Adoption of no-test and telehealth medication abortion care among independent abortion providers in response to COVID-19

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.

Estimating the cost of Rh testing and prophylaxis in early pregnancy: A time-driven activity-based costing study

OBJECTIVE

To estimate the cost of Rhesus (Rh) testing and prophylaxis for first-trimester vaginal bleeding in the ambulatory setting.

STUDY DESIGN

We used time-driven, activity-based costing to analyze tasks associated with Rh testing and prophylaxis of first-trimester vaginal bleeding at one hospital-based outpatient and two independent reproductive health clinics. At each site, we observed 10 patients undergoing Rh-typing and two patients undergoing Rh prophylaxis. We computed the costs of blood Rh-typing by both fingerstick and phlebotomy, cost of locating previous blood type in the electronic health record (available for 69.8% of hospital-based patients), and costs associated with Rh immune globulin prophylaxis. All costs are reported in 2021 US dollars.

RESULTS

The hospital-based clinic reviewed the electronic health record to confirm Rh-status (cost, $26.18 per patient) and performed a phlebotomy, at $47.11 per patient, if none was recorded. The independent clinics typed blood by fingerstick, at a per-patient cost of $4.07. Rh-immune globulin administration costs, including the medication, were similar across facilities, at a mean of $145.66 per patient. Projected yearly costs for testing and prophylaxis were $55,831 for the hospital-based clinic, which was the lowest-volume site, $47,941 for Clinic A, which saw 150 patients/month, and $185,654 for Clinic B, which saw 600 patients/month.

CONCLUSIONS

Rh testing and prophylaxis for first-trimester vaginal bleeding generates considerable costs for outpatient facilities, even for Rh-positive patients with a prior blood type on record.

IMPLICATIONS

Rh testing and prophylaxis for first-trimester bleeding generate considerable costs even for Rh-positive patients and those with a previously known blood type. These findings highlight the need to reconsider this practice, which is no longer supported by evidence and already safely waived in multiple medical settings in the United States and around the world.

Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion After In-Person Screening

Importance

Before 2021, the US Food and Drug Administration required mifepristone to be dispensed in person, limiting access to medication abortion.

Objective

To estimate the effectiveness, acceptability, and feasibility of dispensing mifepristone for medication abortion using a mail-order pharmacy.

Design, Setting, and Participants

This prospective cohort study was conducted from January 2020 to May 2022 and included 11 clinics in 7 states (5 abortion clinics and 6 primary care sites, 4 of which were new to abortion provision). Eligible participants were seeking medication abortion at 63 or fewer days' gestation, spoke English or Spanish, were age 15 years or older, and were willing to take misoprostol buccally. After assessing eligibility for medication abortion through an in-person screening, mifepristone and misoprostol were prescribed using a mail-order pharmacy. Patients had standard follow-up care with the clinic. Clinical information was collected from medical records. Consenting participants completed online surveys about their experiences 3 and 14 days after enrolling. A total of 540 participants were enrolled; 10 withdrew or did not take medication. Data were analyzed from August 2022 to December 2023.

Intervention

Mifepristone, 200 mg, and misoprostol, 800 µg, prescribed to a mail-order pharmacy and mailed to participants instead of dispensed in person.

Main Outcomes and Measures

Proportion of patients with a complete abortion with medications only, reporting satisfaction with the medication abortion, and reporting timely delivery of medications.

Results

Clinical outcome information was obtained and analyzed for 510 abortions (96.2%) among 506 participants (median [IQR] age, 27 [23-31] years; 506 [100%] female; 194 [38.3%] Black, 88 [17.4%] Hispanic, 141 [27.9%] White, and 45 [8.9%] multiracial/other individuals). Of these, 436 participants (85.5%; 95% CI, 82.2%-88.4%) received medications within 3 days. Complete abortion occurred after medication use in 499 cases (97.8%; 95% CI, 96.2%-98.9%). There were 24 adverse events (4.7%) for which care was sought for medication abortion symptoms; 3 patients (0.6%; 95% CI, 0.1%-1.7%) experienced serious adverse events requiring hospitalization (1 with blood transfusion); however, no adverse events were associated with mail-order dispensing. Of 477 participants, 431 (90.4%; 95% CI, 87.3%-92.9%) indicated that they would use mail-order dispensing again for abortion care, and 435 participants (91.2%; 95% CI, 88.3%-93.6%) reported satisfaction with the medication abortion. Findings were similar to those of other published studies of medication abortion with in-person dispensing.

Conclusions and Relevance

The findings of this cohort study indicate that mail-order pharmacy dispensing of mifepristone for medication abortion was effective, acceptable to patients, and feasible, with a low prevalence of serious adverse events. This care model should be expanded to improve access to medication abortion services.

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.

Pricing of medication abortion in the United States, 2021-2023

INTRODUCTION

Financial costs remain one of the greatest barriers to abortion, leading to delays in care and preventing some from getting a desired abortion. Medication abortion is available through in-person facilities and telehealth services. However, whether telehealth offers a more affordable option has not been well-documented.

METHODS

We used Advancing New Standards in Reproductive Health (ANSIRH)'s Abortion Facility Database, which includes data on all publicly advertising abortion facilities and is updated annually. We describe facility out-of-pocket prices for medication abortion in 2021, 2022, and 2023, comparing in-person and telehealth provided by brick-and-mortar and virtual clinics, and by whether states allowed Medicaid coverage for abortion.

RESULTS

The national median price for medication abortion remained consistent at $568 in 2021 and $563 in 2023. However, medications provided by virtual clinics were notably lower in price than in-person care and this difference widened over time. The median cost of a medication abortion offered in-person increased from $580 in 2021 to $600 by 2023, while the median price of a medication abortion offered by virtual clinics decreased from $239 in 2021 to $150 in 2023. Among virtual clinics, few (7%) accepted Medicaid. Median prices in states that accept Medicaid were generally higher than in states that did not.

DISCUSSION

Medication abortion is offered at substantially lower prices by virtual clinics. However, not being able to use Medicaid or other insurance may make telehealth cost-prohibitive for some people, even if prices are lower. Additionally, many states do not allow telehealth for abortion, deepening inequities in healthcare.

"Maybe if we weren't in the pandemic, I would have reconsidered": Experiences of abortion care-seeking during the COVID-19 pandemic in Maryland

OBJECTIVE

To understand the COVID-19 pandemic's impact on abortion care-seeking in Maryland, a state with Medicaid coverage for abortion, high service availability, and laws supporting abortion rights.

METHODS

We conducted semi-structured telephone interviews with 15 women who had an abortion between January 2021 and March 2022 at a hospital-based clinic in a mid-sized Maryland city. We purposively recruited participants with varied pandemic financial impacts. Interview questions prompted participants to reflect on how the pandemic affected their lives, pregnancy decisions, and experiences seeking abortion care. We analyzed our data for themes.

RESULTS

All participants had some insurance coverage for their abortion; over half paid using Medicaid. Many participants experienced pandemic financial hardship, with several reporting job, food, and housing insecurity as circumstances influencing their decision to have an abortion. Most women who self-reported minimal financial hardship caused by the pandemic indicated they sought an abortion for reasons unrelated to COVID-19. In contrast, women with economic hardship viewed their pregnancies as unsupportable due to COVID-19 exacerbating financial instability, even when they desired to continue the pregnancy. All participants expressed that having an abortion was the best decision for their lives. Yet, when making decisions about their pregnancy, the most financially disadvantaged women weighed their desires against the pandemic's constraints on their reproductive self-determination.

CONCLUSIONS

The pandemic changed abortion care-seeking circumstances even in a setting with minimal access barriers. Financial hardship influenced some women to have an abortion for a pregnancy that-while unplanned-they may have preferred to continue.

Abortion Training in Family Medicine Residency Programs: A National Survey of Program Directors 5 Months After the Dobbs Decision

BACKGROUND AND OBJECTIVES

Routine abortion training during family medicine (FM) residency leads to higher rates of postresidency provision; increased availability of abortion care in the FM setting could greatly improve access. Especially in the post-Dobbs context, understanding the landscape of abortion training in US family medicine residency programs (FMRPs) is critical.

METHODS

We invited all directors of US FMRPs accredited by the Accreditation Council for Graduate Medical Education to complete a larger omnibus online survey that included questions on abortion training. We compiled descriptive statistics and conducted χ2 tests and multivariate regression analyses to detect associations with abortion training.

RESULTS

The response rate was 42% (N=286). Nineteen percent of programs had routine medication abortion (MAB) training and 10% had routine aspiration training. In addition, 58% of programs offered elective MAB training and 52% offered elective aspiration training. In multivariate regression, the presence of abortion training was associated with a program having 31 or more residents, being in a state with protected abortion access, not having a Catholic affiliation, and having a program director who believed abortion training should be routine in FMRPs.

CONCLUSIONS

While more than half of responding FMRPs reported some abortion training, much of it was elective, and 40% of programs lacked abortion training completely. Although abortion training is severely limited or prohibited in states with abortion bans, more training opportunities in the states where abortion is possible could increase access to abortion within primary care.

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.

What attributes of abortion care affect people's decision-making? Results from a discrete choice experiment

OBJECTIVES

We aimed to measure both stated and experimentally "revealed" abortion provision preferences among US people with capacity for pregnancy.

STUDY DESIGN

In July 2022, we recruited US residents assigned female sex at birth and aged 18 to 55 years using Prolific, an online survey hosting platform. We asked participants what first-trimester abortion method and delivery model they would prefer. We also assessed abortion care preferences with a discrete choice experiment, which examined the relative importance of the following care attributes: method, distance, wait time for appointment, delivery model (telehealth vs in-clinic), and cost.

RESULTS

More than half of the 887 respondents (59%) self-reported a slight (22%) or strong (37%) preference for medication compared to aspiration abortion; 11% stated no preference. Our discrete choice experiment found that cost and wait time had a greater effect on hypothetical decision-making than did method and delivery model (discrete choice experiment average importances = 44.3 and 23.2, respectively, compared to 15.9 and 8.2, respectively). Simulations indicated that holding other attributes constant, respondents preferred medication to aspiration abortion and telehealth to in-clinic care.

CONCLUSIONS

This study, the first to examine abortion preferences in the United States, using a discrete choice experiment, demonstrates the importance of wait time and cost in abortion care decision-making. Our work indicates that for this population, factors related to health care financing and organization may matter more than clinical aspects of care.

IMPLICATIONS

Although people in this study preferred medication to aspiration abortion and telehealth to in-clinic care, wait time and cost of care played a greater role in care decision-making. Focusing solely on clinical aspects of care (i.e., method, delivery model) may ignore other attributes of care that are particularly important for potential patients.

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.

Catalyst for change: Lessons learned from overcoming barriers to providing safe abortion care in Médecins Sans Frontières projects

CONTEXT

Despite instituting a policy in 2004, Médecins Sans Frontières (MSF) continuously struggled to routinely provide safe abortion care (SAC). In 2016, the organization launched an initiative aimed at increasing availability of SAC in MSF projects and increasing understanding of abortion-related dynamics in humanitarian settings.

METHODOLOGY

From March 2017 to April 2018, MSF staff conducted support visits to 10 projects in a country in sub-Saharan Africa. Each visit followed a systematic approach with six key components and related tools that were later shared with teams worldwide. Data regarding women seeking abortion services and related outcomes were collected and analyzed retrospectively.

RESULTS

From Q1 2017 through Q4 2019, SAC provision increased significantly in all 10 projects, rising from three to 759 safe abortions per quarter. Teams received 3831 patients seeking SAC and provided 3640 first and second trimester abortions, over 99% via medication methods. The overall complication rate was 4.29% and 0.3% for severe, life-threatening complications. No major security incidents were reported. MSF provision of SAC worldwide increased from 781 in 2016 (the year before this initiative began) to 21,546 in 2019.

CONCLUSION

Implementation of SAC in humanitarian settings-even those with significant legal restrictions-is possible and necessary. Both first and second trimester medication abortion can be safely and effectively provided through both home- and facility-based models of care. Programmatic data provide valuable insights into abortion-related dynamics which must shape operational decision-making. Addressing internal barriers and providing direct field support were key to stimulating organizational cultural change.

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.

Changes in Induced Medical and Procedural Abortion Rates in a Commercially Insured Population, 2018 to 2022 : An Interrupted Time-Series Analysis

BACKGROUND

During the COVID-19 pandemic, access to in-person care was limited, and regulations requiring in-person dispensing of mifepristone for medical abortions were relaxed. The effect of the pandemic and accompanying regulatory changes on abortion use is unknown.

OBJECTIVE

To estimate changes in the incidence rate of induced medical and procedural abortions.

DESIGN

Serial cross-sectional study with interrupted time-series analyses.

SETTING

Commercially insured persons in the United States.

PARTICIPANTS

Reproductive-aged women.

INTERVENTION

Onset of the COVID-19 pandemic in March 2020 and subsequent regulatory changes affecting the in-person dispensing requirement for mifepristone.

MEASUREMENTS

Monthly age-adjusted incidence rates of medical and procedural abortions were measured among women aged 15 to 44 years from January 2018 to June 2022. Medical abortions were classified as in-person or telehealth. Linear segmented time-series regression was used to calculate changes in abortion rates after March 2020.

RESULTS

In January 2018, the estimated age-adjusted monthly incidence rate of abortions was 151 per million women (95% CI, 142 to 161 per million women), with equal rates of medical and procedural abortions. After March 2020, there was an immediate 14% decrease in the monthly incidence rate of abortions (21 per million women [CI, 7 to 35 per million women]; P = 0.004), driven by a 31% decline in procedural abortions (22 per million women [CI, 16 to 28 per million women]; P < 0.001). Fewer than 4% of medical abortions each month were administered via telehealth.

LIMITATION

Only abortions reimbursed by commercial insurance were measured.

CONCLUSION

The incidence rate of procedural abortions declined during the COVID-19 pandemic, and this lower rate persisted after other elective procedures rebounded to prepandemic rates. Despite removal of the in-person dispensing requirement for mifepristone, the use of telehealth for insurance-covered medical abortions remained rare. Amid increasing state restrictions, commercial insurers have the opportunity to increase access to abortion care, particularly via telehealth.

PRIMARY FUNDING SOURCE

Health Resources and Services Administration.

Mifepristone use for early pregnancy loss: A qualitative study of barriers and facilitators among OB/GYNS in Massachusetts, USA

CONTEXT

Early pregnancy loss (EPL) affects 1 million patients in the United States (US) annually, but integration of mifepristone into EPL care may be complicated by regulatory barriers, practice-related factors, and abortion stigma.

METHODS

We conducted qualitative, semi-structured interviews among obstetrician-gynecologists in independent practice in Massachusetts, US on mifepristone use for EPL. We recruited participants via professional networks and purposively sampled for mifepristone use, practice type, time in practice, and geographic location within Massachusetts until we reached thematic saturation. We analyzed interviews using inductive and deductive coding under a thematic analysis framework to identify facilitators of and barriers to mifepristone use.

RESULTS

We interviewed 19 obstetrician-gynecologists; 12 had used mifepristone for EPL and 7 had not. Participants were in private practice (n = 12), academic practice (n = 6), or worked at a federally qualified health center (n = 1). Seven had fellowship training, including four in complex family planning. The most common facilitators of mifepristone use for EPL were access to the expertise or protocols of local-regional experts, leadership from a "champion," prior experience with abortion care, and hospital capacity constraints during the COVID-19 pandemic. The most common barriers were related to the Mifepristone Risk Evaluation and Mitigation Strategy (REMS) Program imposed by the US Food and Drug Administration (FDA). Additionally, mifepristone's affiliation with abortion was a barrier to its use in EPL for some obstetrician-gynecologists.

CONCLUSION

The FDA Mifepristone REMS Program presents substantial barriers to obstetrician-gynecologists incorporating mifepristone into their EPL care.

Demand for medication abortion among public university students in Washington

Provision of medication abortion in student health centers is safe and effective, but no public universities in Washington state provide such services. We estimate demand for medication abortion and describe barriers to care among students at four-year public universities in Washington. Using publicly available data, we estimated that students at the 11 Washington public universities obtained between 549 and 932 medication abortions annually. Students must travel an average of 16 miles (range:1-78) or 73 minutes via public transit (range:22-284) round trip to the nearest abortion-providing facility. Average wait time for the first available appointment was 10 days (range:4-14), and average cost was $711. Public universities can play an integral role in expanding abortion access post-Dobbs by providing medication abortion, effectively reducing barriers to care for students. The state legislature can pass legislation requiring universities to provide medication abortion, similar to what other states also protective of abortion rights have done.

Person-centred sexual and reproductive health: A call for standardized measurement

Person-centred sexual and reproductive health (PCSRH) care refers to care that is respectful of and responsive to people's preferences, needs, and values, and which empowers them to take charge of their own sexual and reproductive health (SRH). It is an important indicator of SRH rights and quality of care. Despite the recognition of the importance of PCSRH, there is a gap in standardized measurement in some SRH services, as well as a lack of guidance on how similar person-centred care measures could be applied across the SRH continuum. Drawing on validated scales for measuring person-centred family planning, abortion, prenatal and intrapartum care, we propose a set of items that could be validated in future studies to measure PCSRH in a standardized way. A standardized approach to measurement will help highlight gaps across services and facilitate efforts to improve person-centred care across the SRH continuum. PATIENT OR PUBLIC CONTRIBUTION: This viewpoint is based on a review of validated scales that were developed through expert reviews and cognitive interviews with services users and providers across the different SRH services. They provided feedback on the relevance, clarity, and comprehensiveness of the items in each scale.

"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.

An exploratory study of COVID-19-related changes in abortion service availability and use in Washington, DC, Maryland, and Virginia

OBJECTIVES

This exploratory study aimed to assess COVID-19-related changes in abortion service availability and use in Washington, DC, Maryland, and Virginia.

DESIGN

Data came from a convenience sample of eight abortion clinics in this region. We implemented a cross-sectional survey and collected retrospective aggregate monthly abortion data overall and by facility type, abortion type, and patient characteristics for March 2019-August 2020. We evaluated changes in the distribution of the total number of patients for March-August in 2019 compared to March-August 2020. We also conducted segmented regression analyses and produced scatter plots of monthly abortion patients overall and by facility type, abortion type, and patient characteristics, with separate fitted regression lines from the segmented regression models for the pre- and during-COVID-19 periods.

RESULTS

Five clinics reported a reduced number of appointments early in the pandemic while four reported increased call volume. There were declines in the monthly abortion trend at hospital-based clinics at the outset of the pandemic. Monthly number of medication abortions increased from March 2020 through August 2020 compared to pre-COVID-19 trends while instrumentation abortions 11 up to 19 weeks decreased. The share of abortions to Black individuals increased during the early phase of the pandemic, as did the monthly trend in abortions among this group. We also saw changes in payment type, with declines in patients paying out-of-pocket.

CONCLUSIONS

Results revealed differences in abortion services, numbers, and types during the early stages of the COVID-19 pandemic in Washington, DC, Maryland, and Virginia.

Fear of procedure and pain in individuals considering abortion: A qualitative study

OBJECTIVES

To explore concerns about procedural abortion and abortion-related pain in a cohort searching for abortion online.

METHODS

The Google Ads Abortion Access Study was a national longitudinal cohort study that recruited people searching for abortion online. Participants completed a baseline demographic survey and a follow-up survey four weeks later evaluating barriers and facilitators to abortion. This qualitative study utilized thematic analysis to produce a descriptive narrative based on overarching themes about procedural abortion and abortion-related pain.

RESULTS

There were 57 separate mentions from 45 participants regarding procedural abortion or abortion-related pain. We identified two main themes: 1) concerns about the procedure (with subthemes, fear of procedural abortion, comparison to medication abortion, lack of sedation) and 2) abortion-related pain (with subthemes fear of abortion-related pain, experiences of pain, fear of complications and cost-barriers to pain control).

CONCLUSIONS

This study highlights the need for improved anticipatory guidance and accessible resources to assuage potential fears and misconceptions regarding abortion.

PRACTICE IMPLIACTIONS

Abortion resources, particularly online, should provide accurate and unbiased information about abortion methods and pain to help patients feel more prepared. Providers should be aware of potential concerns surrounding procedural abortion and pain when counseling patients presenting for care.

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.

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.

Experiences seeking, sourcing, and using abortion pills at home in the United States through an online telemedicine service

A growing number of people in the United States seek to self-manage their abortions by self-sourcing abortion medications online. Prior research focuses on people's motivations for seeking self-management of abortion and experiences trying to obtain medications. However, little is known about the experiences of people in the U.S. who actually complete a self-managed abortion using medications they self-sourced online. We conducted anonymous in-depth interviews with 80 individuals who sought abortion medications through Aid Access, the only online telemedicine service that provides abortion medications in all 50 U.S. states. Through grounded theory analysis we identified five key themes: 1) participants viewed Aid Access as a "godsend"; 2) Fears of scams, shipping delays, and surveillance made ordering pills online a "nerve-racking" experience; 3) a "personal touch" calmed fears and fostered trust in Aid Access; 4) participants were worried about the "what ifs" of the self-managed abortion experience; and 5) overall, participants felt that online telemedicine met their important needs. Our findings demonstrate that online telemedicine provided by Aid Access not only provided a critical service, but also offered care that participants deemed legitimate and trustworthy.

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.

Improving experience of medical abortion at home in a changing therapeutic, technological and regulatory landscape: a realist review

OBJECTIVE

To inform UK service development to support medical abortion at home, appropriate for person and context.

DESIGN

Realist review SETTING/PARTICIPANTS: Peer-reviewed literature from 1 January 2000 to 9 December 2021, describing interventions or models of home abortion care. Participants included people seeking or having had an abortion.

INTERVENTIONS

Interventions and new models of abortion care relevant to the UK.

OUTCOME MEASURES

Causal explanations, in the form of context-mechanism-outcome configurations, to test and develop our realist programme theory.

RESULTS

We identified 12 401 abstracts, selecting 944 for full text assessment. Our final review included 50 papers. Medical abortion at home is safe, effective and acceptable to most, but clinical pathways and user experience are variable and a minority would not choose this method again. Having a choice of abortion location remains essential, as some people are unable to have a medical abortion at home. Choice of place of abortion (home or clinical setting) was influenced by service factors (appointment number, timing and wait-times), personal responsibilities (caring/work commitments), geography (travel time/distance), relationships (need for secrecy) and desire for awareness/involvement in the process. We found experiences could be improved by offering: an option for self-referral through a telemedicine consultation, realistic information on a range of experiences, opportunities to personalise the process, improved pain relief, and choice of when and how to discuss contraception.

CONCLUSIONS

Acknowledging the work done by patients when moving medical abortion care from clinic to home is important. Patients may benefit from support to: prepare a space, manage privacy and work/caring obligations, decide when/how to take medications, understand what is normal, assess experience and decide when and how to ask for help. The transition of this complex intervention when delivered outside healthcare environments could be supported by strategies that reduce surprise or anxiety, enabling preparation and a sense of control.

Geographic disparities in disruptions to abortion care in Louisiana at the onset of the COVID-19 pandemic

OBJECTIVES

Prior research identified a significant decline in the number of abortions in Louisiana at the onset of the COVID-19 pandemic, as well as increases in second-trimester abortions and decreases in medication abortions. This study examines how service disruptions in particular areas of the state disparately affected access to abortion care based on geography.

STUDY DESIGN

We collected monthly service data from Louisiana's abortion clinics (January 2018-May 2020) and conducted mystery client calls to determine whether clinics were scheduling appointments at pandemic onset (April-May 2020). We used segmented regression to assess whether service disruptions modified the main pandemic effects on the number, timing, and type of abortions using stratified models and interaction terms. Additionally, we calculated the median distance that Louisiana residents traveled to the clinic where they obtained care.

RESULTS

For residents whose closest clinic was consistently scheduling appointments at the onset of the pandemic, the number of monthly abortions did not change (IRR = 1.07, 95% CI: 0.84-1.36). For those whose closest clinic services were disrupted, the number of monthly abortions decreased by 46% (IRR = 0.54, 95% CI: 0.45-0.65). Similarly, increases in second-trimester abortions and decreases in medication abortions were concentrated in areas where residents experienced service disruptions (AOR = 2.25, 95% CI: 1.21-4.56 and AOR = 0.59, 95% CI: 0.29-0.87, respectively) and were not seen elsewhere in the state.

CONCLUSION

Changes in the number, timing and type of abortions were concentrated among residents in particular areas of Louisiana. The early stages of the COVID-19 pandemic exacerbated geographic disparities in access to abortion care.

IMPLICATIONS

Disruptions in services at the beginning of the COVID-19 pandemic in Louisiana meaningfully affected pregnant people's ability to obtain an abortion at their nearest clinic. These findings reinforce the importance of developing mechanisms to support pregnant people during emergency situations when traveling to a nearby clinic is no longer possible.

Patient opinions on sexual and reproductive health services in primary care in rural and urban clinics

OBJECTIVES

Primary care providers are a major source of sexual and reproductive health care in the United States, particularly in rural areas, and not all providers offer the same services. This study aimed to understand patient preferences and expectations around reproductive health services including abortion care in a primary care setting and if those expectations differed by urban or rural setting.

STUDY DESIGN

An anonymous survey was distributed to all patients 18 years or older in 4 primary care clinics in Idaho, Washington, and Wyoming over a 2-week period. The survey asked patients about which reproductive health services should be available in primary care.

RESULTS

The overall response rate was 69% (745/1086). For all queried reproductive health services except for aspiration abortion, the majority of respondents reported that primary care clinics should have that service available. Forty-two percent of respondents reported that aspiration abortion should be available in primary care. Overall, most respondents reported that medication abortion (58%) and miscarriage management (65%) should be available in primary care. More respondents in urban clinics thought IUD services (84% vs 71%), medication abortion (74% vs 37%), and aspiration abortion (52% vs 28%) should be accessible in primary care compared to those in rural-serving clinics.

CONCLUSIONS

This study of 4 primary care clinics in Idaho, Washington, and Wyoming, spanning urban and rural settings, highlights that most patients desire contraception services and miscarriage management to be available in primary care.

IMPLICATIONS

Increasing training may help meet patient desires for access to reproductive services in primary care, however, further exploration of barriers to this care is warranted. High rates of respondents desiring miscarriage management access highlights the need to train more primary care clinicians to provide full spectrum miscarriage management options.

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.

Telemedicine for First-Trimester Medical Abortion in Canada: Results of a 2019 Survey

Introduction: Telemedicine has the potential to improve abortion access disparities in Canada. We aimed to explore the provision of telemedicine for first-trimester medical abortion and related barriers in 2019. Methods: We conducted a national, cross-sectional, anonymized, web-based survey of clinicians who provided abortion care in 2019 in Canada. We distributed our survey through professional health organizations to maximize identification of possible eligible respondents and used a modified Dillman technique to foster responses. Questions elicited provider demographics, clinical characteristics, including telemedicine first-trimester medical abortion and perceived related barriers. Descriptive statistics were analyzed using R software. Results: Among 465 respondents, 388 reported providing first-trimester medical abortion across Canada; 44.0% reported experience using telemedicine for some components of care: 49.3% of primary care clinicians and 28.7% of specialists. Telemedicine was used for initial consultation (86.0%), prescription (82.2%), or follow-up (92.2%). The median percentage of telemedicine providers' patients who underwent a dating ultrasound was 90.0. The majority usually followed up with patients through quantitative human chorionic gonadotropin (hCG) (84.2%). Seventy-eight percent perceived barriers to telemedicine; the most common being inability to confirm gestational age with ultrasound (43.0%), and lack of provincial telemedicine abortion fee code to pay practitioners (30.2%), timely access to serum hCG testing (24.6%), and nearby emergency services (23.3%). Discussion: In 2019, fewer than half of respondents reported providing some aspects of first-trimester medical abortion through telemedicine and the majority perceived barriers. Our results can inform knowledge translation activities to reduce barriers and increase telemedicine abortion care in Canada.

Mifepristone: A Safe Method of Medical Abortion and Self-Managed Medical Abortion in the Post-Roe Era

BACKGROUND

The U.S. Supreme Court's Dobbs v. Jackson Women's Health Organization decision on June 24, 2022 effectively overturned federal constitutional protections for abortion that have existed since 1973 and returned jurisdiction to the states. Several states implemented abortion bans, some of which banned abortion after 6 weeks and others that permit abortion under limited exceptions, such as if the health or the life of the woman is in danger. Other states introduced bills that define life as beginning at fertilization. As a result of these new and proposed laws, the future availability of mifepristone, one of two drugs used for medical abortion in the United States, has become the topic of intense debate and speculation.

AREAS OF UNCERTAINTY

Although its safety and effectiveness has been confirmed by many studies, the use of mifepristone has been politicized regularly since its approval. Areas of future study include mifepristone for induction termination and fetal demise in the third trimester and the management of leiomyoma.

DATA SOURCES

PubMed, Society of Family Planning, American College of Obstetrician and Gynecologists, the World Health Organization.

THERAPEUTIC ADVANCES

The use of no-touch medical abortion, which entails providing a medical abortion via a telehealth platform without a screening ultrasound or bloodwork, expanded during the COVID-19 pandemic, and studies have confirmed its safety. With the Dobbs decision, legal abortion will be less accessible and, consequently, self-managed abortion with mifepristone and misoprostol will become more prevalent.

CONCLUSIONS

Mifepristone and misoprostol are extremely safe medications with many applications. In the current changing political climate, physicians and pregnancy-capable individuals must have access to these medications.

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.

Mifepristone Adverse Events Identified by Planned Parenthood in 2009 and 2010 Compared to Those in the FDA Adverse Event Reporting System and Those Obtained Through the Freedom of Information Act

Background

As part of the accelerated approval of mifepristone as an abortifacient in 2000, the Food and Drug Administration (FDA) required prescribers to report all serious adverse events (AEs) to the manufacturer who was required to report them to the FDA. This information is included in the FDA Adverse Event Reporting System (FAERS) and is available to the public online. The actual Adverse Event Reports (AERs) can be obtained through the Freedom of Information Act (FOIA).

Methods

We compared the number of specific AEs and total AERs for mifepristone abortions from January 1, 2009 to December 31, 2010 from 1. Planned Parenthood abortion data published by Cleland et al. 2. FAERS online dashboard, and 3. AERs provided through FOIA and analyzed by Aultman et al.

Results

Cleland identified 1530 Planned Parenthood mifepristone cases with specific AEs for 2009 and 2010. For this period, FAERS online dashboard includes a total (from all providers) of only 664, and the FDA released only 330 AERs through FOIA. Cleland identified 1158 ongoing pregnancies in 2009 and 2010. FAERs dashboard contains only 95, and only 39 were released via FOIA.

Conclusions

There are significant discrepancies in the total number of AERs and specific AEs for 2009 and 2010 mifepristone abortions reported in 1. Cleland's documentation of Planned Parenthood AEs, 2. FAERS dashboard, and 3. AERs provided through FOIA. These discrepancies render the FAERS inadequate to evaluate the safety of mifepristone abortions.

Abortion During the COVID-19 Pandemic: Racial Disparities and Barriers to Care in the USA

This article draws on first-hand experience as well as scholarly research to illuminate how COVID-19 has impacted an already-embattled medical service in the USA, subsequently affecting the reproductive health and experiences of diverse individuals navigating an unfamiliar health and economic environment. COVID-19's introduction into a landscape of abortion restrictions has intensified the barriers that providers and communities already face, with disproportionate impacts on Black and Hispanic abortion seekers. Relaxing existing restrictions on medication abortions and telemedicine delivery models may be one way to ease the tension between keeping people home and getting them the treatment they need.

The Critical Role of Midwives in Safe Self-Managed Abortion

As access to legal abortion in the United States becomes more complex, there is increasing interest in self-managed abortion. Choosing to seek abortion care outside the clinical setting can also help people marginalized or harmed by existing health care systems to access needed care in a way that feels safe and empowering. However, patients and midwives alike often have a lack of information about expected outcomes and potential complications that may arise, as well as how to manage these in a health care system that may make appropriate follow-up difficult to access if needed. This article discusses patient education as a harm-reduction approach, and reviews ways that midwives may strategically and ethically participate in this patient education need. As trusted health care providers who are expert in pregnancy and reproductive health, midwives are ideally positioned to meet patient knowledge needs around self-managed abortion.

The perspective of Canadian health care professionals on abortion service during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic and pandemic response created novel challenges for abortion services. Canada was uniquely positioned to transition to telemedicine because internationally common restrictions on abortion medication were removed before the pandemic.

OBJECTIVE

We sought to characterize the experiences of abortion health care professionals in Canada during the COVID-19 pandemic and the impact of the pandemic response on abortion services.

METHODS

We conducted a sequential mixed methods study between July 2020 and January 2021. We invited physicians, nurse practitioners and administrators to participate in a cross-sectional survey containing an open-ended question about the impact of the pandemic response on abortion care. We employed an inductive codebook thematic analysis, which informed the development of a second, primarily quantitative survey.

RESULTS

Our initial survey had 307 respondents and our second had 78. Fifty-three percent were family physicians. Our first survey found respondents considered abortion access essential. We identified three key topicss: access to abortion care was often maintained despite pandemic-related challenges (e.g. difficulty obtaining tests, additional costs); change of practice to low-touch medication abortion care and provider perceptions of patient experience, including shifting demand, telemedicine acceptability and increased rural access. The second survey indicated uptake of telemedicine medication abortion among 89% of participants except in Quebec, where regulations meant procedures were nearly exclusively surgical. Restrictions did not delay care according to 76% of participants.

CONCLUSIONS

Canadian health care professionals report their facilities deemed abortion an essential service. Provinces and territories, except Quebec, described a robust pandemic transition to telemedicine to ensure access to services.

PODCAST

An accompanying podcast is available in the Supplementary Data, in which the authors Dr Madeleine Ennis and Kate Wahl discuss their research on how family planning care and access to abortion services have changed during the COVID-19 pandemic.

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.

Abortion service availability during the COVID-19 pandemic: Results from a national census of abortion facilities in the U.S

Objective

This study assessed the impact of COVID-19 on abortion services in all 50 United States states and the District of Columbia.

Study design

ANSIRH's Abortion Facility Database is a systematic collection of data on all publicly-advertising abortion facilities in the United States, updated annually through online searches and mystery shopper phone calls. Research staff updated the database in May-August 2020, assessing the number of facilities that closed, limited or stopped providing abortions, and provided telehealth options in summer 2020 due to COVID-19.  We describe these changes using frequencies and highlighting themes and examples from coded qualitative data.

Results

Located primarily in the South and Midwest, 24 of 751 facilities that were open in 2019 temporarily closed due to the pandemic, with 9 still closed by August 2020. Other facilities described suspending abortions, referring abortion patients to other facilities, or limiting services to medication abortion. While most facilities required in-person visits for reasons like state abortion restrictions, 22% (n = 150) offered phone or telehealth consultations, no-test visits, or medication abortion by mail to reduce or eliminate patient time in the clinic. Some facilities used creative strategies to reduce COVID-19 risk like allowing patients to wait for visits in their cars or offering drive-through medication pick-up.

Conclusions

The COVID-19 pandemic caused several disruptions to abortion service availability, including closures. To reduce in-person visit time, some clinics shifted to offering medication abortion (versus procedural) or telehealth. While the pandemic and abortion restrictions increased barriers to abortion provision, facilities were resilient and adapted to provide safe care for their patients.

Implications

Barriers to abortion access were exacerbated during the COVID-19 pandemic, particularly in areas of the country with more restrictive policies toward abortion. Telehealth care protocols offered by many abortion facilities provide an option to reduce or eliminate in-person visits.

Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic

OBJECTIVE

To present updated evidence on the safety, efficacy and acceptability of a direct-to-patient telemedicine abortion service and describe how the service functioned during the COVID-19 pandemic.

STUDY DESIGN

We offered the study at 10 sites that provided the service in 13 states and Washington DC. Interested individuals obtained any needed preabortion tests locally and had a videoconference with a study clinician. Sites sent study packages containing mifepristone and misoprostol by mail and had remote follow-up consultations within one month by telephone (or by online survey, if the participant could not be reached) to evaluate abortion completeness. The analysis was descriptive.

RESULTS

We mailed 1390 packages between May 2016 and September 2020. Of the 83% (1157/1390) of abortions for which we obtained outcome information, 95% (1103/1157) were completed without a procedure. Participants made 70 unplanned visits to emergency rooms or urgent care centers for reasons related to the abortion (6%), and 10 serious adverse events occurred, including 5 transfusions (0.4%). Enrollment increased substantially with the onset of COVID-19. Although a screening ultrasound was required, sites determined in 52% (346/669) of abortions that occurred during COVID that those participants should not get the test to protect their health. Use of urine pregnancy test to confirm abortion completion increased from 67% (144/214) in the 6 months prior to COVID to 90% (602/669) in the 6 months during COVID. Nearly all satisfaction questionnaires (99%, 1013/1022) recorded that participants were satisfied with the service.

CONCLUSIONS

This direct-to-patient telemedicine service was safe, effective, and acceptable, and supports the claim that there is no medical reason for mifepristone to be dispensed in clinics as required by the Food and Drug Administration. In some cases, participants did not need to visit any facilities to obtain the service, which was critical to protecting patient safety during the COVID-19 pandemic.

IMPLICATIONS

Medical abortion using telemedicine and mail is effective and can be safely provided without a pretreatment ultrasound. This method of service delivery has the potential to greatly improve access to abortion care in the United States.

"False positive" urine pregnancy test results after successful medication abortion

OBJECTIVE

To examine the proportion of high-sensitivity urine pregnancy test (HSPT) results that were positive by time after successful medication abortion.

STUDY DESIGN

We used data from an ongoing study that provides mifepristone and misoprostol for medication abortion by direct-to-patient telemedicine and mail. Providers evaluated abortion outcomes by patient interview and clinical tests per clinical judgment and participant preference. We identified all participants enrolled July 2016 to September, 2020 who had an HSPT result and no indication of viable pregnancy after treatment. We used logistic regression to examine the association between the timing of the initial post-treatment HSPT, gestational age, and the proportion of HSPTs that gave a positive result.

RESULTS

Of the 472 participants in our analysis, 88 (19%) had positive initial HSPTs. The proportions that were positive at ≤20 days, 21 to 27 days, 28 to 34 days, and ≥35 days after mifepristone ingestion was 14 of 29 (48%), 15 of 58 (26%), 49 of 258 (19%), and 10 of 127 (8%), respectively (p < 0.001). Gestational age at mifepristone ingestion was not significantly related to positive HSPT results (p = 0.28). Multivariable logistic regression confirmed both findings and did not identify a statistically significant interaction between these variables. In the 67 participants who relied solely on further HSPTs to confirm abortion outcome, the median interval between the initial positive test and first negative test was 14 days.

CONCLUSIONS

The proportion of participants with positive HSPTs declined with time after successful medication abortion. However, nearly one-fifth of participants with complete abortion had positive tests 4 weeks after treatment.

IMPLICATIONS

HSPTs provide an inexpensive, convenient option for confirming success of medication abortion at home. However, a substantial minority of patients without ongoing pregnancy have positive HSPT results. Development of a symptom-based strategy for medication abortion outcome assessment without any confirmatory tests should be a priority.

Factors Associated With Use of an Online Telemedicine Service to Access Self-managed Medical Abortion in the US

IMPORTANCE

People in the US have been seeking self-managed abortions outside the formal health care system using medications obtained through online telemedicine. However, little is known about this practice, including potential motivating factors.

OBJECTIVE

To examine individual reasons for accessing medication abortion through an online telemedicine service as well as associations between state- and county-level factors and the rate of requests.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study examined all requests for self-managed medication abortion through an online consultation form available from Aid Access, a telemedicine service in the US, between March 20, 2018, and March 20, 2020.

MAIN OUTCOMES AND MEASURES

Individual-level reasons for accessing the telemedicine service were examined as well as the rate of requests per 100 000 women of reproductive age by state. Zip code data provided by individuals making requests were used to examine county-level factors hypothesized to be associated with increased demand for self-managed abortion: distance to a clinic (calculated using location data for US abortion clinics) and the population proportion identifying as a member of a racial/ethnic minority group, living below the federal poverty level, and having broadband internet access (calculated using census data).

RESULTS

During the 2-year study period, 57 506 individuals in 2458 counties in 50 states requested self-managed medication abortion; 52.1% were aged 20 to 29 years (mean [SD] age, 25.9 [6.7] years), 50.0% had children, and 99.9% were 10 weeks' pregnant or less. The most common reasons cited by individuals making requests were the inability to afford in-clinic care (73.5%), privacy (49.3%), and clinic distance (40.4%). States with the highest rate of requests were Louisiana (202.7 per 100 000 women) and Mississippi (199.9 per 100 000 women). At the county level, an increase of 1 SD (47 miles) in distance to the nearest clinic was significantly associated with a 41% increase in requests (incidence rate ratio, 1.41; 95% CI, 1.31-1.51; P < .001), and a 10% increase in the population living below the federal poverty level was significantly associated with a 20% increase in requests (incidence rate ratio, 1.20; 95% CI, 1.13-1.28; P < .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, clinic access barriers were the most commonly cited reason for requesting self-managed medication abortion using an online telemedicine service. At the county level, distance to an abortion clinic and living below the federal poverty level were associated with a higher rate of requests. State and federal legislation could address these access barriers.

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

OBJECTIVES

To document medication abortion clinical practice changes adopted by providers in response to the COVID-19 pandemic.

STUDY DESIGN

Longitudinal descriptive study, comprised of three online surveys conducted between April to December, 2020. We recruited sites from email lists of national abortion and family planning organizations.

RESULTS

Seventy-four sites opted to participate. We analyzed 55/74 sites (74%) that provided medication abortion and completed all three surveys. The total number of abortion encounters reported by the sites remained consistent throughout the study period, though medication abortion encounters increased while first-trimester aspiration abortion encounters decreased. In response to the COVID-19 pandemic, sites reduced the number of in-person visits associated with medication abortion and confirmation of successful termination. In February 2020, considered prepandemic, 39/55 sites (71%) required 2 or more patient visits for a medication abortion. By April 2020, 19/55 sites (35%) reported reducing the total number of in-person visits associated with a medication abortion. As of October 2020, 37 sites indicated newly adopting a practice of offering medication abortion follow-up with no in-person visits.

CONCLUSIONS

Sites quickly adopted protocols incorporating practices that are well-supported in the literature, including forgoing Rh-testing and pre-abortion ultrasound in some circumstances and relying on patient report of symptoms or home pregnancy tests to confirm successful completion of medication abortion. Importantly, these practices reduce face-to-face interactions and the opportunity for virus transmission. Sustaining these changes even after the public health crisis is over may increase patient access to abortion, and these impacts should be evaluated in future research.

IMPLICATIONS STATEMENT

Medication abortion serves a critical function in maintaining access to abortion when there are limitations to in-person clinic visits. Sites throughout the country successfully and quickly adopted protocols that reduced visits associated with the abortion, reducing in-person screenings, relying on telehealth, and implementing remote follow-up.

Changes needed in Medicaid coverage and reimbursement to meet an evolving abortion care landscape

Medicaid is the largest publicly funded health insurance program in the United States, covering 76 million individuals as of August 2020. Research shows that Medicaid improves health and healthcare access on a variety of indicators. Abortion is a common reproductive health service in the United States. However, Medicaid coverage of abortion varies by state; with 34 states and the District of Columbia limiting themselves to a federal policy that only permits coverage under cases of incest, rape, or life endangerment. With 75% of abortion patients earning low incomes, Medicaid coverage of this service is particularly salient to abortion access. In this commentary, we describe the complexities of Medicaid coverage and reimbursement of abortion in the United States and the implications of this complexity. Further, we consider the potential impact of changes in abortion provision, including increasing provision of medication abortion and the use of healthcare delivery models such as telemedicine for medication abortion, on Medicaid coverage and reimbursement. Finally, we provide a few policy and practice recommendations for abortion coverage now and in the future.