seeking, sourcing, and using abortion pills at home in the United States through an online telemedicine service. SSM. QUALITATIVE RESEARCH IN HEALTH 2022; 2:100075. [PMID: 37503356 PMCID: PMC10372773 DOI: 10.1016/j.ssmqr.2022.100075] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
A growing number of people in the United States seek to self-manage their abortions by self-sourcing abortion medications online. Prior research focuses on people's motivations for seeking self-management of abortion and experiences trying to obtain medications. However, little is known about the experiences of people in the U.S. who actually complete a self-managed abortion using medications they self-sourced online. We conducted anonymous in-depth interviews with 80 individuals who sought abortion medications through Aid Access, the only online telemedicine service that provides abortion medications in all 50 U.S. states. Through grounded theory analysis we identified five key themes: 1) participants viewed Aid Access as a "godsend"; 2) Fears of scams, shipping delays, and surveillance made ordering pills online a "nerve-racking" experience; 3) a "personal touch" calmed fears and fostered trust in Aid Access; 4) participants were worried about the "what ifs" of the self-managed abortion experience; and 5) overall, participants felt that online telemedicine met their important needs. Our findings demonstrate that online telemedicine provided by Aid Access not only provided a critical service, but also offered care that participants deemed legitimate and trustworthy.
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Affiliation(s)
| | | | | | | | | | - Aleta Baldwin
- California State University, Sacramento, Sacramento, CA, USA
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Shukla A, Vazquez-Quesada L, Vieitez I, Acharya R, RamaRao S. Quality of care in abortion in the era of technological and medical advancements and self-care. Reprod Health 2022; 19:191. [PMID: 36109756 PMCID: PMC9479303 DOI: 10.1186/s12978-022-01499-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Discussions around quality of abortion care have been focused mainly on service-delivery aspects inside healthcare facilities. More recently, with availability of medical abortion (MA), increase in its self-use, and emergence of other delivery platforms such as telemedicine, the responsibility of quality care has broadened to actors outside of facilities.
Body of text
This commentary discusses the meaning of quality of abortion care with the paradigm shift brought by medical and technological advancement in abortions, and raises questions on the role of the state in ensuring quality in abortion management—especially in settings where abortion is decriminalized, but also in countries where abortion is permitted under certain circumstances. It consolidates the experience gained thus far in the provision of safe abortion services and also serves as a forward-thinking tool to keep pace with the uptake of newer health technologies (e.g., availability of medical abortion drugs), service delivery platforms (e.g., telemedicine, online pharmacies), and abortion care providers (e.g., community based pharmacists).
Conclusions
This commentary provides context and rationale, and identifies areas for action that different stakeholders, including health advocates, policymakers, program managers, and women themselves, can adopt to fit into an alternative regime of abortion care.
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Killinger K, Günther S, Gomperts R, Atay H, Endler M. Why women choose abortion through telemedicine outside the formal health sector in Germany: a mixed-methods study. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:e6-e12. [PMID: 33229399 DOI: 10.1136/bmjsrh-2020-200789] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/27/2020] [Accepted: 11/03/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Women on Web (WoW) is a global medical abortion telemedicine service operating outside the formal health sector. In April 2019 they opened their helpdesk to Germany. Our aim was to understand the motivations, and perceived barriers to access, for women who choose telemedicine abortion outside the formal health sector in Germany. METHODS We conducted a parallel convergent mixed-methods study among 1090 women consulting WoW from Germany between 1 January and 31 December 2019. We performed a cross-sectional study of data contained in online consultations and a content analysis of 108 email texts. Analysis was done until saturation; results were merged and triangulation used to validate results. RESULTS The quantitative analysis found that the need for secrecy (n=502, 48%) and the wish for privacy (n=500, 48%) were frequent reasons for choosing telemedicine abortion. Adolescents were more likely to report secrecy, cost, stigma and legal restrictions as reasons for using telemedicine abortion compared with older women. The content analysis developed two main themes and seven subsidiary categories, (1) internal motivations for seeking telemedicine abortion encompassing (i) autonomy, (ii) perception of external threat and (iii) shame and stigma, and (2) external barriers to formal abortion care encompassing (iv) financial stress, (v) logistic barriers to access, (vi) provider attitudes and (vii) vulnerability of foreigners. CONCLUSIONS Women in Germany who choose telemedicine abortion outside the formal health sector do so both from a place of empowerment and a place of disempowerment. Numerous barriers to abortion access exist in the formal sector which are of special relevance to vulnerable groups such as adolescents and undocumented immigrants.
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Affiliation(s)
- Kristina Killinger
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Hazal Atay
- Women on Web, Toronto, Ontario, Canada
- Centre of Political Research, Sciences Po (CEVIPOF), Paris, France
| | - Margit Endler
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Women's Health Research Unit, University of Cape Town, Cape Town, South Africa
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Johnson DM, Madera M, Gomperts R, Aiken AR. The economic context of pursuing online medication abortion in the United States. SSM. QUALITATIVE RESEARCH IN HEALTH 2021; 1:100003. [PMID: 35368445 PMCID: PMC8976452 DOI: 10.1016/j.ssmqr.2021.100003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Access to in-clinic abortion has become increasingly restricted in the U.S. and for many, the high cost of care is a significant barrier. However, little is known about how financial circumstances shape the alternate pathways to abortion care people seek when the clinic is out of reach. In a unique sample of people who used medication abortion pills from Aid Access, a non-profit telemedicine service, we examine the impact of economic circumstances on abortion care pathway decision-making and experiences seeking care. Between June and August 2019, we conducted 80 anonymous, semi-structured in-depth interviews with U.S. residents who self-managed their own abortions using medication abortion pills from Aid Access. Participants were asked about their experiences seeking abortion, and their motivations for using the service. We coded interviews using an iteratively developed coding guide and performed thematic analyses to identify key themes. The unaffordable cost of in-clinic abortion was a key reason why participants sought care using online telemedicine. Experiences of personal financial hardship exacerbated by restrictive policies impacted participants' ability to access the clinic. For participants with children, their financial decisions were further guided by the concerns of providing economic stability for their family. Although telemedicine was considered more affordable than in-clinic care, for some, the suggested donation of $90 still posed a financial burden and accessing pills at no cost or a reduced cost was necessary. The availability of affordable telemedicine and policy interventions addressing Medicaid and insurance coverage for abortion would democratize abortion access for populations with low incomes.
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Holten L, de Goeij E, Kleiverda G. Permeability of abortion care in the Netherlands: a qualitative analysis of women's experiences, health professional perspectives, and the internet resource of Women on Web. Sex Reprod Health Matters 2021; 29:1917042. [PMID: 33975533 PMCID: PMC8118432 DOI: 10.1080/26410397.2021.1917042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Despite a relatively permissive abortion law, women in the Netherlands encounter difficulties in accessing abortion care. Little is known about their experiences. This study explores women's experiences with (online) abortion services and relevant health professionals' experiences delivering care, with the goal of identifying key barriers encountered by abortion-seekers in the Netherlands. An exploratory qualitative research design with a constructivist approach and an abbreviated grounded theory method was used. Interviews with 20 women who had had an abortion and 14 health professionals who provide abortion care, and 200 emails of women seeking abortion care through the non-governmental organisation Women on Web, were coded inductively and deductively (using the Candidacy Framework) thereby generating themes. Abortion-seekers faced barriers including: (i) burden of taboo, (ii) vulnerability (emotional, financial, and social), (iii) health professional evaluation and (iv) disempowerment and distress. The overarching theme was women's lack of autonomy in access to abortion care. The key barriers to abortion access in the Netherlands are the institutionalisation of taboo in abortion law and care, complex candidacy regulations, lack of permeability for certain marginalised groups, and women's inability to speak openly about abortion. To increase the permeability of abortion care, and thereby women's autonomy, legislators and policy-makers must trust women to make their own reproductive decisions and avoid actions that stigmatise abortion and hinder access to care, while actively developing systemic support for vulnerable groups.
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Affiliation(s)
- Lianne Holten
- Researcher, Women on Waves, Amsterdam, the Netherlands
| | - Eva de Goeij
- Independent scholar, Dutch Humanist Association (Humanistich Verbond), Amsterdam, the Netherlands
| | - Gunilla Kleiverda
- Consultant Obstetrician and Gynaecologist, Flevoziekenhuis, Almere, the Netherlands
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Shao W, Zheng B, Zhou G, Sun L. Effects of bilateral early breast sucking and unilateral early breast sucking within 2 h after delivery on lactation, breast distending pain and postpartum lochia. Am J Transl Res 2021; 13:13003-13009. [PMID: 34956517 PMCID: PMC8661153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/19/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To investigate the effects of bilateral early breast sucking and unilateral early breast sucking within 2 h after delivery on lactation, breast distending pain and postpartum lochia. METHODS The clinical data of 128 parturients were analyzed retrospectively. According to the different ways of early breast suction, the parturients were divided into control group (n=64) and observation group (n=64). Among them, unilateral early sucking was performed within 2 h after delivery in the control group, while bilateral early sucking was carried out in the observation group. We compared the lactation, breast distending pain, postpartum lochia, nutritional status, coagulation index, complications and breast feeding success rate. RESULTS The lactation amount of the observation group was higher than that of the control group on the 3rd, 5th and 7th day after delivery; the VAS scores showed opposite trends; the amount of lochia in the observation group was less than that in the control group; the ALb, PA and Hb levels in the observation group were higher on the 7th day after delivery. Compared with the control group, the FIB, PT and APTT time was shorter and the D-D level was higher; the incidence of postpartum hemorrhage, galactostasis and postpartum depression in the observation group was lower, and the success rate of feeding on the 1st, 3rd and 7th day after delivery was higher in the observation group seven days after intervention. CONCLUSION Bilateral early breast sucking within 2 h after delivery is helpful to increase lactation and reduce breast distending pain and postpartum lochia. It also promotes maternal nutritional status and coagulation function, reduces the incidence of postpartum complications, and improves the breastfeeding rate.
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Affiliation(s)
- Wei Shao
- Department of Obstetrics, Jiaozhou Central Hospital of Qingdao Qingdao 266300, Shandong Province, China
| | - Bingxin Zheng
- Department of Obstetrics, Jiaozhou Central Hospital of Qingdao Qingdao 266300, Shandong Province, China
| | - Guoxia Zhou
- Department of Obstetrics, Jiaozhou Central Hospital of Qingdao Qingdao 266300, Shandong Province, China
| | - Lin Sun
- Department of Obstetrics, Jiaozhou Central Hospital of Qingdao Qingdao 266300, Shandong Province, China
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Parsons JA, Romanis EC. The Case for Telemedical Early Medical Abortion in England: Dispelling Adult Safeguarding Concerns. HEALTH CARE ANALYSIS 2021; 30:73-96. [PMID: 34687384 PMCID: PMC8540868 DOI: 10.1007/s10728-021-00439-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 12/04/2022]
Abstract
Access to abortion care has been hugely affected by the COVID-19 pandemic. This has prompted several governments to permit the use of telemedicine for fully remote care pathways, thereby ensuring pregnant people are still able to access services. One such government is that of England, where these new care pathways have been publicly scrutinised. Those opposed to telemedical early medical abortion care have raised myriad concerns, though they largely centre on matters of patient safeguarding. It is argued that healthcare professionals cannot adequately carry out their safeguarding duties if the patient is not in the room with them. These concerns lack empirical support. Emerging evidence suggests that safeguarding processes may, in fact, be more effective within telemedical abortion care pathways. In this article, we address two specific safeguarding concerns: (1) that a remote consultation prevents a healthcare professional from identifying instances of abuse, and (2) that healthcare professionals cannot reliably confirm the absence of coercion during a remote consultation. We demonstrate that such concerns are misplaced, and that safeguarding may actually be improved in telemedical care pathways as victims of abuse may find it easier to engage with services. It is inevitable that some individuals will fall through the net, but this is unavoidable even with in-person care and thus does not constitute a strong critique of the use of telemedicine in abortion care. These safeguarding concerns set aside, then, we argue that the current approval that enables telemedical early medical abortion should be afforded permanence.
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Porter Erlank C, Lord J, Church K. Acceptability of no-test medical abortion provided via telemedicine during Covid-19: analysis of patient-reported outcomes. BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:261-268. [PMID: 33602718 PMCID: PMC7977074 DOI: 10.1136/bmjsrh-2020-200954] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/23/2021] [Accepted: 01/31/2021] [Indexed: 05/23/2023]
Abstract
INTRODUCTION The English government approved both stages of early medical abortion (EMA), using mifepristone and misoprostol under 10 weeks' gestation, for at-home use on 30 March 2020. MSI Reproductive Choices UK (MSUK), one of the largest providers of abortion services in England, launched a no-test telemedicine EMA pathway on 6 April 2020. The objectives of this study were to report key patient-reported outcome measures and to assess whether our sample was representative of the whole population receiving no-test telemedicine EMA. METHODS A sample of all MSUK's telemedicine EMA patients between April and August 2020 were invited to opt in to a follow-up call to answer clinical and satisfaction questions. A total of 1243 (13.7% of all telemedicine EMAs) were successfully followed-up, on average within 5 days post-procedure. RESULTS Patients reported high confidence in telemedicine EMA and high satisfaction with the convenience, privacy and ease of managing their abortion at home. The sample responding were broadly equivalent to the whole population receiving telemedicine. No patient reported that they were unable to consult privately. The majority (1035, 83%) of patients reported preferring the telemedicine pathway, with 824 (66%) indicating that they would choose telemedicine again if COVID-19 were no longer an issue. CONCLUSIONS Telemedicine EMA is a valued, private, convenient and more accessible option that is highly acceptable for patients seeking an abortion, especially those for whom in-clinic visits are logistically or emotionally challenging. Evidence that this pathway would be a first choice again in future for most patients supports the case to make telemedicine EMA permanent.
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Affiliation(s)
| | - Jonathan Lord
- Medical Director, MSI Reproductive Choices, London, UK
- Truro Locality, University of Exeter Medical School, Truro, Cornwall, UK
| | - Kathryn Church
- Evidence to Action Department, MSI Reproductive Choices, London, UK
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Romanis EC, Parsons JA, Salter I, Hampton T. Safeguarding and teleconsultation for abortion. Lancet 2021; 398:555-558. [PMID: 34364526 PMCID: PMC9606739 DOI: 10.1016/s0140-6736(21)01062-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Elizabeth Chloe Romanis
- Centre for Ethics and Law in the Life Sciences, Durham Law School, Palatine Centre, Durham University, Durham, UK.
| | - Jordan A Parsons
- Centre for Ethics in Medicine, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Thomas Hampton
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
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17
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De Kort L, Wood J, Wouters E, Van de Velde S. Abortion care in a pandemic: an analysis of the number and social profile of people requesting and receiving abortion care during the first COVID-19 lockdown (March 16 to June 14, 2020) in Flanders, Belgium. ACTA ACUST UNITED AC 2021; 79:140. [PMID: 34344468 PMCID: PMC8331997 DOI: 10.1186/s13690-021-00665-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/25/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND The COVID-19 pandemic and the national COVID-19 measures might have increased potential barriers to abortion care and created new ones, especially for vulnerable groups. This study documents the impact of the pandemic and the lockdown measures on the profile of people going through the abortion process. METHODS Using anonymized patient records from a Belgian abortion centre, we first compared the number of abortion requests and procedures during the first COVID-19 lockdown with the same months in the five preceding years. Next, we analysed the social profile of people requesting an abortion in those two time periods and looked at the number of long-acting reversible contraceptive devices (LARC) placed after curettage. RESULTS The abortion centre saw a drop in the number of abortion requests during the lockdown. This difference was more pronounced for people in paid employment and people using (modern) contraception. People were also more likely to request an abortion earlier in their pregnancy. The drop in abortion procedures and LARC's placed after curettage was proportionate to the drop in abortion requests and did not differ according to clients' characteristics. CONCLUSION Questions arose concerning the potential selectivity with which COVID-19 influenced the need for abortion care and accessibility to services. Although there was a general drop in abortion requests and procedures during the first COVID-19 lockdown in the studied abortion centre, our results suggest that the profile of people requesting and receiving an abortion did only slightly change during the lockdown, and did not affect vulnerable groups visibly harder.
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Affiliation(s)
- Leen De Kort
- Centre for Population, Family and Health, Department of Sociology, University of Antwerp, Sint-Jacobstraat 2-4, 2000, Antwerp, Belgium.
| | - Jonas Wood
- Centre for Population, Family and Health, Department of Sociology, University of Antwerp, Sint-Jacobstraat 2-4, 2000, Antwerp, Belgium
| | - Edwin Wouters
- Centre for Population, Family and Health, Department of Sociology, University of Antwerp, Sint-Jacobstraat 2-4, 2000, Antwerp, Belgium
| | - Sarah Van de Velde
- Centre for Population, Family and Health, Department of Sociology, University of Antwerp, Sint-Jacobstraat 2-4, 2000, Antwerp, Belgium
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18
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Zanini G, Mishtal J, De Zordo S, Ziegler AK, Gerdts C. Abortion information governance and women's travels across European borders. WOMENS STUDIES INTERNATIONAL FORUM 2021. [DOI: 10.1016/j.wsif.2021.102496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Coast E, Lattof SR, van der Meulen Rodgers Y, Moore B, Poss C. The microeconomics of abortion: A scoping review and analysis of the economic consequences for abortion care-seekers. PLoS One 2021; 16:e0252005. [PMID: 34106927 PMCID: PMC8189560 DOI: 10.1371/journal.pone.0252005] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/10/2021] [Indexed: 11/19/2022] Open
Abstract
Background The economic consequences of abortion care and abortion policies for
individuals occur directly and indirectly. We lack synthesis of the economic
costs, impacts, benefit or value of abortion care at the micro-level (i.e.,
individuals and households). This scoping review examines the microeconomic
costs, benefits and consequences of abortion care and policies. Methods and findings Searches were conducted in eight electronic databases and applied
inclusion/exclusion criteria using the PRISMA extension for Scoping Reviews.
For inclusion, studies must have examined at least one of the following
outcomes: costs, impacts, benefits, and value of abortion care or abortion
policies. Quantitative and qualitative data were extracted for descriptive
statistics and thematic analysis. Of the 230 included microeconomic studies,
costs are the most frequently reported microeconomic outcome (n = 180),
followed by impacts (n = 84), benefits (n = 39), and values (n = 26).
Individual-level costs of abortion-related care have implications for the
timing and type of care sought, globally. In contexts requiring multiple
referrals or follow-up visits, these costs are multiplied. The ways in which
people pay for abortion-related costs are diverse. The intersection between
micro-level costs and delay(s) to abortion-related care is substantial.
Individuals forego other costs and expenditures, or are pushed further into
debt and/or poverty, in order to fund abortion-related care. The evidence
base on the economic impacts of policy or law change is from high-income
countries, dominated by studies from the United States. Conclusions Delays underpinned by economic factors can thwart care-seeking, affect the
type of care sought, and impact the gestational age at which care is sought
or reached. The evidence base includes little evidence on the micro-level
costs for adolescents. Specific sub-groups of abortion care-seekers
(transgendered and/or disabled people) are absent from the evidence and it
is likely that they may experience higher direct and indirect costs because
they may experience greater barriers to abortion care.
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Affiliation(s)
- Ernestina Coast
- Department of International Development, London School of Economics and
Political Science, London, United Kingdom
- * E-mail:
| | - Samantha R. Lattof
- Department of International Development, London School of Economics and
Political Science, London, United Kingdom
| | - Yana van der Meulen Rodgers
- Department of Labor Studies and Employment Relations, Rutgers University,
Piscataway, New Jersey, United States of America
- Department of Women’s and Gender Studies, Rutgers University, Piscataway,
New Jersey, United States of America
| | - Brittany Moore
- Ipas, Chapel Hill, North Carolina, United States of
America
| | - Cheri Poss
- Ipas, Chapel Hill, North Carolina, United States of
America
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20
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López Cabello A, Gaitán AC. Safe Abortion in Women's Hands: Autonomy and a Human Rights Approach to COVID-19 and Beyond. Health Hum Rights 2021; 23:191-197. [PMID: 34194212 PMCID: PMC8233031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Andrés López Cabello
- Lawyer at the Center for Legal and Social Studies, Buenos Aires, Argentina.,Please address correspondence to Andrés López Cabello. .
| | - Ana Cecilia Gaitán
- Assistant Researcher at the National University of San Martín, Buenos Aires, Argentina
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21
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O'Shea LE, Hawkins JE, Lord J, Schmidt-Hansen M, Hasler E, Cameron S, Cameron IT. Access to and sustainability of abortion services: a systematic review and meta-analysis for the National Institute of Health and Care Excellence-new clinical guidelines for England. Hum Reprod Update 2021; 26:886-903. [PMID: 32712660 DOI: 10.1093/humupd/dmaa026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/07/2020] [Accepted: 06/15/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Induced abortion is a common procedure. However, there is marked variation in accessibility of services across England. Accessing abortion services may be difficult, particularly for women who live in remote areas, are in the second trimester of pregnancy, have complex pre-existing conditions or have difficult social circumstances. OBJECTIVE AND RATIONALE This article presents a two-part review undertaken for a new National Institute of Health and Care Excellence guideline on abortion care, and aiming to determine: the factors that help or hinder accessibility and sustainability of abortion services in England (qualitative review), and strategies that improve these factors, and/or other factors identified by stakeholders (quantitative review). Economic modelling was undertaken to estimate cost savings associated with reducing waiting times. SEARCH METHODS Ovid Embase Classic and Embase, Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), PsycINFO, Cochrane Library via Wiley Online, Cinahl Plus and Web of Science Core Collection were searched for articles published up to November 2018. Studies were included if they were published in English after 2001, conducted in Organization for Economic Co-operation and Development (OECD) countries and were: qualitative studies reporting views of patients and/or staff on factors that help or hinder the accessibility and sustainability of a safe abortion service, or randomized or non-randomized studies that compared strategies to improve factors identified by the qualitative review and/or stakeholders. Studies were excluded if they were conducted in OECD countries where abortion is prohibited altogether or only performed to save the woman's life. One author assessed risk of bias of included studies using the following checklists: Critical Appraisal Skills Programme checklist for qualitative studies, Cochrane Collaboration quality checklist for randomized controlled trials, Newcastle-Ottawa scale for cohort studies, and Effective Practice and Organization of Care risk of bias tool for before-and-after studies.Qualitative evidence was combined using thematic analysis and overall quality of the evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Confidence in the Evidence from Reviews of Qualitative Research (CERQual). Quantitative evidence was analysed in Review Manager 5.3 and overall quality of evidence was assessed using GRADE. OUTCOMES Eight themes (service level barriers; financial barriers; logistical barriers; personal barriers; legal and policy barriers; privacy and confidentiality concerns; training and education; community prescribing and telemedicine introduce greater flexibility) and 18 subthemes were identified from 23 papers (n = 1016) included in the qualitative review. The quality of evidence ranged from very low to high, with evidence for one theme and seven subthemes rated as high quality. Nine studies (n = 7061) were included in the quantitative review which showed that satisfaction was better (low to high quality evidence) and women were seen sooner (very low quality evidence) when care was led by nurses or midwives compared with physician-led services, women were seen sooner when they could self-refer (very low quality evidence), and clinicians were more likely to provide abortions if training used an opt-out model (very low quality evidence). Economic modelling showed that even small reductions in waiting times could result in large cost savings for services. WIDER IMPLICATIONS Self-referral, funding for travel and accommodation, reducing waiting times, remote assessment, community services, maximizing the role of nurses and midwives and including practical experience of performing abortion in core curriculums, unless the trainee opts out, should improve access to and sustainability of abortion services.
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Affiliation(s)
- Laura E O'Shea
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London SE1 1SZ, UK
| | - James E Hawkins
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London SE1 1SZ, UK
| | - Jonathan Lord
- Department of Obstetrics & Gynaecology, Royal Cornwall Hospital, Truro TR1 3LQ, UK
| | - Mia Schmidt-Hansen
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London SE1 1SZ, UK
| | - Elise Hasler
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London SE1 1SZ, UK
| | - Sharon Cameron
- Sexual and Reproductive Health Services, NHS Lothian and University of Edinburgh, Edinburgh EH3 9EJ, UK
| | - Iain T Cameron
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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22
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Kaller S, Daniel S, Raifman S, Biggs MA, Grossman D. Pre-Abortion Informed Consent Through Telemedicine vs. in Person: Differences in Patient Demographics and Visit Satisfaction. Womens Health Issues 2021; 31:227-235. [PMID: 33832830 DOI: 10.1016/j.whi.2021.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Utah law requires patients to have a face-to-face "informed consent" visit at least 72 hours prior to abortion. Planned Parenthood Association of Utah (PPAU) offers this visit via telemedicine as an alternative to an in-person visit, which can require burdensome travel. This novel study identifies factors associated with using telemedicine for informed consent, patients' reasons for using it, and experiences with it, compared to in-person informed consent. METHODS In 2017 and 2018, patients 18 years and older seeking abortion at PPAU completed a self-administered online survey about their experiences with the informed consent visit. We used linear and logistic regression models to compare participants' demographic characteristics by informed consent visit type, and descriptive statistics to describe reasons for using each visit type and experiences with the visit. Multivariable logistic regression models examined associations between visit type and satisfaction. RESULTS Responses from 166 telemedicine patients and 217 in-person informed consent patients indicate that telemedicine participants would have had to travel significantly further than in-person participants traveled to attend the visit at the clinic (mean of 65 miles versus 21 miles, p < .001). In multivariable analyses, telemedicine participants had higher odds of being "very satisfied" with the visit (aOR, 2,89; 95% CI: 1.93-4.32) and "very comfortable" asking questions during the visit (aOR, 3.76; 95% CI: 2.58-5.49), compared to participants who attended in-person visits. CONCLUSIONS Telemedicine offers a convenient, acceptable option for mandated pre-abortion informed consent visits and reduces the burden of additional travel and associated barriers for some patients, particularly those who live further away from clinics.
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Affiliation(s)
- Shelly Kaller
- Department of Obstetrics, Gynecology & Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California, Oakland, California.
| | - Sara Daniel
- Department of Obstetrics, Gynecology & Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California, Oakland, California
| | - Sarah Raifman
- Department of Obstetrics, Gynecology & Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California, Oakland, California
| | - M Antonia Biggs
- Department of Obstetrics, Gynecology & Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California, Oakland, California
| | - Daniel Grossman
- Department of Obstetrics, Gynecology & Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California, Oakland, California
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23
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Harden J, Ancian J, Cameron S, Boydell N. Women's experiences of self-administration of misoprostol at home as part of early medical abortion: a qualitative evaluation. BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:144-149. [PMID: 32718985 DOI: 10.1136/bmjsrh-2020-200661] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/04/2020] [Accepted: 06/21/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Between 2017 and 2019, legislation was introduced in the UK that approved the home as a place for self-administration of misoprostol for early medical abortion. While research has shown that early medical abortion at home is as safe as in a clinical setting, women's experiences in the UK in the light of this change have not yet been investigated. This qualitative research explored the experiences of women in one region of Scotland, UK who accessed early medical abortion with home self-administration of misoprostol. METHODS Qualitative interviews were conducted with 20 women who had recently undergone early medical abortion (≤69 days' gestation) with home self-administration of misoprostol. The data were analysed thematically using an approach informed by the Framework analytic approach. RESULTS Women appreciated the flexibility that home administration of misoprostol offered, including the opportunity to control the timing of the abortion. This was particularly important for women who sought not to disclose the abortion to others. Most women valued being in the comfort and privacy of the home when preparing for self-administration, although a small number highlighted some concerns about being at home. Most women reported that self-administration of misoprostol was straightforward; however, some expressed concerns around assessing whether their experiences were 'normal'. CONCLUSIONS Women welcomed the opportunity for home self-administration of misoprostol. To further improve women's early medical abortion experience we suggest that the legislation be amended so that women can self-administer in an appropriate non-clinical setting, not just their home.
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Affiliation(s)
- Jeni Harden
- Usher Institute, The University of Edinburgh, Edinburgh, UK
| | | | - Sharon Cameron
- Chalmers Sexual and Reproductive Health Centre, NHS Lothian, Edinburgh, UK
- University of Edinburgh Division of Health Sciences, Edinburgh, UK
| | - Nicola Boydell
- University of Edinburgh Centre for Population Health Sciences, Edinburgh, UK
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24
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Aiken A, Lohr PA, Lord J, Ghosh N, Starling J. Effectiveness, safety and acceptability of no-test medical abortion (termination of pregnancy) provided via telemedicine: a national cohort study. BJOG 2021; 128:1464-1474. [PMID: 33605016 PMCID: PMC8360126 DOI: 10.1111/1471-0528.16668] [Citation(s) in RCA: 132] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To compare outcomes before and after implementation of medical abortion (termination of pregnancy) without ultrasound via telemedicine. DESIGN Cohort analysis. SETTING The three main abortion providers. POPULATION OR SAMPLE Medical abortions at home at ≤69 days' gestation in two cohorts: traditional model (in-person with ultrasound, n = 22 158) from January to March 2020 versus telemedicine-hybrid model (either in person or via telemedicine without ultrasound, n = 29 984, of whom 18 435 had no-test telemedicine) between April and June 2020. Sample (n = 52 142) comprises 85% of all medical abortions provided nationally. METHODS Data from electronic records and incident databases were used to compare outcomes between cohorts, adjusted for baseline differences. MAIN OUTCOME MEASURES Treatment success, serious adverse events, waiting times, gestation at treatment, acceptability. RESULTS Mean waiting time from referral to treatment was 4.2 days shorter in the telemedicine-hybrid model and more abortions were provided at ≤6 weeks' gestation (40% versus 25%, P < 0.001). Treatment success (98.8% versus 98.2%, P > 0.999), serious adverse events (0.02% versus 0.04%, P = 0.557) and incidence of ectopic pregnancy (0.2% versus 0.2%, P = 0.796) were not different between models. In the telemedicine-hybrid model, 0.04% were estimated to be over 10 weeks' gestation at the time of the abortion; all were completed safely at home. Within the telemedicine-hybrid model, effectiveness was higher with telemedicine than in-person care (99.2% versus 98.1%, P < 0.001). Acceptability of telemedicine was high (96% satisfied) and 80% reported a future preference for telemedicine. CONCLUSIONS A telemedicine-hybrid model for medical abortion that includes no-test telemedicine and treatment without an ultrasound is effective, safe, acceptable and improves access to care. TWEETABLE ABSTRACT Compelling evidence from 52 142 women shows no-test telemedicine abortion is safe, effective and improves care.
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Affiliation(s)
- Ara Aiken
- LBJ School of Public Affairs, University of Texas at Austin, Austin, TX, USA
| | - P A Lohr
- British Pregnancy Advisory Service, Stratford upon Avon, UK
| | - J Lord
- MSI Reproductive Choices, London, UK
| | - N Ghosh
- National Unplanned Pregnancy Advisory Service (NUPAS), Birmingham, UK
| | - J Starling
- Mathematica Policy Research, Cambridge, MA, USA
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Low ST, Chen ZE, Cameron S. Women's experiences of self-referral to an abortion service: qualitative study. BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:37-42. [PMID: 32269055 DOI: 10.1136/bmjsrh-2019-200568] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Guidelines from the UK recommend that women should be able to self-refer to abortion services. In 2016, a self-referral system was introduced to the abortion service in Edinburgh, Scotland, as an option for women. Women could telephone a dedicated phone line during office hours and speak to an administrative assistant working in the abortion service who provided them the next available appointment to be seen in the service. This study aimed to evaluate a self-referral service to abortion by investigating its impact on women's experiences of the referral process. METHODOLOGY 21 semistructured interviews of women attending a specialist abortion service in Edinburgh, Scotland, were conducted. Interviews were transcribed verbatim and thematically analysed. The interviews focused on women's experience of the referral process. RESULTS Three main themes arose from the interviews, including reasons for choosing self-referral, experience of self-referral and challenges to using self-referral. Reasons for choosing self-referral were related to convenience, privacy and autonomy. Women found the experience of self-referral to be pleasant, non-judgemental and patient-centred, and self-referral prepared them for the appointment at the specialist abortion service. However, some women felt rushed, and self-referral made them anxious to attend the appointment. Challenges were difficulty with getting through on telephone lines, varying levels of support required for different individuals and awareness about the option of self-referral. CONCLUSION Women valued the option of self-referral. Women felt that the service should be expanded to increase availability,and promoted to women more widely within the community .
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Affiliation(s)
- Shin Thong Low
- The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
| | - Zhong Eric Chen
- Clinical Effectiveness Unit of the FSRH, Chalmers Centre, Edinburgh, UK
| | - Sharon Cameron
- Clinical Effectiveness Unit of the FSRH, Chalmers Centre, Edinburgh, UK
- Sexual and Reproductive Health, NHS Lothian, Edinburgh, UK
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Wingo E, Ralph LJ, Kaller S, Biggs MA. Abortion method preference among people presenting for abortion care. Contraception 2020; 103:269-275. [PMID: 33373612 DOI: 10.1016/j.contraception.2020.12.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/16/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To explore abortion method preference, interpersonal and cultural factors associated with preference, and whether, among people with a preference for medication abortion, those presenting past 10 weeks gestation had experienced more obstacles to care. METHODS In 2019, we invited people aged 15 to 45 years presenting to 4 U.S. abortion clinics to complete a self-administered, anonymous iPad survey prior to seeing the health care provider. Questions focused on their pregnancy, including self-reported gestational age and experiences accessing abortion care, including abortion method preference. We used multivariate logistic regression to assess associations between worry about perceived pregnancy-related stigma or abortion-related health myths and abortion method preference. RESULTS The majority (784 [77%]) of those approached (1092) initiated the survey and 712 responded to the preference question. Most (597 [84%]) preferred a method: 246 (41%) preferred medication abortion and 351 (59%) an in-clinic procedure. About one-third (110 [32%]) of those preferring medication abortions exceeded 10 weeks gestation and 83% (n = 91) had experienced delay-causing obstacles to care. In multivariate analyses, we found a greater odd of preference for medication abortion over in-clinic procedure among those very worried about people's reaction to the pregnancy (adjusted OR [aOR] 1.95, 95% CI 1.16-3.28), judgment from God or religion (aOR 1.93, 95% CI 1.17-3.19) and abortion affecting mental health (aOR 2.51, 95% CI 1.45-4.34) or ability to get pregnant later (aOR 1.80, 95% CI: 1.09-2.97). CONCLUSIONS Many people seeking abortion have a method preference; delayed presentation to care may impede ability to obtain desired method. Pregnancy-related stigma and misinformation are associated with preference for medication abortion. IMPLICATIONS STATEMENT Pregnancy-related stigma and misinformation, such as health and safety myths promulgated by state-mandated abortion counseling, may motivate preference for medication abortion. Abortion access obstacles may impede individuals' ability to obtain their preferred method. Removing barriers to clinic access may enhance people's ability to obtain their preferred abortion method.
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Affiliation(s)
- Erin Wingo
- Department of Family and Community Medicine, University of California, San Francisco, CA, United States.
| | - Lauren J Ralph
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States
| | - Shelly Kaller
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States
| | - M Antonia Biggs
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States
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Parsons JA, Romanis EC. 2020 developments in the provision of early medical abortion by telemedicine in the UK. Health Policy 2020; 125:17-21. [PMID: 33239186 PMCID: PMC8847102 DOI: 10.1016/j.healthpol.2020.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/13/2020] [Accepted: 11/03/2020] [Indexed: 11/07/2022]
Abstract
The COVID-19 pandemic has necessitated the rapid implementation of telemedical health services. In the United Kingdom, one service that has benefitted from this response is the provision of early medical abortion. England, Wales, and Scotland have all issued approval orders to this effect. These orders allow women to terminate pregnancies up to certain gestational limits, removing the need for them to contravene social distancing measures to access care. However, they are intended only as temporary measures for the duration of the pandemic response. In this paper, we chart these developments and further demonstrate the already acknowledged politicisation of abortion care. We focus on two key elements of the orders: (1) the addition of updated clinical guidance in the Scottish order that suggests an extended gestational limit, and (2) sunset clauses in the English and Welsh orders, as well as an indication of similar intentions in Scotland. In discussing these two issues, we suggest that the refusal of UK governments to introduce telemedical provision of early medical abortion previously has not been based on health concerns. Further, we question whether it would be appropriate for the approval orders to be lifted following the pandemic, suggesting that to do so would represent regressive and harmful policy.
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Affiliation(s)
- Jordan A Parsons
- Centre for Ethics in Medicine, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, BS8 2BN, United Kingdom.
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Freeman C. Viapolitics and the emancipatory possibilities of abortion mobilities. MOBILITIES 2020; 15:896-910. [PMID: 34849148 PMCID: PMC7612045 DOI: 10.1080/17450101.2020.1803588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 07/02/2020] [Indexed: 06/13/2023]
Abstract
Scholarship on abortion travel has examined the places women travel between and why such journeys are necessary. However, there has been scant attention paid to the journeys themselves and how these journeys are undertaken. This paper uses William Walters' notion of 'viapolitics' to better attend to how people travel by focussing on the role of vehicles in abortion politics. This takes three parts: an exploration of the emotional and embodied journeys that women have to take to access abortions; the role of the vehicle as a site of political activism around abortion rights; and the transportation of abortion medication. Viapolitics has to date only been used within migration politics but as this paper shows, it has utility beyond this field to interrogate abortion travels and highlight the role of vehicles in abortion access as well as to explore how abortion transport can be emancipatory for women. This paper furthers viapolitics by arguing that we need to consider the journeys of 'things' and not just people. In the case of abortion access, it is the transportation of abortion medication rather than the travel of women that is the most socially just solution to discriminatory laws and extra-legal barriers.
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Parsons JA. 2017–19 governmental decisions to allow home use of misoprostol for early medical abortion in the UK. Health Policy 2020; 124:679-683. [DOI: 10.1016/j.healthpol.2020.04.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 02/21/2020] [Accepted: 04/28/2020] [Indexed: 11/29/2022]
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Aiken ARA, Starling JE, van der Wal A, van der Vliet S, Broussard K, Johnson DM, Padron E, Gomperts R, Scott JG. Demand for Self-Managed Medication Abortion Through an Online Telemedicine Service in the United States. Am J Public Health 2019; 110:90-97. [PMID: 31622157 DOI: 10.2105/ajph.2019.305369] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To examine demand for abortion medications through an online telemedicine service in the United States.Methods. We examined requests from US residents to the online telemedicine abortion service Women on Web (WoW) between October 15, 2017, and August 15, 2018. We calculated the population-adjusted rate of requests by state and examined the demographics, clinical characteristics, and motivations of those seeking services, comparing those in states with hostile versus supportive abortion policy climates.Results. Over 10 months, WoW received 6022 requests from US residents; 76% from hostile states. Mississippi had the highest rate of requests (24.9 per 100 000 women of reproductive age). In both hostile and supportive states, a majority (60%) reported a combination of barriers to clinic access and preferences for self-management. Cost was the most common barrier (71% in hostile states; 63% in supportive states; P < .001). Privacy was the most common preference (49% in both hostile and supportive states; P = .66).Conclusions. Demand for self-managed medication abortion through online telemedicine is prevalent in the United States. There is a public health justification to make these abortions as safe, effective, and supported as possible.
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Affiliation(s)
- Abigail R A Aiken
- Abigail R. A. Aiken and Dana M. Johnson are with the LBJ School of Public Affairs, University of Texas, Austin. Jennifer E. Starling and James G. Scott are with the Department of Statistics and Data Sciences, University of Texas, Austin. Alexandra van der Wal and Sascha van der Vliet are with the Faculty of Science, VU University, Amsterdam. Kathleen Broussard is with the Department of Sociology, University of Texas, Austin. Elisa Padron is with the College of Natural Sciences, University of Texas, Austin. Rebecca Gomperts is with the Women on Web International Foundation, Amsterdam
| | - Jennifer E Starling
- Abigail R. A. Aiken and Dana M. Johnson are with the LBJ School of Public Affairs, University of Texas, Austin. Jennifer E. Starling and James G. Scott are with the Department of Statistics and Data Sciences, University of Texas, Austin. Alexandra van der Wal and Sascha van der Vliet are with the Faculty of Science, VU University, Amsterdam. Kathleen Broussard is with the Department of Sociology, University of Texas, Austin. Elisa Padron is with the College of Natural Sciences, University of Texas, Austin. Rebecca Gomperts is with the Women on Web International Foundation, Amsterdam
| | - Alexandra van der Wal
- Abigail R. A. Aiken and Dana M. Johnson are with the LBJ School of Public Affairs, University of Texas, Austin. Jennifer E. Starling and James G. Scott are with the Department of Statistics and Data Sciences, University of Texas, Austin. Alexandra van der Wal and Sascha van der Vliet are with the Faculty of Science, VU University, Amsterdam. Kathleen Broussard is with the Department of Sociology, University of Texas, Austin. Elisa Padron is with the College of Natural Sciences, University of Texas, Austin. Rebecca Gomperts is with the Women on Web International Foundation, Amsterdam
| | - Sascha van der Vliet
- Abigail R. A. Aiken and Dana M. Johnson are with the LBJ School of Public Affairs, University of Texas, Austin. Jennifer E. Starling and James G. Scott are with the Department of Statistics and Data Sciences, University of Texas, Austin. Alexandra van der Wal and Sascha van der Vliet are with the Faculty of Science, VU University, Amsterdam. Kathleen Broussard is with the Department of Sociology, University of Texas, Austin. Elisa Padron is with the College of Natural Sciences, University of Texas, Austin. Rebecca Gomperts is with the Women on Web International Foundation, Amsterdam
| | - Kathleen Broussard
- Abigail R. A. Aiken and Dana M. Johnson are with the LBJ School of Public Affairs, University of Texas, Austin. Jennifer E. Starling and James G. Scott are with the Department of Statistics and Data Sciences, University of Texas, Austin. Alexandra van der Wal and Sascha van der Vliet are with the Faculty of Science, VU University, Amsterdam. Kathleen Broussard is with the Department of Sociology, University of Texas, Austin. Elisa Padron is with the College of Natural Sciences, University of Texas, Austin. Rebecca Gomperts is with the Women on Web International Foundation, Amsterdam
| | - Dana M Johnson
- Abigail R. A. Aiken and Dana M. Johnson are with the LBJ School of Public Affairs, University of Texas, Austin. Jennifer E. Starling and James G. Scott are with the Department of Statistics and Data Sciences, University of Texas, Austin. Alexandra van der Wal and Sascha van der Vliet are with the Faculty of Science, VU University, Amsterdam. Kathleen Broussard is with the Department of Sociology, University of Texas, Austin. Elisa Padron is with the College of Natural Sciences, University of Texas, Austin. Rebecca Gomperts is with the Women on Web International Foundation, Amsterdam
| | - Elisa Padron
- Abigail R. A. Aiken and Dana M. Johnson are with the LBJ School of Public Affairs, University of Texas, Austin. Jennifer E. Starling and James G. Scott are with the Department of Statistics and Data Sciences, University of Texas, Austin. Alexandra van der Wal and Sascha van der Vliet are with the Faculty of Science, VU University, Amsterdam. Kathleen Broussard is with the Department of Sociology, University of Texas, Austin. Elisa Padron is with the College of Natural Sciences, University of Texas, Austin. Rebecca Gomperts is with the Women on Web International Foundation, Amsterdam
| | - Rebecca Gomperts
- Abigail R. A. Aiken and Dana M. Johnson are with the LBJ School of Public Affairs, University of Texas, Austin. Jennifer E. Starling and James G. Scott are with the Department of Statistics and Data Sciences, University of Texas, Austin. Alexandra van der Wal and Sascha van der Vliet are with the Faculty of Science, VU University, Amsterdam. Kathleen Broussard is with the Department of Sociology, University of Texas, Austin. Elisa Padron is with the College of Natural Sciences, University of Texas, Austin. Rebecca Gomperts is with the Women on Web International Foundation, Amsterdam
| | - James G Scott
- Abigail R. A. Aiken and Dana M. Johnson are with the LBJ School of Public Affairs, University of Texas, Austin. Jennifer E. Starling and James G. Scott are with the Department of Statistics and Data Sciences, University of Texas, Austin. Alexandra van der Wal and Sascha van der Vliet are with the Faculty of Science, VU University, Amsterdam. Kathleen Broussard is with the Department of Sociology, University of Texas, Austin. Elisa Padron is with the College of Natural Sciences, University of Texas, Austin. Rebecca Gomperts is with the Women on Web International Foundation, Amsterdam
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Moseson H, Herold S, Filippa S, Barr-Walker J, Baum SE, Gerdts C. Self-managed abortion: A systematic scoping review. Best Pract Res Clin Obstet Gynaecol 2019; 63:87-110. [PMID: 31859163 DOI: 10.1016/j.bpobgyn.2019.08.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 08/06/2019] [Accepted: 08/07/2019] [Indexed: 12/20/2022]
Abstract
Self-managed abortion, when a person performs their own abortion without clinical supervision, is a model of abortion care used across a range of settings. To provide a comprehensive synthesis of the available literature on self-managed abortion, we conducted a systematic search for peer-reviewed research in April 2019 in PubMed, Embase, Web of Science, Popline, PsycINFO, Google Scholar, Scielo, and Redalyc. We included studies that had a research question focused on self-managed abortion; and were published in English or Spanish. The combined search returned 7167 studies; after screening, 99 studies were included in the analysis. Included studies reported on methods, procurement, characteristics of those who self-managed, effectiveness, safety, reasons for self-managed abortion, and emotional and physical experiences. Numerous abortion methods were reported, most frequently abortion with pills and herbs. Studies reporting on self-managed medication abortion reported high-levels of effectiveness. We identify gaps in the research, and make recommendations to address those gaps.
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Affiliation(s)
- Heidi Moseson
- Ibis Reproductive Health, 1736 Franklin Street, Oakland, CA, 94612, USA.
| | - Stephanie Herold
- Advancing New Standards in Reproductive Health, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA.
| | - Sofia Filippa
- Ibis Reproductive Health, 1736 Franklin Street, Oakland, CA, 94612, USA.
| | - Jill Barr-Walker
- Zuckerberg San Francisco General (ZSFG) Library, University of California, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
| | - Sarah E Baum
- Ibis Reproductive Health, 1736 Franklin Street, Oakland, CA, 94612, USA.
| | - Caitlin Gerdts
- Ibis Reproductive Health, 1736 Franklin Street, Oakland, CA, 94612, USA.
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The patient perspective: perceptions of the quality of the abortion experience. Curr Opin Obstet Gynecol 2019; 30:407-413. [PMID: 30299320 DOI: 10.1097/gco.0000000000000492] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Abortion services are essential in sexual and reproductive health and should be held to the same standards as other health services. Patient (or person)-centeredness is a key dimension of healthcare quality that incorporates the perspectives of patients in care provision. The purpose of this review is to summarize studies published in the last year examining women's experiences with abortion care and to describe facilitators and barriers to person-centered care. RECENT FINDINGS Considering person-centeredness in abortion care using dimensions of dignity, autonomy, privacy, communication, social support, supportive care and health facility environment allows for critical evaluation of data describing women's experiences with abortion and postabortion services. Review of the available literature shed light on the impact of social stigma, health policy and abortion restrictions on women's abortion experiences. SUMMARY Considering multiple domains and varied settings, current data suggest abortion services worldwide generally fail to provide person-centered care. Institutions and providers may be limited in their ability to provide patient-centered abortion care because of deeply embedded social stigma, institutional regulations and legal restrictions.
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Cameron S, Rowlands S, Gemzell-Danielsson K. Self-assessment of success of early medical abortion using a self-performed urine pregnancy test. EUR J CONTRACEP REPR 2019; 24:319-321. [PMID: 31204845 DOI: 10.1080/13625187.2019.1618446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Purpose: The European Society of Contraception Expert Group on Abortion identified as one of its priorities the need to disseminate up-to-date evidence-based information on the use of urine pregnancy tests by women for the self assessment of the success of early medical abortion (EMA). Methods and materials: A concise communication was produced which summarises the latest research in an easy-to-read format suitable for busy clinicians. Information about individual urinary pregnancy tests is presented in boxes for ease of reference. Results: Urinary pregnancy tests (low sensitivity, high sensitivity and multilevel) can be used in combination with signs and symptoms of pregnancy to exclude an ongoing pregnancy after EMA. Conclusion: Women are able to determine the success of early medical abortion (EMA) themselves using a combination of signs, symptoms and a urine pregnancy test. This simplifies EMA, expands the range of professionals able to provide EMA and most importantly gives women greater control over their bodies and treatment.
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Affiliation(s)
- Sharon Cameron
- a Chalmers Sexual and Reproductive Healthcare Service , NHS Lothian and University of Edinburgh , Edinburgh , UK
| | - Sam Rowlands
- b Centre of Postgraduate Medical Research & Education , Bournemouth University , Bournemouth , UK
| | - Kristina Gemzell-Danielsson
- c Department of Women's and Children's Health , Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
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Fathalla MF. Safe abortion: The public health rationale. Best Pract Res Clin Obstet Gynaecol 2019; 63:2-12. [PMID: 31201007 DOI: 10.1016/j.bpobgyn.2019.03.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 03/19/2019] [Accepted: 03/19/2019] [Indexed: 11/27/2022]
Abstract
It is now more than 50 years since the World Health Assembly recognized abortion as a serious public health problem. The challenge still stands. Addressing the problem of unsafe abortion is a national and global public health imperative, dictated by the magnitude of the problem and its impact on individuals and society, inequity of the burden of disease, and an international consensus of the global health community. Almost every abortion death and disability could be prevented through cost-effective public health interventions including sexuality education, use of effective contraception, provision of safe, legal induced abortion, and quality humane postabortion care. Safe abortion continues to be a challenge to public health because of diverse national restrictive legal regulations, prevailing stigma, and lack of political commitment. Health professionals have a social responsibility to educate policymakers, legislators, and the public at large about adverse impacts of restrictive abortion regulations, laws, and policies on women's health.
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Affiliation(s)
- Mahmoud F Fathalla
- Department of Obstetrics and Gynecology, Assiut University, P.O.Box.30, Assiut, Egypt.
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Smith JL, Cameron S. Current barriers, facilitators and future improvements to advance quality of abortion care: views of women. BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:bmjsrh-2018-200264. [PMID: 31028169 DOI: 10.1136/bmjsrh-2018-200264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/14/2019] [Accepted: 03/19/2019] [Indexed: 05/05/2023]
Abstract
BACKGROUND Barriers to accessing abortion care continue to exist even in settings where abortion is legal. We aimed to determine current barriers faced by women seeking abortion, factors that facilitate access to care, and what future improvements women would like made to abortion care in Scotland. METHODS A self-administered anonymous questionnaire of women requesting abortion care at a community abortion service in Edinburgh. Women selected the top three options from predefined lists of barriers to seeking abortion, facilitators of care, and future service improvements. RESULTS 154/165 (93%) questionnaires were completed by women presenting for abortion. The most commonly ranked number one barrier to seeking an abortion (n = 49; 32%) was 'being scared about what the abortion process involved'. The highest ranked facilitator of care was information provided to women via the abortion clinic website. The most commonly chosen number one response for potential improvement to abortion services was the option to get an early medical abortion from a general practitioner, which was chosen by 70 (45%) women. CONCLUSIONS This study suggests that lack of knowledge and information surrounding the abortion process and the ease with which women can receive abortion care are areas of concern. Efforts are needed to reduce waiting times, to ensure that high-quality, standardised information is widely and publicly available regarding what women can expect during the abortion process, and to expand provision of early medical abortion within the community, in order to improve abortion care.
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Affiliation(s)
- Jodie Louise Smith
- Centre for Reproductive Health, University of Edinburgh, College of Medicine and Veterinary Medicine Erskine Medical Library, Edinburgh, UK
| | - Sharon Cameron
- Sexual and Reproductive Health, NHS Lothian, Edinburgh, UK
- Division of Health Sciences, University of Edinburgh, Edinburgh, UK
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Chemlal S, Russo G. Why do they take the risk? A systematic review of the qualitative literature on informal sector abortions in settings where abortion is legal. BMC Womens Health 2019; 19:55. [PMID: 30961574 PMCID: PMC6454783 DOI: 10.1186/s12905-019-0751-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 03/28/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Restrictive abortion laws are the single most important determinant of unsafe abortion, a major, yet preventable, global health issue. While reviews have been conducted on the extent of the phenomenon, no study has so far analysed the evidence of why women turn to informal sector providers when legal alternatives are available. This work provides a systematic review of the qualitative literature on informal sector abortion in setting where abortion is legal. METHODS We used the PRISMA guidelines to search Pubmed, Web of Science, Sciencedirect and Google Scholar databases between January and February 2018. 2794 documents in English and French were screened for eligibility against pre-determined inclusion and exclusion criteria. Articles investigating women's reasons for aborting in the informal sector in settings where abortion is legal were included. In total, sixteen articles were identified as eligible for this review. Findings were reported following the PRISMA guidelines. RESULTS The review highlights the diverse reasons women turn to the informal sector, as abortions outside of legal health facilities were reported to be a widespread and normalised practice in countries where legal abortion is provided. Women cited a range of reasons for aborting in the informal sector; these included fear of mistreatment by staff, long waiting lists, high costs, inability to fulfil regulations, privacy concerns and lack of awareness about the legality of abortion or where to procure a safe and legal abortion. Not only was unsafe abortion spoken of in terms of medical and physical safety, but also in terms of social and economic security. CONCLUSION The use of informal sector abortions (ISAs) is a widespread and normalised practice in many countries despite the liberalisation of abortion laws. Although ISAs are not inherently unsafe, the practice in a setting where it is illegal will increase the likelihood that women will not be given the necessary information, or that they will be punished. This study brings to the fore the diverse reasons why women opt to abort outside formal healthcare settings and their issues with provision of abortion services in legal contexts, providing an evidence base for future research and policies.
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Affiliation(s)
- Sonia Chemlal
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Giuliano Russo
- Centre for Primary Care and Public Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner street, London, E1 2AB UK
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Aiken ARA, Broussard K, Johnson DM, Padron E. Motivations and Experiences of People Seeking Medication Abortion Online in the United States. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2018; 50:157-163. [PMID: 29992793 PMCID: PMC8256438 DOI: 10.1363/psrh.12073] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 05/16/2023]
Abstract
CONTEXT State legislation restricting access to abortion in the clinic setting raises the possibility that an increasing number of individuals in the United States will self-manage their abortion at home. Medications sourced online represent a potential pathway to abortion self-management. Yet, very little is known about the reasons U.S. residents may seek abortion online or their experiences finding medications and information. METHODS In January-June 2017, anonymous in-depth interviews were conducted with 32 people from 20 states who sought abortion medications online (30 women and two men seeking medications for their partners). Participants were asked about their (or their partners') motivations for considering self-managed abortion, the sources of medications they identified and any other methods they considered. Transcripts were coded and analyzed according to the principles of grounded theory. RESULTS The analysis revealed four key themes: Seeking abortion medications online can be a response to clinic access barriers both in states with and in ones without restrictive abortion laws; self-managed abortion can be a preference over clinical care; online options offer either information or medications, but not both; and the lack of trusted online options can delay care and lead to consideration of ineffective or unsafe alternatives. CONCLUSION Current online options for abortion medications leave many important needs unmet, particularly for women who encounter barriers to obtaining clinic-based abortion services. There is a public health justification to reduce clinic access barriers and to make medication abortion that is sourced online and managed at home as safe and supported as possible.
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Affiliation(s)
- Abigail R A Aiken
- Assistant professor, LBJ School of Public Affairs, and faculty research associate, Population Research Center, University of Texas at Austin
| | - Kathleen Broussard
- Graduate student, Department of Sociology, and graduate research trainee, Population Research Center, University of Texas at Austin
| | - Dana M Johnson
- Graduate student, LBJ School of Public Affairs, University of Texas at Austin
| | - Elisa Padron
- Undergraduate student, College of Natural Sciences, University of Texas at Austin
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Biggs MA, Ralph L, Raifman S, Foster DG, Grossman D. Support for and interest in alternative models of medication abortion provision among a national probability sample of U.S. women. Contraception 2018; 99:118-124. [PMID: 30448203 DOI: 10.1016/j.contraception.2018.10.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/10/2018] [Accepted: 10/22/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The objective was to assess women's personal interest in and support for three alternative models of medication abortion (MA) provision. STUDY DESIGN Using an online survey of a U.S. national, probability-based representative sample of women ages 18-49, we gauged personal interest in and general support for three alternative models for accessing abortion pills: (1) in advance from a doctor for future use, (2) over-the-counter (OTC) from a drugstore and (3) online without a prescription. We conducted multivariable analyses to identify characteristics associated with support for these provision models. RESULTS Fifty percent (n=7022) of eligible women invited completed the survey. Nearly half (49%) supported and 30% were personally interested in one or more of the three access models; 44% supported advance provision, 37% supported OTC access, and 29% supported online access. Common advantages reported for advance provision, OTC and online access included privacy (49%, 29% and 46%, respectively), convenience (38%, 44% and 38%) and being able to end the pregnancy earlier (48%, 40% and 29%). Common disadvantages included concern that women might take the pills incorrectly (55%, 53% and 57%), not seeing a clinician before the abortion (52%, 54% and 53%) and safety (42%, 43% and 60%). History of abortion and experiencing barriers accessing reproductive health services were associated with greater support for the alternative models. CONCLUSION Women are interested in and support alternative models of MA provision, in particular, advance provision. However, they also reported concerns about incorrect pill use and not seeing a clinician beforehand. IMPLICATIONS Offering women more choices in how they access medication abortion, including options where they can safely self-manage their own care, has the potential to expand access to care.
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Affiliation(s)
- M Antonia Biggs
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, CA 94612, USA.
| | - Lauren Ralph
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, CA 94612, USA
| | - Sarah Raifman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, CA 94612, USA
| | - Diana G Foster
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, CA 94612, USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, CA 94612, USA
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Regan L. Abortion: View from Westminster. Int J Gynaecol Obstet 2018; 143:133-136. [DOI: 10.1002/ijgo.12589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lesley Regan
- Royal College of Obstetricians and Gynaecologists; London UK
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Lord J, Regan L, Kasliwal A, Massey L, Cameron S. Early medical abortion: best practice now lawful in Scotland and Wales but not available to women in England. BMJ SEXUAL & REPRODUCTIVE HEALTH 2018; 44:bmjsrh-2018-200134. [PMID: 29986873 DOI: 10.1136/bmjsrh-2018-200134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 06/05/2018] [Accepted: 06/06/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Jonathan Lord
- Department of Gynaecology, Royal Cornwall Hospitals NHS Trust, Truro, UK
- British Society of Abortion Care Providers (BSACP), London, UK
| | - Lesley Regan
- Royal College of Obstetricians and Gynaecologists, London, UK
- Department of Obstetrics and Gynaecology, Imperial College London, London, UK
| | - Asha Kasliwal
- Faculty of Sexual and Reproductive Healthcare, London, UK
- Community Gynaecology and Reproductive Health, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Louise Massey
- British Society of Abortion Care Providers (BSACP), London, UK
- Sexual and Reproductive Health, Aneurin Bevan University Health Board, Wales, UK
| | - Sharon Cameron
- British Society of Abortion Care Providers (BSACP), London, UK
- Sexual and Reproductive Health, NHS Lothian, Edinburgh, UK
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Aiken AR, Johnson DM, Broussard K, Padron E. Experiences of women in Ireland who accessed abortion by travelling abroad or by using abortion medication at home: a qualitative study. BMJ SEXUAL & REPRODUCTIVE HEALTH 2018; 44:bmjsrh-2018-200113. [PMID: 29972360 PMCID: PMC6237647 DOI: 10.1136/bmjsrh-2018-200113] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/25/2018] [Accepted: 05/01/2018] [Indexed: 05/28/2023]
Abstract
BACKGROUND The Republic of Ireland has one of the world's most restrictive abortion laws, allowing abortion only to preserve a pregnant woman's life. We examined the impact of the law on women's options for accessing abortion, their decision-making regarding whichpathway to follow, and their experiences with their chosen approach. METHODS We conducted semi-structured in-depth interviews with 38 women who had either travelled abroad to access abortion in a clinic or had self-managed a medical abortion at home using online telemedicine, between 2010 and 2017. We coded interview transcripts according to an iteratively developed coding guide and performed a thematic analysis to identify key themes. RESULTS We identified four key themes: (1) self-managing a medical abortion at home using online telemedicine can be a preference over travelling abroad to access abortion services; (2) regardless of the pathway chosen, women experience a lack of pre- and post-abortion support in the Irish healthcare system; (3) feelings of desperation while searching for safe abortion care can lead to considering or attempting dangerous methods; and (4) Irish abortion law and attitudes have impacts beyond physical health considerations, engendering shame and stigma. CONCLUSIONS Despite the country's restrictive abortion law, women in Ireland do obtain abortions, using methods that are legal and safe elsewhere. However, the law negatively impacts women's ability to discuss their options with their healthcare professionals and to seek follow-up care, and can have serious implications for their physical and emotional health. This study's findings provide evidence to inform public and policy discourse on Ireland's abortion laws.
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Affiliation(s)
- Abigail R.A. Aiken
- LBJ School of Public Affairs, University of Texas at Austin, Austin, TX, 78712, USA
- Population Research Center, University of Texas at Austin, Austin, TX, 78712, USA
| | - Dana M. Johnson
- LBJ School of Public Affairs, University of Texas at Austin, Austin, TX, 78712, USA
| | - Kathleen Broussard
- Population Research Center, University of Texas at Austin, Austin, TX, 78712, USA
- Department of Sociology, University of Texas at Austin, Austin, TX, 78712, USA
| | - Elisa Padron
- College of Natural Sciences, University of Texas at Austin, Austin, TX, 78712, USA
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Lohr PA, Starling JE, Scott JG, Aiken ARA. Simultaneous Compared With Interval Medical Abortion Regimens Where Home Use Is Restricted. Obstet Gynecol 2018; 131:635-641. [PMID: 29528933 PMCID: PMC5869142 DOI: 10.1097/aog.0000000000002536] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate outcomes with simultaneous administration of mifepristone and misoprostol for medical abortion at 63 days of gestation or less in the year after its implementation in a British clinic system. METHODS We conducted a retrospective cohort study using deidentified data from the electronic booking and complications databases and medical records of women who underwent medical abortion at British Pregnancy Advisory Service. Our primary outcome was treatment success with simultaneous dosing compared with a regimen with a 24- to 48-hour interval between medications. We defined success as complete abortion without surgical evacuation and without continuing pregnancy. To assess relative regimen effectiveness while accounting for self-assignment to simultaneous or interval dosing, we modeled the probability of treatment success using logistic regression with propensity score adjustment for demographic and clinical characteristics. Secondary outcomes were reasons for abortion failure and clinically significant adverse events (hospital admission, blood transfusion, intravenous antibiotic administration). RESULTS Of 28,901 women treated between May 2015 and April 2016, 85% chose simultaneous dosing. Overall success rates were high with both regimens but lower with simultaneous than with interval dosing (94.5% vs 97.1%, respectively, adjusted relative risk 0.973, 95% CI 0.967-0.979). For both regimens, success rates were lower at higher gestational ages, but the relative effectiveness of simultaneous dosing did not vary significantly with gestational age (P=.268). Surgical intervention rates for continuing pregnancy were lowest at 49 days of gestation or less (1.4% simultaneous vs 0.2% interval, P<.001) and highest at 57-63 days of gestation (5.0% and 2.2%, P<.001). The rate of clinically significant adverse events was 0.2% and did not differ by regimen (P=.972). CONCLUSION Simultaneous administration of mifepristone and misoprostol is 97% as effective as a 24- to 48-hour interval at all gestational ages 63 days or less with no increase in the risk of clinically significant adverse events. Pragmatic use of simultaneous dosing is reasonable given the small difference in effectiveness.
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Affiliation(s)
- Patricia A Lohr
- British Pregnancy Advisory Service, Stratford-upon-Avon, United Kingdom; and the Departments of Statistics and Data Sciences and Information, Risk and Operations Management and the LBJ School of Public Affairs and Population Research Center, the University of Texas at Austin, Austin, Texas
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Aiken AR, Gomperts R, James A. Using evidence to guide abortion law reform on the Isle of Man. BMJ SEXUAL & REPRODUCTIVE HEALTH 2018; 44:77-81. [PMID: 29921628 PMCID: PMC6086668 DOI: 10.1136/bmjsrh-2017-200044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Abigail R.A Aiken
- Assistant Professor, LBJ School of Public Affairs, University of Texas at Austin, Texas, 78713, USA
- Faculty Associate, Population Research Center, University of Texas at Austin, Texas, 78712, USA
| | - Rebecca Gomperts
- Founder and Director, Women on Web International Foundation, Amsterdam, The Netherlands
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