1
|
Grossman D, Raifman S, Morris N, Arena A, Bachrach L, Beaman J, Biggs MA, Collins A, Hannum C, Ho S, Seibold-Simpson SM, Sobota M, Tocce K, Schwarz EB, Gold M. Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion After In-Person Screening. JAMA Intern Med 2024; 184:873-881. [PMID: 38739404 PMCID: PMC11091818 DOI: 10.1001/jamainternmed.2024.1476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/07/2024] [Indexed: 05/14/2024]
Abstract
Importance Before 2021, the US Food and Drug Administration required mifepristone to be dispensed in person, limiting access to medication abortion. Objective To estimate the effectiveness, acceptability, and feasibility of dispensing mifepristone for medication abortion using a mail-order pharmacy. Design, Setting, and Participants This prospective cohort study was conducted from January 2020 to May 2022 and included 11 clinics in 7 states (5 abortion clinics and 6 primary care sites, 4 of which were new to abortion provision). Eligible participants were seeking medication abortion at 63 or fewer days' gestation, spoke English or Spanish, were age 15 years or older, and were willing to take misoprostol buccally. After assessing eligibility for medication abortion through an in-person screening, mifepristone and misoprostol were prescribed using a mail-order pharmacy. Patients had standard follow-up care with the clinic. Clinical information was collected from medical records. Consenting participants completed online surveys about their experiences 3 and 14 days after enrolling. A total of 540 participants were enrolled; 10 withdrew or did not take medication. Data were analyzed from August 2022 to December 2023. Intervention Mifepristone, 200 mg, and misoprostol, 800 µg, prescribed to a mail-order pharmacy and mailed to participants instead of dispensed in person. Main Outcomes and Measures Proportion of patients with a complete abortion with medications only, reporting satisfaction with the medication abortion, and reporting timely delivery of medications. Results Clinical outcome information was obtained and analyzed for 510 abortions (96.2%) among 506 participants (median [IQR] age, 27 [23-31] years; 506 [100%] female; 194 [38.3%] Black, 88 [17.4%] Hispanic, 141 [27.9%] White, and 45 [8.9%] multiracial/other individuals). Of these, 436 participants (85.5%; 95% CI, 82.2%-88.4%) received medications within 3 days. Complete abortion occurred after medication use in 499 cases (97.8%; 95% CI, 96.2%-98.9%). There were 24 adverse events (4.7%) for which care was sought for medication abortion symptoms; 3 patients (0.6%; 95% CI, 0.1%-1.7%) experienced serious adverse events requiring hospitalization (1 with blood transfusion); however, no adverse events were associated with mail-order dispensing. Of 477 participants, 431 (90.4%; 95% CI, 87.3%-92.9%) indicated that they would use mail-order dispensing again for abortion care, and 435 participants (91.2%; 95% CI, 88.3%-93.6%) reported satisfaction with the medication abortion. Findings were similar to those of other published studies of medication abortion with in-person dispensing. Conclusions and Relevance The findings of this cohort study indicate that mail-order pharmacy dispensing of mifepristone for medication abortion was effective, acceptable to patients, and feasible, with a low prevalence of serious adverse events. This care model should be expanded to improve access to medication abortion services.
Collapse
Affiliation(s)
- Daniel Grossman
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Sarah Raifman
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Natalie Morris
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Andrea Arena
- Department of Family Medicine, Brown University, Pawtucket, Rhode Island
| | - Lela Bachrach
- Department of Pediatrics, University of California, San Francisco
| | - Jessica Beaman
- Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - M. Antonia Biggs
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Amy Collins
- Allegheny Reproductive Health Center, Pittsburgh, Philadelphia
| | | | - Stephanie Ho
- Highland Hospital, Alameda Health System, Oakland, California
| | | | - Mindy Sobota
- Department of Medicine, Alpert Medical School at Brown University, Providence, Rhode Island
| | - Kristina Tocce
- Planned Parenthood of the Rocky Mountains, Denver, Colorado
| | - Eleanor B. Schwarz
- Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - Marji Gold
- Department of Family and Social Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| |
Collapse
|
2
|
Raifman S, Gurazada T, Beaman J, Biggs MA, Schwarz EB, Gold M, Grossman D. Primary care and abortion provider perspectives on mail-order medication abortion: a qualitative study. BMC Womens Health 2024; 24:382. [PMID: 38956609 PMCID: PMC11221167 DOI: 10.1186/s12905-024-03202-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 06/11/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND This qualitative study aims to assess perspectives of clinicians and clinic staff on mail-order pharmacy dispensing for medication abortion. METHODS Participants included clinicians and staff involved in implementing a mail-order dispensing model for medication abortion at eleven clinics in seven states as part of a prospective cohort study, which began in January 2020 (before the FDA removed the in-person dispensing requirement for mifepristone). From June 2021 to July 2022, we invited participants at the participating clinics, including six primary care and five abortion clinics, to complete a semi-structured video interview about their experiences. We then conducted qualitative thematic analysis of interview data, summarizing themes related to perceived benefits and concerns about the mail-order model, perceived patient interest, and potential barriers to larger-scale implementation. RESULTS We conducted 24 interviews in total with clinicians (13 physicians and one nurse practitioner) and clinic staff (n = 10). Participants highlighted perceived benefits of the mail-order model, including its potential to expand abortion services into primary care, increase patient autonomy and privacy, and to normalize abortion services. They also highlighted key logistical, clinical, and feasibility concerns about the mail-order model, and specific challenges related to integrating abortion into primary care. CONCLUSION Clinicians and clinic staff working in primary care and abortion clinics were optimistic that mail-order dispensing of medication abortion can improve the ability of some providers to provide abortion and enable more patients to access services. The feasibility of mail-order pharmacy dispensing of medication abortion following the Supreme Court Dobbs decision is to be determined. TRIAL REGISTRATION Registry: Clinicaltrials.gov. TRIAL REGISTRATION NUMBER NCT03913104. Date of registration: first submitted on April 3, 2019 and first posted on April 12, 2019.
Collapse
Affiliation(s)
- Sarah Raifman
- Advancing New Standards in Reproductive Health, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA.
| | - Tanvi Gurazada
- Nell Hodgson Woodruff School of Nursing at Emory University, 1520 Clifton Rd, Atlanta, GA, 30322, USA
| | - Jessica Beaman
- San Francisco Division of General Internal Medicine, University of California, 1001 Potrero Ave, San Francisco, CA, USA
| | - M Antonia Biggs
- Advancing New Standards in Reproductive Health, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
| | - Eleanor Bimla Schwarz
- San Francisco Division of General Internal Medicine, University of California, 1001 Potrero Ave, San Francisco, CA, USA
| | - Marji Gold
- Montefiore Medical Center, Albert Einstein College of Medicine, 3544 Jerome Ave, Bronx, NY, 10467, USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
| |
Collapse
|
3
|
Ferketa M, Moore A, Klein-Barton J, Stulberg D, Hasselbacher L. Pharmacists' experiences dispensing misoprostol and readiness to dispense mifepristone. J Am Pharm Assoc (2003) 2024; 64:245-252.e1. [PMID: 37913990 DOI: 10.1016/j.japh.2023.10.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/21/2023] [Accepted: 10/25/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Mifepristone, followed by misoprostol, is commonly used for medication abortion and early miscarriage care. Since mifepristone's approval in 2000, the Food and Drug Administration (FDA) has placed restrictions on where and how it could be dispensed, including applying a Risk Evaluation and Mitigation Strategy in 2011. In December 2021, the FDA removed the in-person dispensing requirement and, in January 2023, began allowing certified pharmacies to dispense the drug directly to patients. OBJECTIVES To explore pharmacist knowledge about misoprostol and mifepristone, experience dispensing misoprostol, as well as comfort and readiness to dispense mifepristone should federal regulations allow. METHODS We conducted in-depth interviews with 21 U.S.-based pharmacists and pharmacy trainees between June and December of 2021, a time when few pharmacists were allowed to dispense mifepristone. RESULTS Participants reported varied knowledge about medications for miscarriage and abortion but described themselves as generally knowledgeable about medications and reported strategies for learning about new medications. Most said they would feel ready to dispense mifepristone, and many described dispensing misoprostol without difficulty. Potential challenges specific to mifepristone dispensing included employer hesitation and colleague refusals. To assure successful dispensing, participants recommended basic training and fact sheets; relationships with prescribers for follow-up; and policies for prescription transfers in the event of refusal. CONCLUSIONS We found that nearly all participants would feel ready to dispense mifepristone with some basic training. Pharmacists self-report having the skills and resources to learn about new medications quickly. Our findings support the FDA's rule change allowing pharmacist dispensing of mifepristone and suggest that most challenges would stem from individual or institutional refusals.
Collapse
|
4
|
Fleurant E, McCloskey L. Medication Abortion: A Comprehensive Review. Clin Obstet Gynecol 2023; 66:706-724. [PMID: 37910067 DOI: 10.1097/grf.0000000000000812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
This chapter provides an overview of evidence-based guidelines for medication abortion in the first trimester. We discuss regimens, both FDA-approved and other clinical-based protocols, and will briefly discuss novel self-managed abortion techniques taking place outside the formal health care system. Overview of patient counseling and pain management are presented with care to include guidance on "no touch" regimens that have proven both feasible and effective. We hope that this comprehensive review helps the health care community make strides to increase access to abortion in a time when reproductive health care is continuously restricted.
Collapse
Affiliation(s)
- Erin Fleurant
- Department of Obstetrics and Gynecology, Northwestern McGaw Medical Center, Chicago, Illinois
| | | |
Collapse
|
5
|
Neill S, Mokashi M, Goldberg A, Fortin J, Janiak E. Mifepristone use for early pregnancy loss: A qualitative study of barriers and facilitators among OB/GYNS in Massachusetts, USA. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2023; 55:210-217. [PMID: 37394759 DOI: 10.1363/psrh.12237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
CONTEXT Early pregnancy loss (EPL) affects 1 million patients in the United States (US) annually, but integration of mifepristone into EPL care may be complicated by regulatory barriers, practice-related factors, and abortion stigma. METHODS We conducted qualitative, semi-structured interviews among obstetrician-gynecologists in independent practice in Massachusetts, US on mifepristone use for EPL. We recruited participants via professional networks and purposively sampled for mifepristone use, practice type, time in practice, and geographic location within Massachusetts until we reached thematic saturation. We analyzed interviews using inductive and deductive coding under a thematic analysis framework to identify facilitators of and barriers to mifepristone use. RESULTS We interviewed 19 obstetrician-gynecologists; 12 had used mifepristone for EPL and 7 had not. Participants were in private practice (n = 12), academic practice (n = 6), or worked at a federally qualified health center (n = 1). Seven had fellowship training, including four in complex family planning. The most common facilitators of mifepristone use for EPL were access to the expertise or protocols of local-regional experts, leadership from a "champion," prior experience with abortion care, and hospital capacity constraints during the COVID-19 pandemic. The most common barriers were related to the Mifepristone Risk Evaluation and Mitigation Strategy (REMS) Program imposed by the US Food and Drug Administration (FDA). Additionally, mifepristone's affiliation with abortion was a barrier to its use in EPL for some obstetrician-gynecologists. CONCLUSION The FDA Mifepristone REMS Program presents substantial barriers to obstetrician-gynecologists incorporating mifepristone into their EPL care.
Collapse
Affiliation(s)
- Sara Neill
- Department of Obstetrics, Gynecology, & Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Alisa Goldberg
- Department of Obstetrics, Gynecology, & Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| | - Jennifer Fortin
- ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| | - Elizabeth Janiak
- Department of Obstetrics, Gynecology, & Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Zaręba K, La Rosa VL, Wójtowicz S, Kołb-Sielecka E, Banasiewicz J, Ciebiera M, Jakiel G. The Opinions of Specialists in Obstetrics and Gynecology on the Indications for Pregnancy Termination in Poland-A Preliminary Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12578. [PMID: 36231879 PMCID: PMC9564862 DOI: 10.3390/ijerph191912578] [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: 09/01/2022] [Revised: 09/25/2022] [Accepted: 09/29/2022] [Indexed: 06/16/2023]
Abstract
The physician's decision concerning pregnancy termination is influenced by a number of factors. The study aimed at obtaining the opinions of obstetricians and gynecologists with regard to the indications for pregnancy termination, the readiness to perform the procedure personally and the assessment of the determinants thereof. The survey study was conducted between 1 January 2020 and 31 December 2021 among physicians who performed diagnostic prenatal ultrasonography. A considerable majority of physicians participating in the study did not approve of termination without medical indications (62.5%). A marked majority of them considered the following cases as indications for pregnancy termination: severe fetal defects (90%), lethal defects (91.5%) and a disease threatening maternal life (91.5%). A small group of physicians declared that they were ready to perform a termination without medical indications (12.5%). However, they were ready to perform a pregnancy termination personally in cases of threat to maternal life (77.5%), severe fetal defects (75%), lethal fetal defects (75%) and a pregnancy being a result of rape (75%). No statistical significance was observed with regard to the influence of the respondents' sex, the fact of having children or the workplace on the issue of indications for pregnancy termination. It seems justified to develop case-centered counseling concerning abortion, based on specialists in perinatology, law and ethics, especially in countries with more restrictive abortion law or strongly religious societies.
Collapse
Affiliation(s)
- Kornelia Zaręba
- Department of Obstetrics and Gynecology, College of Medicine and Health Sciences (CMHS), United Arab Emirates University (UAEU), Al Ain 17666, United Arab Emirates
| | - Valentina Lucia La Rosa
- Unit of Psychodiagnostics and Clinical Psychology, University of Catania, 95124 Catania, Italy
| | - Stanisław Wójtowicz
- Department of Medical Psychology and Medical Communication, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Ewelina Kołb-Sielecka
- First Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, 01-813 Warsaw, Poland
| | - Jolanta Banasiewicz
- Department of Medical Psychology and Medical Communication, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Michał Ciebiera
- Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, 01-813 Warsaw, Poland
| | - Grzegorz Jakiel
- First Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, 01-813 Warsaw, Poland
| |
Collapse
|
7
|
LaRoche KJ, Wylie A, Persaud M, Foster AM. Integrating mifepristone into primary care in Canada's capital: A multi-methods exploration of the Medical Abortion Access Project. Contraception 2022; 109:37-42. [PMID: 35031301 DOI: 10.1016/j.contraception.2022.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/01/2022] [Accepted: 01/03/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Following the 2017 introduction of mifepristone in Canada and both ensuing regulatory changes and increased demand for medication abortion care, Planned Parenthood Ottawa created the Medical Abortion Access Project (MAAP). This study aimed to document outcomes, identify facilitators and barriers, and distill learnings from an initiative that sought to recruit and support primary care clinicians in providing mifepristone/misoprostol in Canada's capital. METHODS We employed a multi-methods evaluation strategy that included reviewing MAAP-related documents, evaluating the project log, and conducting in-depth interviews with clinicians at five sites. In the final analytic phase, we integrated the findings from the different evaluation components. RESULTS From May 2017 through July 2018, the MAAP helped 14 primary care facilities in Ottawa become medication abortion providers; nine began providing mifepristone/misoprostol to existing patients and five began offering mifepristone/misoprostol to the public. The program recruited four new pharmacies to stock the combination package and trained two sonography clinics in abortion-related protocols. Program participants identified patient demand as a key driver of medication abortion provision but required information and logistical support from the MAAP to operationalize service delivery. New abortion providers reflected positively on the community of practice that the MAAP created, which enabled them to offer and receive technical and emotional support from colleagues across the city. CONCLUSIONS A number of primary care clinicians in Ottawa were able to successfully integrate medication abortion care into their practices with MAAP support. Future research should explore whether this type of community-based intervention can be replicated in other settings. IMPLICATIONS Evidence-based regulation of mifepristone by health authorities is a critical step to increasing access to medication abortion care. However, deregulation alone was insufficient to integrate medication abortion services into primary care in Ottawa. Community-based programs like the MAAP can help providers make sense of shifting regulations and practice guidelines, overcome logistical barriers, and ultimately increase access to this medically necessary service. Establishing and facilitating communities of practice is especially important for new primary care providers.
Collapse
Affiliation(s)
- Kathryn J LaRoche
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada; School of Public Health, Indiana University, Bloomington, IN, USA
| | | | - Mira Persaud
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Angel M Foster
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada.
| |
Collapse
|
8
|
Kaye J, Reeves R, Chaiten L. The mifepristone REMS: A needless and unlawful barrier to care✰. Contraception 2021; 104:12-15. [DOI: 10.1016/j.contraception.2021.04.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 11/30/2022]
|
9
|
The disproportionate burdens of the mifepristone REMS. Contraception 2021; 104:16-19. [DOI: 10.1016/j.contraception.2021.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/28/2021] [Accepted: 05/02/2021] [Indexed: 11/23/2022]
|
10
|
Contraception Special Issue on the mifepristone Risk Evaluation and Mitigation Strategy (REMS). Contraception 2021; 104:1-3. [PMID: 34130794 DOI: 10.1016/j.contraception.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|