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Mara T, Barbara T, Lucia P, Giulia S, Cristina T, Greco P, Stefano S. Exploring the impact of integrating telehealth in obstetric care: A scoping review. Eur J Obstet Gynecol Reprod Biol 2024; 302:242-248. [PMID: 39332087 DOI: 10.1016/j.ejogrb.2024.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2024] [Revised: 09/14/2024] [Accepted: 09/19/2024] [Indexed: 09/29/2024]
Abstract
BACKGROUND The use of telemedicine has spread to all areas of medicine, including obstetrics, over the last few decades. OBJECTIVE To identify and map the diversity and applicability of telemedicine in the obstetric literature, in the antenatal, intrapartum or postnatal period. To assess patient satisfaction and possible areas for future development. METHODS This scoping review was conducted following the Joanna Briggs Institute (JBI) methodological guidelines for scoping reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and its extension for scoping reviews (PRISMA-ScR). We searched the databases PubMed (Medline), CINAHL, CENTRAL (Cochrane Library), EMBASE Ovid and Scopus. We also searched Google Scholar, clinicaltrial.gov, the WHO International Clinical Trials Registry Platform (ICTRP-WHO) and the reference lists of the included studies. We included any primary study design that focused on a population of women in the antenatal, intrapartum or postnatal period. Studies selection and data extraction were performed blindly and independently by two authors. We summarised the results narratively and used graphs and tables to present key concepts thematically. RESULTS We included 66 studies. We categorised the studies according to population, type of intervention, outcomes and user satisfaction. Most of the studies involved pathological (36%) and physiological (30%) pregnancy management, the type of intervention was mainly divided into televisits or video calls with professionals (43%) and the use of specific apps or devices (40%). The maternal outcomes studied were mainly quantitative, i.e., improvement in blood chemistry tests or vital parameters (65%) and treatment adherence (frequency of follow-up visits or keeping appointments, 27%). Patient satisfaction was positive in the majority of cases. CONCLUSIONS There is still little international agreement on the concept and possible applications of telemedicine in obstetrics, although it is increasingly being used in clinical practice. Studies have shown positive results in terms of improved care, particularly in terms of treatment adherence and as an alternative strategy in the management of pregnancy, postpartum and abortion care. Both patients and health professionals were satisfied with it, especially when offered as a complement or alternative to the traditional method of face-to-face visits. Future developments seem to be the time and cost-saving potential of telemedicine and its application to couples' infertility.
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Affiliation(s)
- Tormen Mara
- Maternal and Child Department, Unit of Obstetrics and Gynecology, S. Anna University Hospital, Cona, Ferrara, Italy; Department of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44124 Ferrara, Italy.
| | - Toniolo Barbara
- Maternal and Child Department, Unit of Obstetrics and Gynecology, Pietro Cosma Hospital - Ulss 6 Euganea, Camposampiero, Padova, Italy
| | - Pecci Lucia
- Maternal and Child Department, Unit of Obsterics and Gynecology San Daniele del Friuli, "ASUFC", Udine, Italy
| | - Soraci Giulia
- Maternal and Child Department, Unit of Obstetrics and Gynecology, S. Anna University Hospital, Cona, Ferrara, Italy
| | - Taliento Cristina
- Maternal and Child Department, Unit of Obstetrics and Gynecology, S. Anna University Hospital, Cona, Ferrara, Italy; Department of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44124 Ferrara, Italy; Maternal and Child Department, Unit of Obstetrics and Gynecology, Pietro Cosma Hospital - Ulss 6 Euganea, Camposampiero, Padova, Italy; Maternal and Child Department, Unit of Obsterics and Gynecology San Daniele del Friuli, "ASUFC", Udine, Italy; Department of Development and Regeneration - Woman and Child, KU Leuven, Leuven, Belgium
| | - Pantaleo Greco
- Maternal and Child Department, Unit of Obstetrics and Gynecology, S. Anna University Hospital, Cona, Ferrara, Italy; Department of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44124 Ferrara, Italy
| | - Salvioli Stefano
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Sciences (DINOGMI), University of Genoa - Campus of Savona, Italy
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Lindig A, Heger S, Zill JM. Assessment of relevance and actual implementation of person-centeredness in healthcare and social support services for women with unintended pregnancy in Germany (CarePreg): results of expert workshops. BMC Pregnancy Childbirth 2024; 24:247. [PMID: 38582864 PMCID: PMC10998354 DOI: 10.1186/s12884-024-06453-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 03/26/2024] [Indexed: 04/08/2024] Open
Abstract
INTRODUCTION Person-centeredness is a key principle in the German healthcare system. However, access to high-quality care for women with unintended pregnancy is limited due to social stigma and legal restrictions. There is little research on the adoption of person-centeredness in care for women with unintended pregnancy. The aim of this study was to analyze relevance and actual implementation of dimensions of person-centeredness in psycho-social and medical abortion care from the view of abortion care providers. METHODS Counselors and gynecologist working in psycho-social or medical abortion care participated in one of two digital workshops. Discussions were semi-structured based on the 16 dimensions of an integrative model of person-centeredness, audio-recorded and transcribed verbatim. During qualitative content analysis, deductive categories based on the integrative model of person-centeredness were applied and inductive categories were developed. Additionally, participants rated relevance and actual implementation of the dimensions in an online survey. RESULTS The 18 workshop participants most intensively discussed the dimensions "access to care", "person-centered characteristics of healthcare providers" and "personally tailored information". Four additional categories on a macro level ("stigmatization of women with unintended pregnancy", "stigmatization of healthcare providers", "political and legal aspects" and "corona pandemic") were identified. Most dimensions were rated as highly relevant but implementation status was described as rather low. CONCLUSIONS In Germany, high quality person-centered care for women with unintended pregnancy is insufficiently implemented through limited access to information, a lack of abortion care providers, and stigmatization. There is a need for changes in health care structures to enable nationwide person-centered care for women with unintended pregnancy. Those changes include a more easy access to evidence-based information and person-centered abortion care, more education on abortion care for healthcare providers, integration of topics of abortion care in medical schools and promotion of de-stigmatizing actions to enable abortions as part of the general healthcare.
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Affiliation(s)
- Anja Lindig
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
- Center of Health Care Research, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Stefanie Heger
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Jördis Maria Zill
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Center of Health Care Research, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Lands M, Dyer RL, Seymour JW. Sampling strategies among studies of barriers to abortion in the United States: A scoping review of abortion access research. Contraception 2024; 131:110342. [PMID: 38012964 DOI: 10.1016/j.contraception.2023.110342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVES Understanding barriers to abortion care is particularly important post-Dobbs. However, many abortion access studies recruit from abortion-providing facilities, which overlook individuals who do not present for clinic-based care. To our knowledge, no studies have reviewed research recruitment strategies in the literature or considered how they might affect our knowledge of abortion barriers. We aimed to identify populations included and sampling methods used in studies of abortion barriers in the United States. STUDY DESIGN We used a scoping review protocol to search five databases for articles examining US-based individuals' experiences accessing abortion. We included English-language articles published between January 2011 and February 2022. For included studies, we identified the sampling strategy and population recruited. RESULTS Our search produced 2763 articles, of which 71 met inclusion criteria. Half of the included papers recruited participants at abortion-providing facilities (n = 35), while the remainder recruited from online sources (n = 14), other health clinics (n = 10), professional organizations (n = 8), abortion funds (n = 2), community organizations (n = 2), key informants (n = 2), and an abortion storytelling project (n = 1). Most articles (n = 61) reported information from people discussing their own abortions; the rest asked nonabortion seekers (e.g., physicians, genetic counselors, attorneys) about barriers to care. CONCLUSIONS Studies of abortion barriers enroll participants from a range of venues, but the majority recruit people who obtained abortions, and half recruit from abortion clinics. IMPLICATIONS As abortion access becomes constrained and criminalized in the post-Roe context, our findings indicate how investigators might recruit study participants from a variety of settings to fully understand the abortion seeking experience.
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Affiliation(s)
- Madison Lands
- University of Wisconsin Collaborative for Reproductive Equity, Madison, WI, United States.
| | - Rachel L Dyer
- University of Wisconsin Collaborative for Reproductive Equity, Madison, WI, United States; University of Wisconsin Department of Counseling Psychology, Madison, WI, United States
| | - Jane W Seymour
- University of Wisconsin Collaborative for Reproductive Equity, Madison, WI, United States
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Dunlop H, Sinay AM, Kerestes C. Telemedicine Abortion. Clin Obstet Gynecol 2023; 66:725-738. [PMID: 37910115 DOI: 10.1097/grf.0000000000000818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
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.
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Affiliation(s)
| | - Anne-Marie Sinay
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Courtney Kerestes
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
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Kumsa FA, Prasad R, Shaban-Nejad A. Medication abortion via digital health in the United States: a systematic scoping review. NPJ Digit Med 2023; 6:128. [PMID: 37438435 PMCID: PMC10338479 DOI: 10.1038/s41746-023-00871-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/26/2023] [Indexed: 07/14/2023] Open
Abstract
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.
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Affiliation(s)
- Fekede Asefa Kumsa
- The University of Tennessee Health Science Center (UTHSC) - Oak Ridge National Laboratory (ORNL) Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, Memphis, TN, 38103, USA.
| | - Rameshwari Prasad
- The University of Tennessee Health Science Center (UTHSC) - Oak Ridge National Laboratory (ORNL) Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, Memphis, TN, 38103, USA
| | - Arash Shaban-Nejad
- The University of Tennessee Health Science Center (UTHSC) - Oak Ridge National Laboratory (ORNL) Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, Memphis, TN, 38103, USA.
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Nagendra D, Gutman SM, Koelper NC, Loza-Avalos SE, Sonalkar S, Schreiber CA, Harvie HS. Medical management of early pregnancy loss is cost-effective compared with office uterine aspiration. Am J Obstet Gynecol 2022; 227:737.e1-737.e11. [PMID: 35780811 PMCID: PMC10302401 DOI: 10.1016/j.ajog.2022.06.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/17/2022] [Accepted: 06/26/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Early pregnancy loss, also referred to as miscarriage, is common, affecting approximately 1 million people in the United States annually. Early pregnancy loss can be treated with expectant management, medications, or surgical procedures-strategies that differ in patient experience, effectiveness, and cost. One of the medications used for early pregnancy loss treatment, mifepristone, is uniquely regulated by the Food and Drug Administration. OBJECTIVE This study aimed to compare the cost-effectiveness from the healthcare sector perspective of medical management of early pregnancy loss, using the standard of care medication regimen of mifepristone and misoprostol, with that of office uterine aspiration. STUDY DESIGN We developed a decision analytical model to compare the cost-effectiveness of early pregnancy loss treatment with medical management with that of office uterine aspiration. Data on medical management came from the Pregnancy Failure Regimens randomized clinical trial, and data on uterine aspiration came from the published literature. The analysis was from the healthcare sector perspective with a 30-day time horizon. Costs were in 2018 US dollars. Effectiveness was measured in quality-adjust life-years gained and the rate of complete gestational sac expulsion with no additional interventions. Our primary outcome was the incremental cost per quality-adjust life-year gained. Sensitivity analysis was performed to identify the key uncertainties. RESULTS Mean per-person costs were higher for uterine aspiration than for medical management ($828 [95% confidence interval, $789-$868] vs $661 [95% confidence interval, $556-$766]; P=.004). Uterine aspiration more frequently led to complete gestational sac expulsion than medical management (97.3% vs 83.8%; P=.0001); however, estimated quality-adjust life-years were higher for medical management than for uterine aspiration (0.082 [95% confidence interval, 0.8148-0.08248] vs 0.079 [95% confidence interval, 0.0789-0.0791]; P<.0001). Medical management dominated uterine aspiration, with lower costs and higher confidence interval. The probability that medical management is cost-effective relative to uterine aspiration is 97.5% for all willingness-to-pay values of ≥$5600/quality-adjust life-year. Sensitivity analysis did not identify any thresholds that would substantially change outcomes. CONCLUSION Although office-based uterine aspiration more often results in treatment completion without further intervention, medical management with mifepristone pretreatment costs less and yields similar quality-adjust life-years, making it an attractive alternative. Our findings provided evidence that increasing access to mifepristone and eliminating unnecessary restrictions will improve early pregnancy care.
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Affiliation(s)
- Divyah Nagendra
- Department of Obstetrics and Gynecology, Cambridge Health Alliance, Cambridge, MA; Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sarah M Gutman
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Nathanael C Koelper
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sandra E Loza-Avalos
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Heidi S Harvie
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Shukla A, Vazquez-Quesada L, Vieitez I, Acharya R, RamaRao S. Quality of care in abortion in the era of technological and medical advancements and self-care. Reprod Health 2022; 19:191. [PMID: 36109756 PMCID: PMC9479303 DOI: 10.1186/s12978-022-01499-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Discussions around quality of abortion care have been focused mainly on service-delivery aspects inside healthcare facilities. More recently, with availability of medical abortion (MA), increase in its self-use, and emergence of other delivery platforms such as telemedicine, the responsibility of quality care has broadened to actors outside of facilities.
Body of text
This commentary discusses the meaning of quality of abortion care with the paradigm shift brought by medical and technological advancement in abortions, and raises questions on the role of the state in ensuring quality in abortion management—especially in settings where abortion is decriminalized, but also in countries where abortion is permitted under certain circumstances. It consolidates the experience gained thus far in the provision of safe abortion services and also serves as a forward-thinking tool to keep pace with the uptake of newer health technologies (e.g., availability of medical abortion drugs), service delivery platforms (e.g., telemedicine, online pharmacies), and abortion care providers (e.g., community based pharmacists).
Conclusions
This commentary provides context and rationale, and identifies areas for action that different stakeholders, including health advocates, policymakers, program managers, and women themselves, can adopt to fit into an alternative regime of abortion care.
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de Londras F, Cleeve A, Rodriguez MI, Farrell A, Furgalska M, Lavelanet A. The impact of mandatory waiting periods on abortion-related outcomes: a synthesis of legal and health evidence. BMC Public Health 2022; 22:1232. [PMID: 35725439 PMCID: PMC9210763 DOI: 10.1186/s12889-022-13620-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
This review follows an established methodology for integrating human rights to address knowledge gaps related to the health and non-health outcomes of mandatory waiting periods (MWPs) for access to abortion. MWP is a requirement imposed by law, policy, or practice, to wait a specified amount of time between requesting and receiving abortion care. Recognizing that MWPs “demean[] women as competent decision-makers”, the World Health Organization recommends against MWPs. International human rights bodies have similarly encouraged states to repeal and not to introduce MWPs, which they recognize as operating as barriers to accessing sexual and reproductive healthcare. This review of 34 studies published between 2010 and 2021, together with international human rights law, establishes the health and non-health harms of MWPs for people seeking abortion, including delayed abortion, opportunity costs, and disproportionate impact. Impacts on abortion providers include increased workloads and system costs.
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Affiliation(s)
- Fiona de Londras
- Birmingham Law School, University of Birmingham (UK), B15 2TT, Birmingham, UK.
| | - Amanda Cleeve
- Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.,Department of Sexual and Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
| | - Alana Farrell
- Birmingham Law School, University of Birmingham (UK), B15 2TT, Birmingham, UK
| | | | - Antonella Lavelanet
- Department of Sexual and Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
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Matulich MC, Hou MY, Chen MJ, Uhm S, Creinin MD. Implementation of telemedicine preoperative visits for abortion procedures through 18 weeks gestation at a Northern California hospital-based center. Contraception 2022; 114:74-78. [PMID: 35750146 DOI: 10.1016/j.contraception.2022.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 05/24/2022] [Accepted: 06/03/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Describe the implementation of a preoperative telemedicine program at a Northern California hospital-based center for abortion procedures requiring cervical preparation. STUDY DESIGN We implemented a pilot program using telemedicine for preoperative visits for patients needing cervical preparation prior to an abortion procedure from 12 to 18 weeks. We required ultrasonography for gestational age documentation in addition to placental localization in patients with a prior cesarean delivery. We prescribed misoprostol for cervical preparation for patients undergoing the telemedicine preoperative visit; in-person preoperative visits typically involve placement of osmotic dilators. Secondarily, we surveyed patients who had telemedicine and in-person preoperative visits to compare their preoperative experiences. RESULTS Implementation required eight months of multidisciplinary meetings. From March 2018 through March 2019, we received 200 abortion referrals at 12 to 18 weeks gestation. Of these 200 patients, 119 did not meet telemedicine eligibility criteria, most commonly due to inability to obtain required ultrasonography (n=89 [75%]). Of the remaining 81 patients, 43 scheduled telemedicine visits of which 41 initiated and 38 (88%) completed the visits. Twenty-one (55%) telemedicine encounters had no or minor technical difficulties. Thirty-one of 34 (91%) telemedicine and 91 of 108 (84%) in-person visit patients expressed high satisfaction with their preoperative appointment (p=0.4); none reported dissatisfaction. Patients chose the telemedicine visit primarily for convenience and transportation concerns. CONCLUSION A multidisciplinary team is essential for the successful implementation of a preoperative telemedicine program for procedural abortion care. Patients reported high satisfaction and reduced logistical burdens with the telemedicine option. IMPLICATIONS Telemedicine preoperative visits for abortion procedures at 12-18 weeks gestation may improve access to abortion care, reduce patient burdens, and provide an alternative encounter option which may improve the patient experience.
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Affiliation(s)
- Melissa C Matulich
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA.
| | - Melody Y Hou
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA
| | - Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA
| | - Suji Uhm
- Current institution: Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh/Magee-Womens Hospital, Pittsburgh, PA
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA
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Civil Disobedience and Abortion Services After Roe v Wade: Legal and Ethical Considerations. Obstet Gynecol 2021; 137:626-628. [PMID: 33709990 DOI: 10.1097/aog.0000000000004319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/22/2020] [Indexed: 11/26/2022]
Abstract
The future of Roe v Wade is uncertain. If it is overturned, protection of reproductive rights will be determined by the acts of individual state governments, some of which have already signaled that they will ban or severely restrict access to abortion. Health care professionals working in states that maintain the laws that applied in the time before the overturn of Roe may wish to provide assistance-anything from consultation to shipping medications-to women living in more restrictive venues. However, it is important for health care professionals to be aware of the legal consequences of those acts, as well as ethical considerations, when deciding whether to adhere to or to defy laws that they believe threaten the well-being of women. It is likely that legal consequences will vary with the type of act in which a physician engages. This article will review legal considerations, to the extent that they can be known at this point, as well as the ethics of civil disobedience.
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Kerestes C, Delafield R, Elia J, Chong E, Kaneshiro B, Soon R. “It was close enough, but it wasn't close enough”: A qualitative exploration of the impact of direct-to-patient telemedicine abortion on access to abortion care. Contraception 2021; 104:67-72. [DOI: 10.1016/j.contraception.2021.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
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Chong E, Shochet T, Raymond E, Platais I, Anger HA, Raidoo S, Soon R, Grant MS, Haskell S, Tocce K, Baldwin MK, Boraas CM, Bednarek PH, Banks J, Coplon L, Thompson F, Priegue E, Winikoff B. Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic. Contraception 2021; 104:43-48. [PMID: 33781762 PMCID: PMC9748604 DOI: 10.1016/j.contraception.2021.03.019] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/10/2021] [Accepted: 03/18/2021] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Erica Chong
- Gynuity Health Projects, New York, NY, USA,Present address: Reproductive Health Education in Family Medicine, 3544 Jerome Avenue, Bronx, NY 10467.,Corresponding author
| | | | | | | | | | - Shandhini Raidoo
- Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
| | - Reni Soon
- Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
| | | | - Susan Haskell
- carafem, 1001 Connecticut Avenue NW, Washington, DC, USA
| | - Kristina Tocce
- Planned Parenthood of the Rocky Mountains, Denver, CO, USA
| | | | | | | | - Joey Banks
- Planned Parenthood of Montana, Missoula, MT, USA
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Chandrasekaran S, Chandrashekar VS, Dalvie S, Sinha A. The case for the use of telehealth for abortion in India. Sex Reprod Health Matters 2021; 29:1920566. [PMID: 34078249 PMCID: PMC8183532 DOI: 10.1080/26410397.2021.1920566] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
India has the world’s fastest growing outbreak of COVID-19. With limited mobility, increased reports of intimate partner violence, changes in living patterns of migrants, delays in accessing contraception and safe abortion care, and potential changes to decisions about parenting, there may be an increased need for abortion services in India due to the pandemic. The use of technology for providing abortion information and services has been well documented in global literature. The safety of abortion provision using telehealth has been established in several contexts including the United States and Australia. The importance of hotlines and other support systems that use technology to provide information and support to clients through their abortion is also highlighted in the literature. Several countries, such as the United Kingdom, France, New Zealand, and Pakistan are now allowing the use of technology for abortion/post-abortion care in light of the pandemic; however, India’s telemedicine guidelines do not include abortion. In a country where the majority of abortions take place outside the health system, allowing the use of telemedicine for abortion can help bring legality to users, and expand access to those facing additional barriers in accessing the care they deserve. We outline models for telemedicine provision of abortion in India and discuss the regulatory changes required to make telehealth for abortion a reality in India.
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Affiliation(s)
- Sruthi Chandrasekaran
- Senior Project Manager, Ibis Reproductive Health, Cambridge, MA, USA. Correspondence:
| | - V S Chandrashekar
- CEO, Foundation for Reproductive Health Services India, New Delhi, India (affiliate of MSI Reproductive Choices)
| | - Suchitra Dalvie
- Coordinator, Asia Safe Abortion Partnership, New Delhi, India
| | - Anand Sinha
- Country Advisor (India), The David and Lucile Packard Foundation, New Delhi, India
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14
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Kaller S, Daniel S, Raifman S, Biggs MA, Grossman D. Pre-Abortion Informed Consent Through Telemedicine vs. in Person: Differences in Patient Demographics and Visit Satisfaction. Womens Health Issues 2021; 31:227-235. [PMID: 33832830 DOI: 10.1016/j.whi.2021.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Utah law requires patients to have a face-to-face "informed consent" visit at least 72 hours prior to abortion. Planned Parenthood Association of Utah (PPAU) offers this visit via telemedicine as an alternative to an in-person visit, which can require burdensome travel. This novel study identifies factors associated with using telemedicine for informed consent, patients' reasons for using it, and experiences with it, compared to in-person informed consent. METHODS In 2017 and 2018, patients 18 years and older seeking abortion at PPAU completed a self-administered online survey about their experiences with the informed consent visit. We used linear and logistic regression models to compare participants' demographic characteristics by informed consent visit type, and descriptive statistics to describe reasons for using each visit type and experiences with the visit. Multivariable logistic regression models examined associations between visit type and satisfaction. RESULTS Responses from 166 telemedicine patients and 217 in-person informed consent patients indicate that telemedicine participants would have had to travel significantly further than in-person participants traveled to attend the visit at the clinic (mean of 65 miles versus 21 miles, p < .001). In multivariable analyses, telemedicine participants had higher odds of being "very satisfied" with the visit (aOR, 2,89; 95% CI: 1.93-4.32) and "very comfortable" asking questions during the visit (aOR, 3.76; 95% CI: 2.58-5.49), compared to participants who attended in-person visits. CONCLUSIONS Telemedicine offers a convenient, acceptable option for mandated pre-abortion informed consent visits and reduces the burden of additional travel and associated barriers for some patients, particularly those who live further away from clinics.
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Affiliation(s)
- Shelly Kaller
- Department of Obstetrics, Gynecology & Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California, Oakland, California.
| | - Sara Daniel
- Department of Obstetrics, Gynecology & Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California, Oakland, California
| | - Sarah Raifman
- Department of Obstetrics, Gynecology & Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California, Oakland, California
| | - M Antonia Biggs
- Department of Obstetrics, Gynecology & Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California, Oakland, California
| | - Daniel Grossman
- Department of Obstetrics, Gynecology & Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California, Oakland, California
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Kaimal A, Norton ME. Society for Maternal-Fetal Medicine Consult Series #55: Counseling women at increased risk of maternal morbidity and mortality. Am J Obstet Gynecol 2021; 224:B16-B23. [PMID: 33309561 DOI: 10.1016/j.ajog.2020.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Women should be provided with evidence-based information when considering options for contraception and pregnancy management. When counseling about health conditions and available treatments, healthcare practitioners should employ strategies that encourage the incorporation of informed patient preferences into a shared decision-making process with the patient. To optimize the health of women at risk of experiencing adverse health outcomes during or after pregnancy, counseling should be a continuous process throughout the reproductive life course. The purpose of this Consult is to provide guidance for all healthcare practitioners about counseling reproductive-aged women who may be at high risk of experiencing maternal morbidity or mortality.
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Affiliation(s)
- Anjali Kaimal
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Mary E Norton
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Thompson TA, Sonalkar S, Butler JL, Grossman D. Telemedicine for Family Planning: A Scoping Review. Obstet Gynecol Clin North Am 2020; 47:287-316. [PMID: 32451019 PMCID: PMC10093687 DOI: 10.1016/j.ogc.2020.02.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Telemedicine has the potential to increase access to family planning. The most common application involved the use of text message reminders and mobile apps. Text messaging increased knowledge in a variety of settings, but had no effect on contraceptive uptake and use. Two randomized studies found that text messaging improved continuation of oral contraceptives and injectables. Telemedicine provision of medication abortion included both clinic-to-clinic and direct-to-patient models of care. Telemedicine provision of medication abortion has been found to be equally safe and effective as in-person provision. Some measures of satisfaction are higher with telemedicine. Telemedicine may improve access to early abortion.
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Affiliation(s)
- Terri-Ann Thompson
- Ibis Reproductive Health, 2067 Massachusetts Avenue, Suite 320, Cambridge, MA 02140, USA.
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania, 1000 Courtyard, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Jessica L Butler
- The American College of Obstetricians and Gynecologists, 409 12th Street, Southwest, PO Box 96920, Washington, DC 20090-6920, USA
| | - Daniel Grossman
- Department of Obstetrics, Gynecology and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA. https://twitter.com/DrDGrossman
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Betstadt SJ, Heyrana KJ, Whaley NS. Telemedicine for Medication Abortion: The Time Is Now. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020. [DOI: 10.1007/s13669-020-00283-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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18
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Characteristics of patients having telemedicine versus in-person informed consent visits before abortion in Utah. Contraception 2020; 101:56-61. [DOI: 10.1016/j.contraception.2019.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 11/21/2022]
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Carroll E, White K. Abortion patients' preferences for care and experiences accessing services in Louisiana. Contracept X 2019; 2:100016. [PMID: 32550531 PMCID: PMC7286147 DOI: 10.1016/j.conx.2019.100016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 11/17/2022] Open
Abstract
Objective The objective was to compare abortion patients' expectations and preferences for care with their experiences accessing services in Louisiana where there are numerous restrictive abortion laws. Study design Between June 2018 and January 2019, we conducted in-depth interviews with 35 English-speaking Louisiana residents who were ≥ 18 years of age and seeking care from the three in-state facilities to explore their perspectives and experiences locating, obtaining and paying for abortion services. We analyzed interview transcripts using a theme-based approach and categorized themes into dimensions of health care access: availability/accessibility, accommodation, acceptability and affordability. Results Participants were surprised to learn that there were so few facilities providing abortion, which required some of them to drive between 1 and 3 h to the nearest clinic. Many were unable to schedule their visits at a convenient time or obtain care as early in pregnancy as desired because the next available appointment was often a week or more away. Protestor activity and congested waiting rooms did not provide most patients their desired level of privacy, but participants expressed diverse views about other approaches to care that would maintain their confidentiality. To pay for an unplanned health care expense that was not covered by insurance, many participants deferred paying monthly bills and borrowed money, which contributed to financial hardships and additional delays in care. Conclusions Many Louisiana abortion patients' expectations and preferences for care are not being met across multiple dimensions of health care access assessed in this study, and the state's highly regulated policy environment may limit options for tailoring services to patients' needs. Implications Abortion patients in Louisiana value accessible, timely, private and affordable services, but a constrained network of providers and medically unnecessary requirements make it difficult for them to obtain patient-centered care. Federal- and state-level policy changes, as well as local initiatives, could ensure abortion patients have access to quality, evidence-based services.
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Affiliation(s)
- Erin Carroll
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, 1720 2 Ave South RPHB 320, Birmingham, AL, 35294
| | - Kari White
- Steve Hicks School of Social Work, University of Texas at Austin, 1925 San Jacinto Blvd, Stop D3500, Austin, TX 78712
- Population Research Center and the Department of Sociology, University of Texas at Austin, 305 E. 23rd Street, Stop G1800, Austin, TX, 78712
- Corresponding author at: Steve Hicks School of Social Work, University of Texas at Austin, 1925 San Jacinto Blvd, Stop D3500, Austin, TX 78712. Tel.: + 1 512 232 5742.
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Ehrenreich K, Marston C. Spatial dimensions of telemedicine and abortion access: a qualitative study of women's experiences. Reprod Health 2019; 16:94. [PMID: 31269958 PMCID: PMC6610771 DOI: 10.1186/s12978-019-0759-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 06/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Telemedicine may help women comply with onerous legislative requirements for accessing abortion services. In Utah, there are three mandatory steps: a state-mandated information visit, a 72-h waiting period, and finally the abortion procedure itself. We explored women's experiences of using telemedicine for the first step: the information visit. METHODS We conducted 20 in-depth interviews with women recruited from Planned Parenthood Association of Utah in 2017 and analyzed them using iterative thematic techniques, using a framework based on Massey's conceptualization of space as comprising temporal, material and social dimensions. RESULTS Temporal, material and social dimensions of women's access to abortion services intertwined to reduce access and cause discomfort and inconvenience among women in our sample. The 72-h waiting period and travel distance were the key temporal and material barriers, while social dimensions included fear of social judgement, religious influence, and negative stereotyping about people who have abortions. Women described traveling long distances alone and risking excessive pain (e.g. denying pain medication in order to drive immediately after the procedure) to try to overcome these barriers. CONCLUSION Using telemedicine helped patients reduce burdens created by policies requiring attendance at multiple appointments in a state with limited abortion services. Attending to spatial aspects of abortion provision helps identify how these different dimensions of abortion access interact to reduce access and impose undue burdens. Telemedicine can improve privacy, reduce travel expenses, and reduce other burdens for women seeking abortion care.
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Affiliation(s)
- Katherine Ehrenreich
- London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK. .,Present address: Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, 1330 Broadway, Ste 1100, Oakland, CA, 94612, USA.
| | - Cicely Marston
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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