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

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.

No test medical abortion - a review of the evidence on selective use of preabortion testing

PURPOSE OF REVIEW

The last decade has seen a cascade of different telemedicine models for medical abortion (MA) being tested and implemented. Among these service delivery models is the 'no-test' MA model, in which care is provided remotely and eligibility for the MA is based on history alone. The purpose of this review is to provide an overview of the existing evidence for no-test MA.

RECENT FINDINGS

The evidence base for no-test MA relies heavily on cohort and noncomparative studies predominantly from high resource settings. Recent findings indicate that no-test MA is safe, effective, and highly acceptable. Diagnoses of ectopic pregnancy and underestimation of gestational age were rare. Identified advantages included shortening time to access MA and mitigating access barriers such as cost, and geographical barriers. Abortion seekers valued omitting the ultrasound citing reasons such as privacy concerns, costs, more flexibility, and control. The impacts of no-test MA on unscheduled postabortion contacts and visits and on contraceptive use were unclear due to limited evidence.

SUMMARY

No-test MA can be provided to complement other care pathways including those with some or no in-person care. Further research is needed to allow for widespread adoption of no-test MA and scale-up in a variety of contexts, including low-resource settings.

Effectiveness and safety of medication abortion via telemedicine versus in-person: A cohort of pregnant people in Colombia

OBJECTIVE

To compare the effectiveness and safety of medication abortion (MAB) via telemedicine versus in-person in pregnant people with less than 12 gestational weeks in Colombia.

STUDY DESIGN

A retrospective cohort study was conducted with 23,362 pregnant people who requested MAB service from Profamilia (a Colombian non-governmental organization) in 2021-2022. The outcomes were success and safety of MAB. We performed a descriptive and a multivariate statistical analysis using the binary regression model to obtain an adjusted Odds Ratio (aOR) to identify factors associated with abortion success.

RESULTS

In comparison to in-person care (n = 20,289), individuals in telemedicine (n = 3073) were predominantly from urban areas, belonged to a lower socioeconomic stratum, single and did not identify with any ethnic group. In-person users tended to have higher levels of education and accessed the service through private insurance (p < 0,05). There were no differences in the odd of a successful abortion based on the modality of care (aOR 1.18; 95% CI=0.87-1.59). The results were also the same with sensitivity analysis stratified: pregnant people who were nine weeks gestation or less (aOR 0.86; 95% CI=0.63-1.17) or more (aOR 0.87; 95% CI=0.28-2.65).

CONCLUSION

Telemedicine is an effective and safe option for MAB, as in-person care. Telemedicine has the potential to increase abortion access by extending the availability of providers and offering people a new option for obtaining care conveniently and privately, especially for women with disadvantaged socioeconomic and educational background.

IMPLICATIONS

This study demonstrates that medication abortion (MAB) administered via telemedicine produces outcomes akin to those of in-person care, providing a compelling rationale for its adoption, particularly in underserved regions. This approach can be replicated in other countries in Latin America and the Caribbean.

Person-centered abortion care scale: Validation for medication abortion in the United States

OBJECTIVE

Medication abortions now make up the majority of abortions in the US, with new service delivery models such as telehealth; however, it is unclear how this may impact patient experiences. The objective of the study is to adapt and validate a person-centered abortion care (PCAC) scale for medication abortions that was developed in a global South context (Kenya) for use in the United States.

STUDY DESIGN

This study includes medication abortion patients from a hospital-based clinic who had one of two modes of service delivery: (1) telemedicine with no physical exam or ultrasound; or (2) in-person with clinic-based exams and ultrasounds. We conducted a sequential approach to scale development including: (1) defining constructs and item generation; (2) expert reviews; (3) cognitive interviews (n = 12); (4) survey development and online survey data collection (N = 182, including 45 telemedicine patients and 137 in-person patients); and (5) psychometric analyses.

RESULTS

Exploratory factor analyses identified 29-items for the US-PCAC scale with three subscales: (1) Respect and Dignity (10 items), (2) Responsive and Supportive Care (nine items for the full scale, one additional mode-specific item each for in-person and telemedicine), and (3) Communication and Autonomy (10 items for the full scale, one additional item for telemedicine). The US-PCAC had high content, construct, and criterion validity. It also had high reliability, with a standardized alpha for the full 29-item US-PCAC scale of 0.95. The US-PCAC score was associated with overall satisfaction.

CONCLUSION

This study found high validity and reliability of a newly-developed person-centered abortion care scale for use in the US. As medication abortion provision expands, this scale can be used in quality improvement efforts.

IMPLICATIONS

This study found high validity and reliability of a newly-developed person-centered care scale for use in the United States for in-person and telemedicine medication abortion.

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.

Virtual Clinic Telehealth Abortion Services in the United States One Year After Dobbs: Landscape Review

BACKGROUND

Telehealth abortion has taken on a vital role in maintaining abortion access since the Dobbs v. Jackson Women's Health Organization Supreme Court decision. However, little remains known about the landscape of new telehealth-only virtual clinic abortion providers that have expanded since telehealth abortion first became widely available in the United States in 2021.

OBJECTIVE

This study aimed to (1) document the landscape of telehealth-only virtual clinic abortion care in the United States, (2) describe changes in the presence of virtual clinic abortion services between September 2022, following the Dobbs decision, and June 2023, and (3) identify structural factors that may perpetuate inequities in access to virtual clinic abortion care.

METHODS

We conducted a repeated cross-sectional study by reviewing web search results and abortion directories to identify virtual abortion clinics in September 2022 and June 2023 and described changes in the presence of virtual clinics between these 2 periods. In June 2023, we also described each virtual clinic's policies, including states served, costs, patient age limits, insurance acceptance, financial assistance available, and gestational limits.

RESULTS

We documented 11 virtual clinics providing telehealth abortion care in 26 states and Washington DC in September 2022. By June 2023, 20 virtual clinics were providing services in 27 states and Washington DC. Most (n=16) offered care to minors, 8 provided care until 10 weeks of pregnancy, and median costs were US $259. In addition, 2 accepted private insurance and 1 accepted Medicaid, within a limited number of states. Most (n=16) had some form of financial assistance available.

CONCLUSIONS

Virtual clinic abortion providers have proliferated since the Dobbs decision. We documented inequities in the availability of telehealth abortion care from virtual clinics, including age restrictions that exclude minors, gestational limits for care, and limited insurance and Medicaid acceptance. Notably, virtual clinic abortion care was not permitted in 11 states where in-person abortion is available.

An assessment of clinical outcomes of medication abortion without pretreatment ultrasonography in Planned Parenthood, United States, 2020-2021

OBJECTIVES

Routine ultrasound before medication abortion (MAB) may create an impediment to expanding abortion access. This study examines clinical outcomes of MAB without pretreatment ultrasound evaluation at Planned Parenthood health centers in multiple states.

STUDY DESIGN

We conducted a secondary analysis of data from 23 US-based Planned Parenthood affiliates that provided MAB without pretreatment ultrasound for eligible patients from March 2020 to December 2021. Affiliates aggregated electronic health record data from MABs at ≤77 days gestation (based on self-report of last menstrual period) without a pretreatment ultrasound (N = 18,041). Among MABs with known outcomes (N = 9821), we calculated the incidence rates and 95% confidence intervals (CI) for completed abortion, ongoing pregnancy, subsequent procedure, emergency department/hospital visits associated with MAB, ectopic pregnancies, and gestational duration greater than 77 days.

RESULTS

Among MABs with known outcomes, 96.3% had a complete abortion (95% CI = 95.9%-96.7%), and 2.0% had an ongoing pregnancy (95% CI = 1.7%-2.3%). Four percent had a subsequent procedure (95% CI = 3.6%-4.4%), and 2.3% had a documented emergency department/hospital visit (95% CI = 2.0%-2.6%). Less than 1% had a confirmed ectopic pregnancy (0.15%, 95% CI = 0.09%-0.25%) and had a gestational duration later identified to be greater than 77 days (0.13%, 95% CI = 0.05%-0.29%).

CONCLUSIONS

Our calculated incidence rates of clinical outcomes align with rates from the previous literature on MAB and from the emerging literature on MAB without pretreatment ultrasonography. Findings from this analysis suggest that MAB without pretreatment ultrasound is safe and effective for eligible patients.

IMPLICATIONS

This large US study found that medication abortion without pretreatment ultrasonography results in similar clinical outcomes to prepandemic models that include pretreatment ultrasonography. Medication abortion without a pretreatment ultrasound may be adopted by abortion providers seeking to expand options for their patients as access to abortion continues to erode.

Brief of over 300 reproductive health researchers as Amici Curiae in FDA v. Alliance for Hippocratic Medicine

On January 30, 2024, over 300 researchers filed an amicus brief in FDA v. Alliance for Hippocratic Medicine, a United States (US) Supreme Court case that could have severely impacted access to mifepristone, one of the two drugs commonly used in medication abortion. The researchers summarize the legal challenges to the US Food and Drug Administration's (FDA's) original approval of mifepristone in 2000 and its 2016 and 2021 decisions modifying mifepristone's Risk Evaluation and Mitigation Strategy (REMS) Program and label, the responses from the FDA and drug manufacturer to the challenges, and the potential implications of the Court's decision on access to mifepristone in the US. The researchers detail how the FDA relied on a robust scientific record analyzing tens of thousands of patient experiences that conclusively demonstrated the safety and effectiveness of the changes to the mifepristone REMS Program and label and urge the Supreme Court to rely on the clear scientific record and preserve access to mifepristone without reimposing restrictions. What follows is a reprint of this brief.

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.

Effectiveness and safety of telehealth medication abortion in the USA

Telehealth abortion has become critical to addressing surges in demand in states where abortion remains legal but evidence on its effectiveness and safety is limited. California Home Abortion by Telehealth (CHAT) is a prospective study that follows pregnant people who obtained medication abortion via telehealth from three virtual clinics operating in 20 states and Washington, DC between April 2021 and January 2022. Individuals were screened using a standardized no-test protocol, primarily relying on their medical history to assess medical eligibility. We assessed effectiveness, defined as complete abortion after 200 mg mifepristone and 1,600 μg misoprostol (or lower) without additional intervention; safety was measured by the absence of serious adverse events. We estimated rates using multivariable logistic regression and multiple imputation to account for missing data. Among 6,034 abortions, 97.7% (95% confidence interval (CI) = 97.2-98.1%) were complete without subsequent known intervention or ongoing pregnancy after the initial treatment. Overall, 99.8% (99.6-99.9%) of abortions were not followed by serious adverse events. In total, 0.25% of patients experienced a serious abortion-related adverse event, 0.16% were treated for an ectopic pregnancy and 1.3% abortions were followed by emergency department visits. There were no differences in effectiveness or safety between synchronous and asynchronous models of care. Telehealth medication abortion is effective, safe and comparable to published rates of in-person medication abortion care.

Patient Acceptability of Telehealth Medication Abortion Care in the United States, 2021‒2022: A Cohort Study

Objectives. Despite the recent expansion of direct-to-patient telehealth abortion care in the United States, patient experiences with the service are not well understood. Methods. We described care experiences of 1600 telehealth abortion patients in 2021 to 2022 and used logistic regression to explore differences by race or ethnicity and between synchronous (phone or video) and asynchronous (secure messaging) telehealth abortion care. Results. Most patients trusted the provider (98%), felt telehealth was the right decision (96%), felt cared for (92%), and were very satisfied (89%). Patients most commonly cited privacy (76%), timeliness (74%), and staying at home (71%) as benefits. The most commonly reported drawback was initial uncertainty about whether the service was legitimate (38%). Asian patients were less likely to be very satisfied than White patients (79% vs 90%; P = .008). Acceptability was high for both synchronous and asynchronous care. Conclusions. Telehealth abortion care is highly acceptable, and benefits include privacy and expediency. Public Health Implications. Telehealth abortion can expand abortion access in an increasingly restricted landscape while maintaining patient-centered care. (Am J Public Health. 2024;114(2):241-250. https://doi.org/10.2105/AJPH.2023.307437).

Potential demand for and access to medication abortion among North Carolina college students

OBJECTIVE

To estimate demand for medication abortion (MAB) among North Carolina (NC) college students and describe access to nearest clinics offering MAB to each campus.

METHODS

We calculated demand using 2019-2020 campus demographics and NC abortion statistics. We used a mystery client technique to gather MAB cost and appointment wait times at the closest clinics and calculated travel distances and times.

RESULTS

We estimated that 2,517 NC students seek MAB annually. Twenty-one clinics were closest to NC's 111 colleges and universities, including five in neighboring states. Mean cost was $450, with an average wait time of six days to appointment. The average round-trip travel distance was 58 miles and time to the nearest clinic was 84 min by car.

CONCLUSIONS

Many NC college students likely obtain MAB every year and face high costs, long wait times and distances to care, which has likely worsened after the overturning 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 Role of Telehealth in Promoting Equitable Abortion Access in the United States: Spatial Analysis

BACKGROUND

Even preceding the Supreme Court's 2022 Dobbs v. Jackson Women's Health Organization decision, patients in the United States faced exceptional barriers to reach abortion providers. Abortion restrictions disproportionately limited abortion access among people of color, young people, and those living on low incomes. Presently, clinics in states where abortion remains legal are experiencing an influx of out-of-state patients and wait times for in-person appointments are increasing. Direct-to-patient telehealth for abortion care has expanded since its introduction in the United States in 2020. However, the role of this telehealth model in addressing geographic barriers to and inequities in abortion access remains unclear.

OBJECTIVE

We sought to examine the amount of travel that patients averted by using telehealth for abortion care, and the role of telehealth in mitigating inequities in abortion access by race or ethnicity, age, pregnancy duration, socioeconomic status, rural residence, and distance to a facility.

METHODS

We used geospatial analyses and data from patients in the California Home Abortion by Telehealth Study, residing in 31 states and Washington DC, who obtained telehealth abortion care at 1 of 3 virtual abortion clinics. We used patients' residential ZIP code data and data from US abortion facility locations to document the round-trip driving distance in miles, driving time, and public transit time to the nearest abortion facility that patients averted by using telehealth abortion services from April 2021 to January 2022, before the Dobbs decision. We used binomial regression to assess whether patients reported that telehealth was more likely to make it possible to access a timely abortion among patients of color, those experiencing food insecurity, younger patients, those with longer pregnancy durations, rural patients, and those residing further from their closest abortion facility.

RESULTS

The 6027 patients averted a median of 10 (IQR 5-26) miles and 25 (IQR 14-46) minutes of round-trip driving, and 1 hour 25 minutes (IQR 46 minutes to 2 hours 30 minutes) of round-trip public transit time. Among a subsample of 1586 patients surveyed, 43% (n=683) reported that telehealth made it possible to obtain timely abortion care. Telehealth was most likely to make it possible to have a timely abortion for younger patients (prevalence ratio [PR] 1.4, 95% CI 1.2-1.6) for patients younger than 25 years of age compared to those 35 years of age or older), rural patients (PR 1.4, 95% CI 1.2-1.6), those experiencing food insecurity (PR 1.3, 95% CI 1.1-1.4), and those who averted over 100 miles of driving to their closest abortion facility (PR 1.6, 95% CI 1.3-1.9).

CONCLUSIONS

These findings support the role of telehealth in reducing abortion-related travel barriers in states where abortion remains legal, especially among patient populations who already face structural barriers to abortion care. Restrictions on telehealth abortion threaten health equity.

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.

Implications of using home urine pregnancy tests versus facility-based tests for assessment of outcome following medication abortion provided via telemedicine

OBJECTIVES

To assess whether planning high-sensitivity urine pregnancy tests (HSPT) rather than facility-based tests for medication abortion follow-up may increase risk of unplanned clinical visits or procedural completion of the abortion.

STUDY DESIGN

We used data from the TelAbortion Project, a 5-year study assessing the safety and feasibility of providing mifepristone and misoprostol by telemedicine and mail in the United States. We categorized participants by whether the pretreatment follow-up plan included HSPT at home 3-5 weeks after treatment or facility-based tests (ultrasound or serum human chorionic gonadotropin) within 2 weeks after treatment. We used multivariable logistic regression to compare likelihood of post-treatment unplanned, abortion-related clinical visits and procedural intervention in these groups.

RESULTS

Of 1324 patients who planned HSPT follow-up and 576 who planned facility-based tests, 85% and 83%, respectively, provided outcome information. Post-treatment clinical visits were less frequent in the HSPT group (19%) than in the facility-based test group (79%); most of the latter were to obtain the planned test. However, unplanned, abortion-related visits were significantly more common in the HSPT group (adjusted risk difference: 6.5%; p < 0.01). The likelihood of procedural completion did not differ by group. Planned follow-up test was not associated with delay in procedural completion or detection of ongoing pregnancy.

CONCLUSIONS

Follow-up of medication abortion with home HSPT was associated with fewer post-treatment clinical visits, modestly more unplanned, abortion-related clinical visits, and no increase in the risk of procedural interventions or delayed identification or management of treatment failures. This option is an appropriate follow-up approach after medication abortion.

IMPLICATIONS

Use of home high-sensitivity pregnancy tests rather than facility-based tests for outcome assessment after medication abortion is associated with a modest increase in unplanned clinical visits but does not lead to an increase in procedural interventions or delays identification and management of treatment failure.

History and Politics of Medication Abortion in the United States and the Rise of Telemedicine and Self-Managed Abortion

This article examines the decades-long campaign to increase access to abortion pills in the United States, including advocates' work to win US Food and Drug Administration approval of mifepristone and misoprostol for abortion, the continuing restrictions on mifepristone, and the multiple strategies advocates have pursued to challenge these restrictions, including lobbying the FDA to remove the restrictions, obtaining a limited research exemption from FDA restrictions, and suing the FDA during the COVID-19 pandemic. The article pays particular attention to the influence of research conducted on the safety and efficacy of medication abortion as well as research on the impact of increased availability of abortion pills through telemedicine during the pandemic. The article also addresses self-managed abortion, wherein people obtain and use mifepristone and/or misoprostol outside the formal health care system, and it documents the growing network of organizations providing logistical, medical, and legal support to people self-managing abortion. The article concludes with reflections on the role abortion pills might play in the post-Roe era amid increasingly divergent abortion access trends across different regions of the United States.

Medication abortion via digital health in the United States: a systematic scoping review

Digital health, including telemedicine, has increased access to abortion care. The convenience, flexibility of appointment times, and ensured privacy to abortion users may make abortion services via telemedicine preferable. This scoping review systematically mapped studies conducted on abortion services via telemedicine, including their effectiveness and acceptability for abortion users and providers. All published papers included abortion services via telemedicine in the United States were considered. Articles were searched in PubMed, CINAHL, and Google Scholar databases in September 2022. The findings were synthesized narratively, and the PRISMA-ScR guidelines were used to report this study. Out of 757 retrieved articles, 33 articles were selected based on the inclusion criteria. These studies were published between 2011 and 2022, with 24 published in the last 3 years. The study found that telemedicine increased access to abortion care in the United States, especially for people in remote areas or those worried about stigma from in-person visits. The effectiveness of abortion services via telemedicine was comparable to in-clinic visits, with 6% or fewer abortions requiring surgical intervention. Both care providers and abortion seekers expressed positive perceptions of telemedicine-based abortion services. However, abortion users reported mixed emotions, with some preferring in-person visits. The most common reasons for choosing telemedicine included the distance to the abortion clinic, convenience, privacy, cost, flexibility of appointment times, and state laws imposing waiting periods or restrictive policies. Telemedicine offered a preferable option for abortion seekers and providers. The feasibility of accessing abortion services via telemedicine in low-resource settings needs further investigation.

Mailing abortion pills does not delay care: A cohort study comparing mailed to in-person dispensing of abortion medications in the United States

OBJECTIVE

Given the substantial barriers to abortion access in the United States, many clinics now mail patients abortion medications. We examined whether dispensing the medications by mail prolonged time to medication use.

STUDY DESIGN

We analyzed data from no-test medication abortions with medication provided either by mail or in a clinic from 11 United States clinics from February 2020 to January 2021. We examined mean number of days from patients' first contact with the clinic to mifepristone ingestion, its two-component intervals (first contact to medication dispensing and dispensing to mifepristone ingestion), and pregnancy duration at mifepristone ingestion. We used Poisson regression to compare mean outcomes across three dispensing methods: in-person, mailed from the clinic, and mailed from a mail-order pharmacy.

RESULTS

Among the 2600 records, patients took mifepristone on average at 49 days of gestation (95% CI, 47-51) and 7 days (95% CI, 4-10) after first contact. Mean time from first contact to mifepristone ingestion was 6 days when medications were dispensed in-person and 9 days when mailed (p = 0.38). While time from first contact to dispensing was similar across methods (6 days in-person, 5 days mailed, p = 0.77), more time elapsed from dispensing to mifepristone ingestion when medications were mailed (4 days from clinic, 5 days from mail-order pharmacy) versus dispensed in-person (0.3 days, p < 0.001). Time to mifepristone ingestion was shorter with higher pregnancy duration. Pregnancy duration at ingestion was similar across methods (48 days in-person, 50 days mailed).

CONCLUSIONS

Mailing medications did not significantly prolong time from patients' first contact with the clinic to mifepristone ingestion or increase pregnancy duration at mifepristone ingestion.

IMPLICATIONS

Abortion providers should offer a range of medication abortion dispensing options, prioritizing patient preference.

Abortion Care in the United States - Current Evidence and Future Directions

Abortion Care in the United StatesAbortion services are a vital component of reproductive health care. Jung and colleagues review medication abortion and procedural abortion as well as implications of increasing restrictions on access in the United States.

An examination of loss to follow-up and potential bias in outcome ascertainment in a study of direct-to-patient telemedicine abortion in the United States

OBJECTIVES

To examine associations between factors associated with loss to follow-up and effectiveness in the TelAbortion project, which provided medication abortion by direct-to-patient telemedicine and mail in the United States.

STUDY DESIGN

The study population for this descriptive analysis included abortions among participants enrolled in the TelAbortion study with data present in a web-based database tool from November 2018 to September 2021 who were mailed a medication package. The analysis included information on abortions across nine sites. In this analysis, we used generalized estimating equations to examine factors associated with loss to follow-up and effectiveness.

RESULTS

Of the 1831 abortions included in this analysis, 1553 (84.8%) were classified as having complete follow-up and 278 (15.2%) were classified as lost to follow-up. In a multivariable analysis, factors significantly associated with loss to follow-up included history of medical abortion, education, gestational age, study site, and whether the TelAbortion was performed pre- or post-COVID-19 onset (p < 0.05). The rate of treatment failure (i.e., abortions resulting in continuing pregnancy or uterine evacuation) reported in this study was 5.1%. The only covariate associated with both loss to follow-up and treatment failure was higher gestational age. However, using gestational age to impute missing abortion outcomes did not substantially change the estimated failure rate.

CONCLUSIONS

Abortions that were lost to follow-up differed substantially from those with complete follow-up, which could bias the effectiveness estimate. However, imputing outcomes based on available and appropriate pretreatment data did not substantially affect the estimate. This finding is encouraging, although it does not exclude the possibility of bias due to unmeasured factors.

IMPLICATIONS

Significant differences between abortion cases with complete follow-up and those lost to follow-up provide insights into abortion cases that may be at a higher risk for being lost. The low treatment failure rate indicates that the telemedicine provision of medication abortion is effective.

No-Test Medication Abortion: A Systematic Review

OBJECTIVE

To summarize the effectiveness and safety outcomes of medication abortion performed without prior pelvic examination or ultrasonogram ("no-test medication abortion").

DATA SOURCES

We searched the MEDLINE, Scopus, Web of Science, Cochrane (including ClinicalTrials.gov), CINAHL, Global Index Medicus, and CAB Direct databases to identify relevant studies published before April 2022 using a peer-reviewed search strategy including terms such as "medication abortion" and "ultrasonography." We contacted experts in the field for unpublished data and ongoing studies.

METHODS OF STUDY SELECTION

We reviewed 2,423 studies using Colandr. We included studies if they presented clinical outcomes of medication abortion performed with mifepristone and misoprostol and without prior pelvic examination or ultrasonogram. We excluded studies with duplicate data. We abstracted successful abortion rates overall, as well as rates by gestational age through 63 days, 70 days and past 84 days. We abstracted complication rates, including the need for surgical evacuation, additional medications, blood transfusion, and ectopic pregnancy.

TABULATION, INTEGRATION AND RESULTS

We included 21 studies with a total of 10,693 patients with outcome data reported. The overall efficacy of no-test medication abortion was 96.4%; 93.8% (95% CI 92.8-94.6%) through 63 days of gestation and 95.2% (95% CI 94.7-95.7%) through 70 days of gestation. The overall rate of surgical evacuation was 4.4% (95% CI 4.0-4.9), need for additional misoprostol 2.2% (95% CI 1.8-2.6), blood transfusion 0.5% (95% CI 0.3-0.6), and ectopic pregnancy 0.06% (95% CI 0.02-0.15).

CONCLUSION

Medication abortion performed without prior pelvic examination or ultrasonogram is a safe and effective option for pregnancy termination.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021240739.

"I don't regret it at all. It's just I wish the process had a bit more humanity to it … a bit more holistic": a qualitative, community-led medication abortion study with Black and Latinx Women in Georgia, USA

Traditional family planning research has excluded Black and Latinx leaders, and little is known about medication abortion (MA) among racial/ethnic minorities, although it is an increasingly vital reproductive health service, particularly after the fall of Roe v. Wade. Reproductive justice (RJ) community-based organisation (CBO) SisterLove led a study on Black and Latinx women's MA perceptions and experiences in Georgia. From April 2019 to December 2020, we conducted key informant interviews with 20 abortion providers and CBO leaders and 32 in-depth interviews and 6 focus groups (n = 30) with Black and Latinx women. We analysed data thematically using a team-based, iterative approach of coding, memo-ing, and discussion. Participants described multilevel barriers to and strategies for MA access, wishing that "the process had a bit more humanity  …  [it] should be more holistic." Barriers included (1) sociocultural factors (intersectional oppression, intersectional stigma, and medical experimentation); (2) national and state policies; (3) clinic- and provider-related factors (lack of diverse clinic staff, long waiting times); and (4) individual-level factors (lack of knowledge and social support). Suggested solutions included (1) social media campaigns and story-sharing; (2) RJ-based policy advocacy; (3) diversifying clinic staff, offering flexible scheduling and fees, community integration of abortion, and RJ abortion funds; and (4) social support (including abortion doulas) and comprehensive sex education. Findings suggest that equitable MA access for Black and Latinx communities in the post-Roe era will require multi-level intervention, informed by community-led evidence production; holistic, de-medicalised, and human rights-based care models; and intersectional RJ policy advocacy.

A telemedicine model for abortion in South Africa: a randomised, controlled, non-inferiority trial

BACKGROUND

Telemedicine for medical abortion increases access to safe abortion but its use has not been described in a controlled trial. We aimed to investigate the effectiveness, adherence, safety, and acceptability of a modified telemedicine protocol for abortion compared with standard care in a low-resource setting.

METHODS

In this randomised, controlled, non-inferiority trial we recruited women seeking medical abortion at or before 9 gestational weeks at four public health clinics in South Africa. Participants were randomly allocated (1:1) by computer-generated blocks of varying sizes to telemedicine or standard care. The telemedicine group received asynchronous online abortion consultation and instruction, self-assessed gestational duration, and had a uterine palpation as a safety measure. Participants in this group took 200 mg mifepristone and 800 μg misoprostol at home. The standard care group received in-person consultation and instruction together with an ultrasound, took 200 mg mifepristone in clinic and 800 μg misoprostol at home. Our primary outcome was complete abortion after initial treatment, assessed at a 6-week interview. Our non-inferiority margin was 4%. Group differences were assessed by modified intention-to-treat (mITT) analysis and per protocol. The trial is registered at ClinicalTrials.gov, NCT04336358, and the Pan African Clinical Trials Registry, PACTR202004661941593.

FINDINGS

Between Feb 28, 2020, and Oct 5, 2021, we enrolled 900 women, 153 (17·0%) of whom were discontinued before the abortion and were not included in the analysis. By mITT analysis, 355 (95·4%) of 372 women in the telemedicine group had a complete abortion compared with 338 (96·6%) of 350 in the standard care group (odds ratio 0·74 [95% CI 0·35 to 1·57]). The risk difference was -1·1% (-4·0 to 1·7). Among women who completed treatment as allocated (per protocol), 327 (95·6%) of 342 women in telemedicine group had complete abortion, compared with 338 (96·6%) of 350 in the standard care group (0·77 [0·36 to 1·68]), with a risk difference of -1·0% (-3·8 to 1·9). One participant (in the telemedicine group) had a ruptured ectopic pregnancy, and a further four participants were admitted to hospital (two in each group), of whom two had blood transfusions (one in each group).

INTERPRETATION

Asynchronous online consultation and instruction for medical abortion and home self-medication, with uterine palpation as the only in-person component, was non-inferior to standard care with respect to rates of complete abortion, and did not affect safety, adherence, or satisfaction.

FUNDING

Grand Challenges Canada and the Swedish Research Council.

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.