Changes to medication abortion clinical practices in response to the COVID-19 pandemic

Comparison of medication abortion outcomes at less than and greater than 6 weeks gestation

OBJECTIVES

To compare outcomes and characteristics of two cohorts of patients: those receiving medication abortion (MAB) at ≤42 days gestation and those at 43 to 56 days gestation.

STUDY DESIGN

We conducted a retrospective cohort study in 2022, comparing 142 patients accessing MAB at ≤42 days with 200 patients at 43 to 56 days. We sought to detect a 7% difference in MAB success with 80% power and alpha of 0.05. We assessed follow-up responses and unscheduled contacts with the health care system.

RESULTS

Abortion success rates were similar between the ≤42-day and 43 to 56-day groups (94.3% vs 97%, p = 0.226). Those ≤42 days had more unscheduled office visits (13% vs 6%, p = 0.01) but no difference in phone calls or emergency room visits. More patients with successful MAB in the ≤42-day group answered that bleeding (11.7% vs 1.9%, p = 0.006) and cramping (10.5% vs 2.9%, p = 0.035) were not heavier or worse than a period and that they had no pregnancy symptoms prior to the abortion (15.8% vs 6.0%, p = 0.034). Patients ≤42 days gestation less often had a pretreatment ultrasound (48% vs 64%, p = 0.004). Patients without prior ultrasound more often needed uterine aspiration to complete the abortion (6.8% vs 2%, p = 0.027).

CONCLUSIONS

Patients undergoing MAB at ≤42 days have similar success rates but more unscheduled office visits, and more ambiguous symptoms when using standardized questions for evaluating abortion success. Clinicians should adapt anticipatory guidance and counseling for this population.

IMPLICATIONS

Access to very early abortion is increasingly relevant as legal restrictions on abortion increase. Earlier gestations may have different responses to standard follow-up questions despite a successful MAB and may have more interactions with the health care system.

Clinical and service delivery outcomes following medication abortion provided with or without pretreatment ultrasound or pelvic examination: An updated comparative analysis

OBJECTIVES

This study aimed to compare medication abortion outcomes among people screened without or with ultrasound or pelvic examination.

STUDY DESIGN

We used data collected from March 24, 2020, to September 27, 2021, at five TelAbortion Project sites that provided medication abortion with mifepristone and misoprostol by mail. Using logistic regression weighted on propensity scores, we compared outcomes in participants who had neither ultrasound nor examination before treatment (No-Test group) or had such tests (Test group). We analyzed outcomes separately for participants screened early in the analysis period (before September 15, 2020) or later. Outcomes included procedural abortion completion or ongoing pregnancy, serious adverse events, and unplanned posttreatment abortion-related clinical visits.

RESULTS

Among 416 participants in the early period, the No-Test group had a significantly higher risk than the Test group of procedural abortion completion or ongoing pregnancy (5.6% vs 0.9%, risk difference 4.6%, 95% CI 1.5%, 7.7%) and abortion-related clinical visits (13.3% vs 6.3%; risk difference 7.0%; 95% CI 1.1%, 12.8%). Among 364 participants screened later, the risk of procedural abortion completion or ongoing pregnancy did not differ by group, while unplanned abortion-related clinical visits were less common in the No-Test group (9.9% vs 20.5%; risk difference -10.6%; 95% CI -20.1%, -1.1%). The risk of serious adverse events did not differ by group in either period.

CONCLUSIONS

When providers first began omitting ultrasound or pelvic examination before medication abortion, the practice was associated with increased risks of failure of complete abortion and posttreatment clinical visits; however, these increased risks resolved over time.

IMPLICATIONS

Medication abortion without pretreatment ultrasound or examination is effective and safe. This model should be routinely offered to eligible patients.

Social connectedness and supported self-management of early medication abortion in the UK: experiences from the COVID-19 pandemic and learning for the future

Medication abortion has been established globally as safe and effective. This modality has increased accessibility and the opportunity to centre individual autonomy at the heart of abortion care, by facilitating self-managed abortion. Previous research has shown how self-managed abortion is beneficial in myriad settings ranging from problematic to (relatively) unproblematic contexts of access. In this paper we explore the relationship between self-management and sources of support (including health professionals, family, and friends); as well as considering issues of reproductive control and autonomy. Drawing on qualitative, experience-centred interviews, we utilise the concept of social connectedness to examine how supported self-managed abortion was experienced in the United Kingdom during the COVID-19 pandemic. Overall, self-management was welcomed, with participants speaking positively about managing their own abortion at home. However, a sense of connectedness was crucial in helping participants deal with difficult experiences; and functioned to support individual autonomy in self-care. This paper is the first to examine factors of connection, support, and isolation, as experienced by those undergoing self-managed abortion in the UK in detail. Our research suggests a continued need to advocate for high quality support for self-managed abortion, as well as for choice of abortion method, to support patient-centered care.

Experiences with and unmet needs for medication abortion support: A qualitative study with US abortion support providers

INTRODUCTION

Quality abortion care must be person-centered. Although academic literature has focused on full-spectrum and abortion doulas supporting instrumentation abortion (also referred to as procedural abortion) clients, clients undergoing medication abortion remain understudied and may have unique needs. We aimed to understand United States (US) abortion support providers' perceptions of medication abortion clients' support needs by exploring which needs they address, which needs remain unmet, and how remote support provision might help address client needs.

METHODOLOGY

Between April and October 2018, we conducted 60- to 90-min semi-structured, in-depth interviews by telephone with medication abortion support providers. The interviews focused on their experiences providing support to medication abortion clients in the US. We used a deductive thematic analysis approach.

RESULTS

We interviewed 16 abortion support providers affiliated with nine US-based organizations. Six participants provided in-person support to medication abortion clients, five provided remote support, and five provided both remote and in-person support. Both in-person and remote providers described offering support that addressed clients' informational, emotional, physical, spiritual, and logistical needs. Through participant narratives, we identified interwoven benefits and challenges to remote support care provision. Participants highlighted that most medication abortion clients did not have a support provider.

DISCUSSION

Participants revealed that abortion support providers, including remote support providers, can be a critical component of high-quality abortion care provision. More work is needed to ensure all abortion clients have access to support services as the abortion landscape in the US continues to evolve.

Evaluation of telemedicine medical abortion using a no-test protocol in the Eastern Europe and Central Asian region: Evidence from Ukraine, Uzbekistan, and Azerbaijan

OBJECTIVE

To evaluate safety, feasibility, and acceptability of a telemedicine medical abortion service without pre-treatment in-person tests in Ukraine, Uzbekistan, and Azerbaijan.

METHODS

We conducted an open-label, prospective, observational clinical study at five clinics in the three countries. Interested and eligible participants scheduled a telemedicine consultation with a study provider by phone or video. Medical abortion pills could be obtained by mail or courier or picked up at the study clinic or a pharmacy. Study providers contacted participants 1 week after mifepristone ingestion to assess abortion outcomes based on symptoms, and 3 weeks later to review the result of an at-home, high-sensitivity, urine pregnancy test. Participants were referred to in-person visit based on symptoms, urine pregnancy test results, or initiative by the participant.

RESULTS

In all, 300 women participated in the study. Almost all participants received medical abortion medications the same day as their first contact with the study clinic, and the majority (n = 297, 99.0%) did not experience any problems receiving them. All except two women (0.67%) followed provider instructions on administration of medications. The majority of participants had a complete abortion without a procedure (Ukraine: n = 115, 95.8%; Uzbekistan: n = 127, 97.7%; Azerbaijan: n = 49, 98.0%), few had in-person visits (Ukraine: n = 30, 25.0%; Uzbekistan: n = 3, 2.3%; Azerbaijan: n = 4, 8.0%), and most were very satisfied or satisfied with the service (Ukraine: n = 116, 96%; Uzbekistan: n = 128, 98%; Azerbaijan: n = 45, 90%). No serious adverse events occurred.

CONCLUSION

Telemedicine medical abortion using the no-test protocol is safe, feasible and acceptable for women in Ukraine, Uzbekistan, and Azerbaijan.

Resilience Amid Chaos: Abortion Provision Across the United States During COVID-19

Background: Pregnant people face many challenges to obtaining abortion services, including cost, stigma, administrative requirements, and legislative barriers. In 2020, the COVID-19 pandemic added additional barriers for clients and abortion service providers to overcome. Methods: The current study uses the Family Planning Visits During COVID-19 longitudinal dataset to explore abortion service provision from April 2020 through November 2020 from a sample of clinics (N = 63) providing abortion services across the United States. Results: Clinics in the sample were 49.2% academic/hospital-based, based in urban counties (96.8%), with a majority (82.5%) utilizing in-house providers for abortion care. Results show that the majority of clinics (59%) experienced staffing changes in response to COVID-19, including staff and clinicians who took extended leave, quit, were furloughed, or hired. Although the volume of overall abortion service provision decreased March through July 2020, the volume returned to pre-COVID numbers by August and surpassed pre-COVID volume in September and October 2020. Conclusion: Findings from this study demonstrate the adaptability and resilience shown by providers to ensure the continued availability of abortion services. Strategies adopted during COVID-19, such as telehealth and mail-delivery of abortion medication, may prove useful in a post-Roe legislative landscape.

Self-diagnosing the end of pregnancy after medication abortion

This qualitative study conducted between November 2020 and March 2021 in the US state of Mississippi examines the experiences of 25 people who obtained medication abortion at the state's only abortion facility. We conducted in-depth interviews with participants after their abortions until concept saturation was reached, and then analysed the content using inductive and deductive analysis. We assessed how people use embodied knowledge about their individual physical experiences such as pregnancy symptoms, a missed period, bleeding, and visual examinations of pregnancy tissue to identify the beginning and end of pregnancy. We compared this to how people use biomedical knowledge such as pregnancy tests, ultrasounds, and clinical examinations to confirm their self-diagnoses. We found that most people felt confident that they could identify the beginning and end of pregnancy through embodied knowledge, especially when combined with the use of home pregnancy tests that confirmed their symptoms, experiences, and visual evidence. All participants concerned about symptoms sought follow-up care at a medical facility, whereas people who felt confident of the successful end of the pregnancy did so less often. These findings have implications for settings of restricted abortion access that have limited options for follow-up care after medication abortion.

Abortion Clients' Perceptions of Alternative Medication Abortion Service Delivery Options in Mississippi

OBJECTIVES

We assessed Mississippi abortion clients' perceptions of alternative medication abortion service delivery options that were restricted under state law but available elsewhere.

METHODS

We conducted in-depth interviews with medication abortion clients between November 2020 and March 2021 at Mississippi's only abortion facility. We described alternative service delivery models: telemedicine, medications by mail, and follow-up care in their community versus returning to the facility. We asked if participants would be interested in using any of these models, if available, and how use of each model would have changed their abortion experience. We used thematic analysis, organizing codes into common themes based on participants' preferences and concerns for each option.

RESULTS

Of the 25 participants interviewed, nearly all (n = 22) expressed interest in at least one option and reported that, had they been available, these would have alleviated cost, travel, and childcare barriers. Many believed these options would further ensure privacy, but a minority thought abortion was too sensitive for telemedicine or were concerned about mailing errors. Participants not interested in the alternative options also feared missing valued aspects of face-to-face care. Most did not return to the facility for follow-up (n = 19), citing financial and logistical barriers. Largely, participants were not interested in obtaining follow-up care in their community, citing concerns about provider judgment, stigma, and privacy.

CONCLUSIONS

Mississippi abortion clients were interested in models that would make abortion care more convenient while ensuring their privacy and allowing for meaningful client-provider interaction. These features of care should guide the development of strategies aimed at helping those in restricted settings, such as Mississippi, to overcome barriers to abortion care following the implementation of abortion bans in many states following the overturn of Roe v. Wade.

Telemedicine Abortion

Telemedicine has become a substantial part of abortion care in recent years. In this review, we discuss the history and regulatory landscape of telemedicine for medication abortion in the United States, different models of care for telemedicine, and the safety and effectiveness of medication abortion via telemedicine, including using history-based screening protocols for medication abortion without ultrasound. We also explore the acceptability of telemedicine for patients and their perspectives on its benefits, as well as the use of telemedicine for other parts of abortion care. Telemedicine has expanded access to abortion for many, although there remain limitations to its implementation.

The Provision of Abortion Care via Telehealth in the United States: A Rapid Review

INTRODUCTION

The recent Supreme Court decision Dobbs v. Jackson Women's Health that has overruled Roe v. Wade has resulted in severe limitations of abortion access throughout the United States. Telehealth has been put forth as one solution for improving access for reproductive health care, including abortion services. Telehealth has demonstrated safety and efficacy in several health care disciplines; however, its use for abortion care and services has not been explored and synthesized.

METHODS

As part of a larger review on telehealth and general reproductive health, our team identified a moderate amount of literature on telehealth and abortion care. We conducted a rapid review searching for eligible studies in MEDLINE, Embase, and CINAHL. Information was extracted from each included study to explore 4 key areas of inquiry: (1) clinical effectiveness, (2) patient and provider experiences, (3) barriers and facilitators, and (4) the impact of the coronavirus disease 2019 (COVID-19) pandemic.

RESULTS

Twenty-five studies on the use of telehealth for providing abortion services published between 2011 and 2022 were included. Telehealth for medical abortion increased during the COVID-19 pandemic and was found to be safe and clinically effective, with high patient satisfaction. Overall, telehealth improved access and removed barriers for patients including lack of transportation. Legal restrictions in certain states were cited as the primary barriers. Studies contained limited information on the perspectives and experiences of health care providers and diverse patient populations.

DISCUSSION

Abortion care via telehealth is safe and effective with high satisfaction and may also remove barriers to care including transportation and fear. Removing restrictions on telehealth for the provision of abortion services may further improve access to care and promote greater health equity.

COVID-19 and abortion in the Ohio River Valley: A case study of Kentucky, Ohio, and West Virginia

INTRODUCTION

During early stages of COVID-19 in the United States, government representatives in Kentucky, Ohio, and West Virginia restricted or threatened to restrict abortion care under elective surgery bans. We examined how abortion utilization changed in these states.

METHODOLOGY

We examined COVID-19 abortion-related state policies implemented in March and April 2020 using publicly available sources. We analyzed data on abortions by method and gestation and experiences of facility staff, using a survey of 14 facilities. We assessed abortions that took place in February-June 2020 and February-June 2021.

RESULTS

In February-June 2020 the monthly average abortion count was 1916; 863 (45%) were medication abortions and 229 (12%) were ≥14 weeks gestation. Of 1959 abortions performed across all three states in April 2020, 1319 (67%) were medication abortions and 231 (12%) were ≥14 weeks gestation. The shift toward medication abortion that took place in April 2020 was not observed in April 2021. Although the total abortion count in the three-state region remained steady, West Virginia had the greatest decline in total abortions, Ohio experienced a shift from instrumentation to medication abortions, and Kentucky saw little change. Staff reported increased stress from concerns over health and safety and increased scrutiny by the state and anti-abortion protesters.

DISCUSSION

Although abortion provision continued in this region, policy changes restricting abortion in Ohio and West Virginia resulted in a decrease in first trimester instrumentation abortions, an overall shift toward medication abortion care, and an increase in stress among facility staff during the early phase of COVID-19.

"I'm going to be forced to have a baby": A study of COVID-19 abortion experiences on Reddit

INTRODUCTION

The initial stages of the COVID-19 pandemic affected abortion care in the United States (US) in myriad ways. While research has documented systems-level pandemic-related impacts on abortion access and care delivery little information exists about the experiences of abortion seekers during this period. We sought to document the effects of COVID-19 pandemic restrictions US abortion seekers by analyzing posts on Reddit, a popular social media website.

METHODS

We compiled and coded 528 anonymous posts on the abortion subreddit from 3/20/2020 to 4/12/2020 and applied inductive qualitative analytic techniques to identify themes.

RESULTS

We identified four primary themes. First, posters reported several COVID-19-related barriers to abortion services: reduced in-person access due to clinic closures, mail delivery delays of abortion medications, and pandemic-related financial barriers to both self-managed and in-clinic abortion. The second theme encompassed quarantine-driven privacy challenges, primarily challenges with concealing an abortion from household members. Third, posters detailed how the pandemic constrained their pregnancy decision making, including time pressure from impending clinic closures. Finally, posters reported COVID-19-related changes to service delivery that negatively affected their abortion experiences, for example being unable to bring a support person into the clinic due to pandemic visitor restrictions.

DISCUSSION

This analysis of real-time social media posts reveals multiple ways that the COVID-19 pandemic limited abortion access in the US and affected abortion seekers' decisions and experiences. Findings shed light on the consequences of sudden changes, whether pandemic or policy related, on abortion service delivery.

Remote Provision of Medication Abortion and Contraception Through Telemedicine

This Narrative Review describes the remote provision of family planning services, including medication abortion and contraception, through telemedicine. The coronavirus disease 2019 (COVID-19) pandemic was a catalyst to shift toward telemedicine to maintain and expand access to crucial reproductive health services when public health measures necessitated social distancing. There are legal and political considerations when providing medication abortion through telemedicine, along with unique challenges, even more so after the Dobbs decision starkly limited options for much of the country. This review includes the literature describing the logistics of telemedicine and modes of delivery for medication abortion and details special considerations for contraceptive counseling. Health care professionals should feel empowered to adopt telemedicine practices to provide family planning services to their patients.

Intrauterine device self-removal practices during the COVID-19 pandemic among family planning clinics

OBJECTIVES

To explore the prevalence of intrauterine device self-removal practices before and during the COVID-19 pandemic among family planning clinics.

STUDY DESIGN

This is a secondary analysis of data from a descriptive, longitudinal study using a clinic-based convenience sample from the Abortion Clinical Research Network assessing baseline and pandemic-adaptive family planning practices.

RESULTS

Of the 63 sites that provided contraception, 5 (7.9%) reported providing guidance on intrauterine device self-removal at baseline. Sixteen sites (25.4%) provided guidance on self-removal by the end of the study period. Self-removal counseling was associated with being an academic center and reporting a median lower number of monthly contraceptive encounters.

CONCLUSIONS

Endorsement of IUD self-removal increased to one-quarter of sites by the final timepoint.

IMPLICATIONS

Twenty-five percent of family planning clinics reported provision of intrauterine device self-removal guidance by eight months into the COVID-19 pandemic, a three-fold increase from baseline; these findings suggest clinician support for patient autonomy in contraceptive self-management and limited concern for safety issues with self-removal during a public health emergency.

Update on medication abortion follow-up options: many sizes to fit all

PURPOSE OF REVIEW

To assess the efficacy, benefits, and limitations of available and emerging follow-up options for medication abortion.

RECENT FINDINGS

Medication abortion follow-up does not have to be a 'one size fits all' protocol. From most to least invasive, follow-up options include facility-based ultrasound, laboratory-based repeat serum beta-human chorionic gonadotropin (hCG) testing, urine hCG testing (high sensitivity, low sensitivity, and multilevel pregnancy tests), self-assessment with symptom evaluation, and no intervention. Provider or facility-dependent follow-up, including ultrasound and serum testing are effective, but have several limitations, including needing to return to a facility and cost. Remote, client-led follow-up options, such as urine pregnancy testing and symptoms evaluation, are well tolerated and effective for ruling out the rare outcome of ongoing pregnancy after medication abortion and have several advantages. Advantages include being inexpensive and flexible. However, it is important to note that low-sensitivity and multilevel pregnancy tests are not available in all settings. In studies evaluating client-led follow-up with urine pregnancy tests, ongoing pregnancies were identified over half the time with symptoms alone.

SUMMARY

Guidelines from several professional organizations have aligned with the evidence and no longer recommend routine office-based follow-up. To ensure care is person-centered, providers should offer follow-up options that align with the comfort, logistical ability, and values of the client.

Abortion incidence and service availability in the United States, 2020

BACKGROUND

This study provides a baseline assessment of abortion incidence and service delivery prior to Roe v. Wade being overturned.

METHODS

We collected information from all facilities known to have provided abortion services in the United States in 2019 and 2020. We examined abortion incidence by state, region and nationally and combined data on number of abortions with population data to estimate abortion rates. We also examined the number of abortion clinics, trends in medication abortion and service disruptions and changes in abortion protocols that occurred during the COVID-19 pandemic. We compare these findings to those of our prior Abortion Provider Census, which collected information for 2017.

RESULTS

We documented 930,160 abortions in 2020, an 8% increase from 2017. Between 2017 and 2020, abortion incidence increased in all four regions of the country and in a majority of states. The total number of clinics providing abortion care remained stable nationally but increased in the Midwest and the West and declined in the Northeast and South. There were 492,210 medication abortions in 2020, a 45% increase from 2017. A substantial minority of clinics adjusted protocols in response to COVID, most commonly adopting remote pre- and post-abortion counseling.

DISCUSSION

This study did not address factors behind the increase in abortion. However, this report demonstrates that the need for abortion care was growing just prior to the overturning Roe v. Wade, and the impact of this decision will be even more far-reaching than previously expected.

Person-centered, high-quality care from a distance: A qualitative study of patient experiences of TelAbortion, a model for direct-to-patient medication abortion by mail in the United States

CONTEXT

Direct-to-patient telemedicine abortion allows people to receive mifepristone and misoprostol for medication abortion in their home without requiring an in-person visit with a healthcare provider. This method has high efficacy and safety, but less is known about the person-centered quality of care provided with telemedicine.

METHODS

We interviewed 45 participants from the TelAbortion study of direct-to-patient telemedicine abortion in the United States from January to July 2020. Semi-structured qualitative interviews queried their choices, barriers to care, expectations for care, actual abortion experience, and suggestions for improvement. We developed a codebook through an iterative, inductive process and performed content and thematic analyses.

RESULTS

The experience of direct-to-patient telemedicine abortion met the person-centered domains of dignity, autonomy, privacy, communication, social support, supportive care, trust, and environment. Four themes relate to the person-centered framework for reproductive health equity: (1) Participants felt well-supported and safe with TelAbortion; (2) Participants had autonomy in their care which led to feelings of empowerment; (3) TelAbortion exceeded expectations; and (4) Challenges arose when interfacing with the healthcare system outside of TelAbortion. Participants perceived abortion stigma which often led them to avoid traditional care and experienced enacted stigma during encounters with non-study healthcare workers.

CONCLUSION

TelAbortion is a high quality, person-centered care model that can empower patients seeking care in an increasingly challenging abortion context.

Abortion Surveillance - United States, 2020

Problem/Condition

CDC conducts abortion surveillance to document the number and characteristics of women obtaining legal induced abortions and number of abortion-related deaths in the United States.

Period Covered

2020.

Description of System

Each year, CDC requests abortion data from the central health agencies for the 50 states, the District of Columbia, and New York City. For 2020, a total of 49 reporting areas voluntarily provided aggregate abortion data to CDC. Of these, 48 reporting areas provided data each year during 2011-2020. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. Abortion-related deaths from 2019 were assessed as part of CDC's Pregnancy Mortality Surveillance System (PMSS).

Results

A total of 620,327 abortions for 2020 were reported to CDC from 49 reporting areas. Among 48 reporting areas with data each year during 2011-2020, in 2020, a total of 615,911 abortions were reported, the abortion rate was 11.2 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 198 abortions per 1,000 live births. From 2019 to 2020, the total number of abortions decreased 2% (from 625,346 total abortions), the abortion rate decreased 2% (from 11.4 abortions per 1,000 women aged 15-44 years), and the abortion ratio increased 2% (from 195 abortions per 1,000 live births). From 2011 to 2020, the total number of reported abortions decreased 15% (from 727,554), the abortion rate decreased 18% (from 13.7 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 9% (from 217 abortions per 1,000 live births).In 2020, women in their 20s accounted for more than half of abortions (57.2%). Women aged 20-24 and 25-29 years accounted for the highest percentages of abortions (27.9% and 29.3%, respectively) and had the highest abortion rates (19.2 and 19.0 abortions per 1,000 women aged 20-24 and 25-29 years, respectively). By contrast, adolescents aged <15 years and women aged ≥40 years accounted for the lowest percentages of abortions (0.2% and 3.7%, respectively) and had the lowest abortion rates (0.4 and 2.6 abortions per 1,000 women aged <15 and ≥40 years, respectively). However, abortion ratios were highest among adolescents (aged ≤19 years) and lowest among women aged 25-39 years.Abortion rates decreased from 2011 to 2020 among all age groups. The decrease in abortion rate was highest among adolescents compared with any other age group. From 2019 to 2020, abortion rates decreased or did not change for all age groups. Abortion ratios decreased from 2011 to 2020 for all age groups, except adolescents aged 15-19 years and women aged 25-29 years for whom abortion ratios increased. The decrease in abortion ratio was highest among women aged ≥40 years compared with any other age group. From 2019 to 2020, abortion ratios decreased for adolescents aged <15 years and women aged ≥35 and increased for women 15-34 years.In 2020, 80.9% of abortions were performed at ≤9 weeks' gestation, and nearly all (93.1%) were performed at ≤13 weeks' gestation. During 2011-2020, the percentage of abortions performed at >13 weeks' gestation remained consistently low (≤9.2%). In 2020, the highest percentage of abortions were performed by early medical abortion at ≤9 weeks' gestation (51.0%), followed by surgical abortion at ≤13 weeks' gestation (40.0%), surgical abortion at >13 weeks' gestation (6.7%), and medical abortion at >9 weeks' gestation (2.4%); all other methods were uncommon (<0.1%). Among those that were eligible (≤9 weeks' gestation), 63.9% of abortions were early medical abortions. In 2019, the most recent year for which PMSS data were reviewed for pregnancy-related deaths, four women died as a result of complications from legal induced abortion.

Interpretation

Among the 48 areas that reported data continuously during 2011-2020, overall decreases were observed during 2011-2020 in the total number, rate, and ratio of reported abortions. From 2019 to 2020, decreases also were observed in the total number and rate of reported abortions; however, a 2% increase was observed in the total abortion ratio.

Public Health Action

Abortion surveillance can be used to help evaluate programs aimed at promoting equitable access to patient-centered quality contraceptive services in the United States to reduce unintended pregnancies.

Changes in the Clinical Workforce Providing Contraception and Abortion Care in the US, 2019-2021

This cross-sectional study investigates changes in the workforce providing contraception and abortion services from before to during the COVID-19 pandemic.

Impact of the COVID-19 pandemic on access to and utilisation of services for sexual and reproductive health: a scoping review

INTRODUCTION

The COVID-19 pandemic has negatively impacted health systems globally and widened preexisting disparities. We conducted a scoping review on the impact of the COVID-19 pandemic on women and girls' access to and utilisation of sexual and reproductive health (SRH) services for contraception, abortion, gender-based and intimate partner violence (GBV/IPV) and sexually transmitted infections (STIs).

METHODS

We systematically searched peer reviewed literature and quantitative reports, published between December 2019 and July 2021, focused on women and girls' (15-49 years old) access to and utilisation of selected SRH services during the COVID-19 pandemic. Included studies were grouped based on setting, SRH service area, study design, population and reported impact. Qualitative data were coded, organised thematically and grouped by major findings.

RESULTS

We included 83 of 3067 identified studies and found that access to contraception, in-person safe abortion services, in-person services for GBV/IPV and STI/HIV testing, prevention and treatment decreased. The geographical distribution of this body of research was uneven and significantly less representative of countries where COVID-19 restrictions were very strict. Access was limited by demand and supply side barriers including transportation disruptions, financial hardships, limited resources and legal restrictions. Few studies focused on marginalised groups with distinct SRH needs.

CONCLUSION

Reports indicated negative impacts on access to and utilisation of SRH services globally, especially for marginalised populations during the pandemic. Our findings call for strengthening of health systems preparedness and resilience to safeguard global access to essential SRH services in ongoing and future emergencies.

[Induced abortion and COVID-19 : What changed with the pandemic in 2020]

Contexte

L'année 2020 a été marquée par la pandémie du SARS-CoV2 dont les mesures de gestion ont fortement perturbé l'organisation de la société en général et particulièrement l'organisation du système de soins. Cette étude avait pour objectif d'analyser l’évolution des indicateurs des interruptions volontaires de grossesse (IVG) dans la région parisienne au cours de l'année 2020 et d'analyser particulièrement ce qui a changé au cours du premier confinement.

Méthode

Les données issues du Système national des données de santé (SNDS) ont été analysées pour comparer les indicateurs de 2020 à ceux de 2016–2019. En 2020, les indicateurs ont été étudiés mensuellement. L’âge des femmes, la méthode utilisée pour interrompre la grossesse, le terme de la grossesse au moment de l'IVG et le département de résidence de la femme ont été analysés.

Résultats

Après cinq années consécutives d'augmentation du taux de recours à l'IVG, l'année 2020 a été marquée par un recul du nombre d'IVG (50 615), soit une baisse de 5,6 % par rapport à 2019 (53 601). Le taux de recours est passé de 17,3 IVG/1000 femmes de 15–49 ans en 2019 à 16,3 ‰ en 2020. Ce recul a été observé dans les quatre semaines ayant suivi le premier confinement. Il concernait plus particulièrement les IVG réalisées à l'hôpital et les IVG des femmes jeunes (< 25 ans). En 2020, les proportions des IVG médicamenteuses et des IVG instrumentales sous anesthésie locale ont augmenté comparativement aux quatre années précédant la crise sanitaire. Par ailleurs, on a dénombré moins d'IVG tardives en 2020 (IVG sur grossesse > 12 semaines d'aménorrhée). Cette analyse met également en évidence une baisse du nombre de naissances dans les huit à neuf mois ayant suivi le premier confinement.

Discussion et conclusion

La crise liée à la COVID-19 a entraîné d'autres conséquences sanitaires non imputables directement au virus. En termes de reproduction, la crise sanitaire, particulièrement le premier confinement, est associée à un recul des conceptions se traduisant par une baisse du nombre de grossesses, qu'elles soient désirées ou non, avec comme conséquence une baisse de recours à l'IVG dans les semaines suivant le premier confinement et un recul de la natalité dans les neuf mois suivants.

The association of U.S. state-level abortion restrictions with medication abortion service delivery innovations during the early COVID-19 pandemic

OBJECTIVES

To assess whether state-level abortion restrictions resulted in differential uptake of innovative medication abortion practices such as changing ultrasound requirements, offering telehealth, or dispensing medications without a physical exam during the early COVID-19 pandemic.

METHODS

We used data from a prospective national survey of abortion providers to assess the association between a novel index of state-level abortion hostility and adoption of medication abortion services innovations during the pandemic.

RESULTS

Clinics in states with low or medium hostility were more likely to adopt innovative practices than those in high or extreme hostility states.

CONCLUSIONS

Clinics in abortion hostile states were less likely to adopt clinical recommendations and public health best practices for abortion care during the COVID-19 pandemic.

Comparison of Pregnancy Preferences Preceding vs Year 1 of the COVID-19 Pandemic

Importance

Understanding how the COVID-19 pandemic affected people's desire to avoid pregnancy is essential for interpreting the pandemic's associations with access to reproductive health care and reproductive autonomy. Early research is largely cross-sectional and relies on people's own evaluations of how their desires changed.

Objective

To investigate longitudinal changes in pregnancy desires during the year before and the first year of the COVID-19 pandemic.

Design, Setting, and Participants

In this cohort study, participants reported their pregnancy preferences at baseline and quarterly for up to 18 months between March 2019 and March 2021. An interrupted time series analysis with mixed-effects segmented linear regression was used to examine population-averaged time trends. People were recruited from 7 primary and reproductive health care facilities in Arizona, New Mexico, and Texas. Participants were sexually active, pregnancy-capable people aged 15 to 34 years who were not pregnant or sterilized. Data analysis was performed from September 2021 to January 2022.

Exposures

Continuous time, with knots at the onset of the first (July 1, 2020, summer surge) and second (November 1, 2020, fall surge) COVID-19 cases surges in the Southwest.

Main Outcomes and Measures

Preferences around potential pregnancy in the next 3 months, measured using the validated Desire to Avoid Pregnancy (DAP) scale (range, 0-4, with 4 indicating a higher desire to avoid pregnancy).

Results

The 627 participants in the analytical sample had a mean (SD) age of 24.9 (4.9) years; 320 (51.0%) identified as Latinx and 180 (28.7%) as White. Over the year before the first case surge in the US Southwest in summer 2020, population-averaged DAP scores decreased steadily over time (-0.06 point per quarter; 95% CI, -0.07 to -0.04 point per quarter; P < .001). During the summer 2020 surge, DAP scores stopped declining (0.05 point per quarter; 95% CI, -0.03 to 0.13 point per quarter; change in slope, P < .001). During the fall 2020 surge, however, DAP scores declined again at -0.11 point per quarter (95% CI, -0.26 to 0.04 point per quarter; change in slope, P = .10). Participants aged 15 to 24 years and those who were nulliparous and primiparous experienced greater declines in DAP score before the summer surge, and greater reversals of decline between summer and fall 2020, than did those who were aged 25 to 34 years and multiparous.

Conclusions and Relevance

These findings suggest that the COVID-19 pandemic onset was associated with the stalling of a prior trend toward greater desire for pregnancy over time, particularly for people earlier in their reproductive lives.

Outcomes and Safety of History-Based Screening for Medication Abortion: A Retrospective Multicenter Cohort Study

IMPORTANCE

Screening for medication abortion eligibility typically includes ultrasonography or pelvic examination. To reduce physical contact during the COVID-19 pandemic, many clinicians stopped requiring tests before medication abortion and instead screened patients for pregnancy duration and ectopic pregnancy risk by history alone. However, few US-based studies have been conducted on the outcomes and safety of this novel model of care.

OBJECTIVE

To evaluate the outcomes and safety of a history-based screening, no-test approach to medication abortion care.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients obtaining a medication abortion without preabortion ultrasonography or pelvic examination between February 1, 2020, and January 31, 2021, at 14 independent, Planned Parenthood, academic-affiliated, and online-only clinics throughout the US.

EXPOSURES

Medications for abortion provided without preabortion ultrasonography or pelvic examination and dispensed to patients in person or by mail.

MAIN OUTCOMES AND MEASURES

Effectiveness, defined as complete abortion after 200 μg of mifepristone and up to 1600 μg of misoprostol without additional intervention, and major abortion-related adverse events, defined as hospital admission, major surgery, or blood transfusion.

RESULTS

The study included data on 3779 patients with eligible abortions. The study participants were racially and ethnically diverse and included 870 (23.0%) Black patients, 533 (14.1%) Latinx/Hispanic patients, 1623 (42.9%) White patients, and 327 (8.7%) who identified as multiracial or with other racial or ethnic groups. For most (2626 [69.5%]), it was their first medication abortion. Patients lived in 34 states, and 2785 (73.7%) lived in urban areas. In 2511 (66.4%) abortions, the medications were dispensed in person; in the other 1268 (33.6%), they were mailed to the patient. Follow-up data were obtained for 2825 abortions (74.8%), and multiple imputation was used to account for missing data. Across the sample, 12 abortions (0.54%; 95% CI, 0.18%-0.90%) were followed by major abortion-related adverse events, and 4 patients (0.22%; 95% CI, 0.00%-0.45%) were treated for ectopic pregnancies. Follow-up identified 9 (0.40%; 95% CI, 0.00%-0.84%) patients who had pregnancy durations of greater than 70 days on the date the mifepristone was dispensed that were not identified at screening. The adjusted effectiveness rate was 94.8% (95% CI, 93.6%-95.9%). Effectiveness was similar when medications were dispensed in person (95.4%; 95% CI, 94.1%-96.7%) or mailed (93.3%; 95% CI, 90.7%-95.9%).

CONCLUSIONS AND RELEVANCE

In this cohort study, screening for medication abortion eligibility by history alone was effective and safe with either in-person dispensing or mailing of medications, resulting in outcomes similar to published rates of models involving ultrasonography or pelvic examination. This approach may facilitate more equitable access to this essential service by increasing the types of clinicians and locations offering abortion care.

Impact of COVID-19 on Abortion Method Under Ten Weeks Gestational Age in Southern California

Objective

We assessed the proportion of medication versus suction aspiration abortions before and after the onset of the COVID-19 pandemic in a health system that did not limit access to abortion.

Study Design

We conducted an interrupted time series analysis among patients having an abortion at 10 weeks gestation or less at Planned Parenthood health centers in San Diego, Imperial, and Riverside Counties in California. Centers required in-person follow up for medication abortion throughout the pandemic. We compared the nine months prior to the pandemic (June 2019 to February 2020) to the first nine months of the pandemic (April 2020 to December 2020), with March 2020 as a washout period.

Results

There was an average monthly increase of 0.78% in the proportion of medication abortions from June 2019 to February 2020 (p = 0.01, pre-pandemic trend). Immediately following the start of the pandemic, there was an estimated increase in the proportion of medication abortions of 2.58% (p = 0.23, post-level change). However, the monthly pre-pandemic trend towards medication abortions reversed by 1.07% after the start of the pandemic (p = 0.02, post-trend change), for an average monthly decrease in the proportion of medication abortions of 0.29% from April to December 2020 (p = 0.37, pandemic trend).

Conclusions

The trend towards medication abortions that was present before the COVID-19 pandemic reversed after an initial increase in medication abortions at the start of the pandemic.

Implications

Both types of abortion should remain available during public health emergencies. Further research is needed to understand how the pandemic affected abortion methods in areas with limited access and in health centers that did not require two in-person appointments for medication abortions.

Reproductive justice in the time of COVID-19: a systematic review of the indirect impacts of COVID-19 on sexual and reproductive health

OBJECTIVE

Despite gendered dimensions of COVID-19 becoming increasingly apparent, the impact of COVID-19 and other respiratory epidemics on women and girls' sexual and reproductive health (SRH) have yet to be synthesized. This review uses a reproductive justice framework to systematically review empirical evidence of the indirect impacts of respiratory epidemics on SRH.

METHODS

We searched MEDLINE and CINAHL for original, peer-reviewed articles related to respiratory epidemics and women and girls' SRH through May 31, 2021. Studies focusing on various SRH outcomes were included, however those exclusively examining pregnancy, perinatal-related outcomes, and gender-based violence were excluded due to previously published systematic reviews on these topics. The review consisted of title and abstract screening, full-text screening, and data abstraction.

RESULTS

Twenty-four studies met all eligibility criteria. These studies emphasized that COVID-19 resulted in service disruptions that effected access to abortion, contraceptives, HIV/STI testing, and changes in sexual behaviors, menstruation, and pregnancy intentions.

CONCLUSIONS

These findings highlight the need to enact policies that ensure equitable, timely access to quality SRH services for women and girls, despite quarantine and distancing policies. Research gaps include understanding how COVID-19 disruptions in SRH service provision, access and/or utilization have impacted underserved populations and those with intersectional identities, who faced SRH inequities notwithstanding an epidemic. More robust research is also needed to understand the indirect impact of COVID-19 and epidemic control measures on a wider range of SRH outcomes (e.g., menstrual disorders, fertility services, gynecologic oncology) in the long-term.

Impact of the SARS-CoV-2 pandemic and first lockdown on pregnancy monitoring in France: the COVIMATER cross-sectional study

BACKGROUND

In the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, consultations and pregnancy monitoring examinations had to be reorganised urgently. In addition, women themselves may have postponed or cancelled their medical monitoring for organisational reasons, for fear of contracting the disease caused by SARS-CoV-2 (COVID-19) or for other reasons of their own. Delayed care can have deleterious consequences for both the mother and the child. Our objective was therefore to study the impact of the SARS-CoV-2 pandemic and the first lockdown in France on voluntary changes by pregnant women in the medical monitoring of their pregnancy and the associated factors.

METHODS

A cross-sectional study was conducted in July 2020 using a web-questionnaire completed by 500 adult (> 18 years old) pregnant women during the first French lockdown (March-May 2020). A robust variance Poisson regression model was used to estimate adjusted prevalence ratios (aPRs).

RESULTS

Almost one women of five (23.4%) reported having voluntarily postponed or foregone at least one consultation or pregnancy check-up during the lockdown. Women who were professionally inactive (aPR = 1.98, CI95%[1.24-3.16]), who had experienced serious disputes or violence during the lockdown (1.47, [1.00-2.16]), who felt they received little or no support (1.71, [1.07-2.71]), and those who changed health professionals during the lockdown (1.57, [1.04-2.36]) were all more likely to have voluntarily changed their pregnancy monitoring. Higher level of worry about the pandemic was associated with a lower probability of voluntarily changing pregnancy monitoring (0.66, [0.46-0.96]).

CONCLUSIONS

Our results can guide prevention and support policies for pregnant women in the current and future pandemics.

Clinical and service delivery implications of omitting ultrasound before medication abortion provided via direct-to-patient telemedicine and mail

OBJECTIVES

To compare outcomes among patients who did or did not have pre-abortion ultrasound or pelvic exam before obtaining medication abortion (MA) via direct-to-patient telemedicine and mail.

STUDY DESIGN

We analyzed data from participants screened for enrollment into the TelAbortion study at five sites from March 25 to September 15, 2020. We compared participants who had preabortion ultrasound or pelvic exam ("test-MA") to those who did not ("no-test MA"). Outcomes were: abortion not complete with pills alone (i.e., had procedure intervention or ongoing pregnancy), ongoing pregnancy separately, ectopic pregnancy, hospitalization and/or blood transfusion, and unplanned clinical encounters. We used propensity score weighting and multivariable logistic regression to adjust for baseline characteristics.

RESULTS

Our analysis included 287 participants who had no-test MA and 125 who had test-MA. Abortion was not complete with pills alone in 16of 287 (5.6%) no-test MA patients compared to 2of 123 (1.9%) test-MA patients (adjusted risk difference [aRD] = 4.3%, 95% confidence interval [CI]: 1.4%-7.1%). No ectopic pregnancies were detected. Groups did not differ regarding hospitalization and/or blood transfusion (p = 0.76) or ongoing pregnancy diagnosis (p = 0.59). Unplanned clinical encounters were more common in no-test MA patients (35of 287, 12.5%) than test-MA patients (10of 125, 8.0%, aRD = 6.7%, 95% CI: 0.5%-13.1%).

CONCLUSIONS

Compared to patients who had pre-abortion ultrasound, patients who had no-test MA via telemedicine were more likely to have abortions that were not complete with pills alone and/or unplanned clinical encounters. However, both no-test and test-MA patients had similar and very low rates of ongoing pregnancy and hospitalization or blood transfusion.

IMPLICATIONS

Omitting pre-abortion ultrasound before provision of medication abortion via telemedicine does not appear to compromise safety or result in more ongoing pregnancies. However, compared to patients who have preabortion ultrasound, patients who do not have pre-abortion tests may be more likely to seek post-treatment care and have procedural interventions.

Comparison of two home pregnancy tests for self-confirmation of medication abortion status: A randomized trial

OBJECTIVES

To evaluate individuals' ability to perform and comprehend low-sensitivity and multilevel urine pregnancy tests during medication abortion follow-up.

STUDY DESIGN

We conducted a pilot study of individuals using mifepristone and misoprostol for medication abortion through 63-days gestation. We randomly assigned participants to use a 1000 mIU/mL low-sensitivity pregnancy test or a five-level multilevel pregnancy test. Seven days after mifepristone, participants performed their test and completed a questionnaire. One week later, participants performed another test if day 7 low-sensitivity test had been positive or day 7 multilevel test had not shown a one-level drop. We assessed comprehension of abortion status based on participants' final test interpretation, and defined correct comprehension when patient report of pregnancy status was consistent with pregnancy test result. We also assessed usability with a 100-mm Visual Analogue Scale (0 'very easy'; 100 'very difficult') and satisfaction.

RESULTS

We enrolled and randomized 88 participants to low-sensitivity (n = 43) and multilevel (n = 45) test groups. Comprehension was correct in 38/39 (97%) and 41/45 (91%) of low-sensitivity and multilevel test users, respectively (p = 0.37). When the test indicated a possible ongoing pregnancy, all three low-sensitivity test users and two of three multilevel test users accurately comprehended their results. Participants rated ease of use as 7.5 (range 0-68) for low-sensitivity and 9.0 (range 0-52) for multilevel (p = 0.24) tests. Most participants were likely or very likely to recommend use of their test (32/36 [89%] low-sensitivity and 42/44 [95%] multilevel test users, p = 0.66).

CONCLUSIONS

Patients could comprehend and use low-sensitivity and multilevel tests during medication abortion follow-up with similar satisfaction.

IMPLICATIONS

Individuals are able to independently use both the low-sensitivity and multilevel tests for medication abortion follow-up. Both are acceptable for medication abortion follow-up without in-person contact, but future, larger studies to compare comprehension of both tests may be necessary.