Normalizing the exceptional: incorporating the "abortion pill" into mainstream medicine

Creating an (ethical) epistemic space for the normalization of clinical and "real food" oral immunotherapy for food allergy

Researchers and sociologists have argued the consequences of standardization vis-à-vis clinical practice guidelines are diverse and argue they should be explored empirically. Sociologists have also argued that "best evidence" for the development of clinical practice guidelines is not restricted to randomized controlled trials and that other forms of knowledge should be embedded in and inform CPGs. There is little research concerning how other types of knowledge are mobilized and taken up in CPGs. This article presents the results of an ethnographic investigation in Canada between 2015 and 2020 of the development of a clinical practice guideline for immunotherapy for food allergy. My research shows that immunotherapy has become the source of controversy regarding whether immunotherapy should be offered in the clinic or remain experimental and whether it should be offered using food or commercial products. I argue that the clinical practice guideline for oral immunotherapy reaffirms what has been previously noted by sociologists; guidelines can serve normative purposes and are not merely technical documents. This case study is unique as it demonstrates how guidelines can serve as "community-making devices" to consolidate "epistemic communities" through the explicit and formal mobilization of ethical principles alongside other forms of "traditional" evidence. The mobilization of a multi-criteria approach that included ethical principles was mobilized in part to counter the de-legitimization and peripheralization of clinical and real food oral immunotherapy.

‘We just don’t know’: ambivalence about treatment strategies in the Australian community-based HIV media

The community-based HIV media in Australia provide a unique arena for the negotiation of competing models of medicine between activists, clinicians, government and people living with HIV/AIDS. This article examines how these media have interpreted developments in HIV treatment strategies since the introduction of new treatments in 1996, and identifies the discursive elements employed in journalistic constructions of the temporality and character of HIV medicine. A discourse of ambivalence recurs throughout this journalism, framing the negotiated shifts in treatment strategies as evidence of the uncertainty and unpredictability of HIV medicine. Associated with this discourse are metaphors of medical ambivalence that employ provocative imagery such as fashion, rollercoaster, obstacle course and guessing game to shore up a notion of the volatility of HIV medicine. This article participates in ongoing engagements between the communities and clinicians affected by HIV/AIDS and, more broadly, in the production of knowledge around medicine and the media.

"Right tool," wrong "job": Manual vacuum aspiration, post-abortion care and transnational population politics in Senegal

The "rightness" of a technology for completing a particular task is negotiated by medical professionals, patients, state institutions, manufacturing companies, and non-governmental organizations. This paper shows how certain technologies may challenge the meaning of the "job" they are designed to accomplish. Manual vacuum aspiration (MVA) is a syringe device for uterine evacuation that can be used to treat complications of incomplete abortion, known as post-abortion care (PAC), or to terminate pregnancy. I explore how negotiations over the rightness of MVA as well as PAC unfold at the intersection of national and global reproductive politics during the daily treatment of abortion complications at three hospitals in Senegal, where PAC is permitted but induced abortion is legally prohibited. Although state health authorities have championed MVA as the "preferred" PAC technology, the primary donor for PAC, the United States Agency for International Development, does not support the purchase of abortifacient technologies. I conducted an ethnography of Senegal's PAC program between 2010 and 2011. Data collection methods included interviews with 49 health professionals, observation of PAC treatment and review of abortion records at three hospitals, and a review of transnational literature on MVA and PAC. While MVA was the most frequently employed form of uterine evacuation in hospitals, concerns about off-label MVA practices contributed to the persistence of less effective methods such as dilation and curettage (D&C) and digital curettage. Anxieties about MVA's capacity to induce abortion have constrained its integration into routine obstetric care. This capacity also raises questions about what the "job," PAC, represents in Senegalese hospitals. The prioritization of MVA's security over women's access to the preferred technology reinforces gendered inequalities in health care.

Knowledge, attitudes, and practice of abortion among women and doctors in Armenia

OBJECTIVE

To assess knowledge and attitudes towards abortion among women and obstetricians/gynaecologists in Armenia, in order to facilitate the introduction of medical abortion.

METHODS

Ninety-nine doctors and 400 women in three cities in Armenia were purposively selected to participate in face-to-face interviews using structured survey instruments.

RESULTS

Most women knew that abortion is legal under any (31%) or certain (50%) circumstances. The majority of women had heard of medical abortion, but had superficial or incorrect knowledge of the method. Thirty percent of women expressed a preference for medical abortion over surgical abortion. Despite the fact that the medications are not readily available in Armenia, nearly one out of three doctors reported having experience in using misoprostol or mifepristone + misoprostol to terminate pregnancies. Doctors not providing medical abortion cited concerns about the method's efficacy and safety, or felt that they did not have enough information. One-third of doctors were very interested in receiving training on medical abortion methods.

CONCLUSIONS

Both doctors and women in Armenia are interested in medical abortion as an alternative to surgical abortion. Efforts should focus on informing women about the legality of abortion and the details of the medical abortion procedure, and on training doctors in this new method.

Objectification, standardization, and commodification in health care: a conceptual readjustment

Historically, medical sociologists have used the interrelated concepts of objectification, commodification, and standardization to point to the pathologies of modern medicine, such as the depersonalization of care and the effects of bureaucratic control. More recent work in science studies, economic sociology, and sociology of health and illness, however, has begun to explore how the social processes of objectification, commodification, and standardization produce a wide variety of biomedical achievements. We provide a theoretical synthesis of this emerging body of scholarship centered upon the intended and unintended consequences of objectification, commodification, and standardization to improve health. We then outline a research agenda that would result from a more comprehensive assessment of how these processes manifest themselves in clinical care.

Determinants of demand: method selection and provider preference among US women seeking abortion services

BACKGROUND

Medication abortion has the potential to increase abortion availability, primarily through new provider networks; however, without a better understanding of how and why women make decisions regarding both their abortion method and their provider, expansion efforts may be misguided and valuable resources may be wasted.

STUDY DESIGN

We undertook an exploratory study to investigate method and provider preferences. Semistructured one-on-one interviews were conducted with 205 abortion clients at three family planning clinics.

RESULTS

Study participants greatly preferred the clinic setting for their abortion; the majority of women in the study would not have gone to their regular physician if they had been given the option. In addition, method choice trumps provider choice for the majority of women who would have preferred their regular provider. Participants who chose the aspiration procedure were more likely to have previous knowledge about the medication method. Travel time was not a predictor of preferring one's regular physician over the clinic.

CONCLUSIONS

Expanding provider networks via the private sector is unlikely to be a panacea. In addition to these efforts, more attention may need to be paid to addressing logistic barriers to access. Physicians offering abortion services need to let their patients know they offer such services prior to their patients' need for them. Questions remain regarding the information being circulated about medication abortion.

Provider practice models for and costs of delivering medication abortion -- evidence from 11 US abortion care settings

PURPOSE

Understanding practice models and provider costs for medication abortion (MAB) provision may elucidate ways to facilitate MAB integration into a larger arena of health care services. This study provides descriptive data on the diverse MAB practice models currently being utilized by US health care providers and the costs associated with the components of those models.

METHOD

Data were gathered from a sample of 11 abortion care settings, using clinic administrative records and patient satisfaction surveys.

RESULTS

Practice models varied dramatically, with a wide range in the type of staff employed to provide MAB. The total episode cost for providing MAB ranged from 252 to 460 US Dollars, and patient satisfaction was high across all practices.

CONCLUSION

Information from this study can be used to guide decisions regarding MAB integration into practices not currently providing abortion or which provide only aspiration abortions. The information may also be useful for providers wishing to refine their MAB services.

Patient costs for medication abortion: Results from a study of five clinical practices

PURPOSE

In 2000, the FDA approved mifepristone as a medication abortion alternative. There is limited understanding of the patient costs associated with use of this method. Our objective was to determine total patient costs for medication abortion. This information may be useful for improving counseling and patient decision making.

METHODS

We surveyed 212 women who received a medication abortion from a convenience sample of 5 health care practices. Patient costs including direct medical costs (pregnancy test costs, charges), direct nonmedical costs (child care, travel, lodging), and productivity losses (value of time away from work or other activities) were determined.

RESULTS

The mean total cost for medication abortion was 351 dollars (0-1,140 dollars). The average charge paid by women themselves for the procedure itself was 306 dollars. Three quarters of total costs were direct medical costs and almost one quarter was time away from work and other activities. Although nearly three quarters of the women were insured, only 1% used insurance to cover their abortion--many (44%) did not know if their insurance covered abortion.

CONCLUSIONS

This study provides descriptive information on patient costs associated with medication abortion that may be integrated into patient counseling to enhance informed decision making by women. The study raises questions about why women who report having insurance are not aware of whether their insurance will cover abortion and suggests that we are unclear about women's and providers' preferences for using insurance. We should continue to develop our knowledge of the clinical and nonclinical trade-offs for women choosing between abortion methods to benefit patient decision making.

Determinants of physician unwillingness to offer medical abortion using mifepristone

PURPOSE

We sought to identify factors associated with contemplating versus not contemplating offering medical abortion with mifepristone among physicians not opposed to it.

METHODS

We analyzed data from a Kaiser Family Foundation survey of a nationally representative sample of 790 American obstetrician/gynecologists and primary care physicians. Our study sample consisted of 419 physicians who were not personally opposed to medical abortion and could be classified as not actively considering (precontemplation) or actively considering (contemplation) offering mifepristone. We conducted multivariate logistic regression to predict being unlikely to offer mifepristone (i.e., in the precontemplation stage of change).

PRINCIPAL FINDINGS

In 2001, 1 year after U.S. Food and Drug Administration (FDA) approval, 5% of physicians surveyed were offering mifepristone. Among the 750 physicians not offering mifepristone, 57% were not opposed. Of those not opposed, 74% reported that they were unlikely to offer mifepristone in the next year (precontemplation) as compared to 23% who might offer it (contemplation). Independent predictors of being in the precontemplation stage were being a primary care versus OB/GYN physician (odds ratio [OR] 3.29, p = .02), being in private versus hospital-based practice (OR 2.40, p = .03), and lacking concerns about FDA regulations (OR 2.06, p = .01) or violence and protests (OR 1.93, p = .03) as barriers to offering mifepristone.

CONCLUSIONS

For precontemplation-stage physicians, the most efficient strategy for increasing the availability of medical abortion may be to design programs that emphasize clinical benefits and feasibility to stimulate interest in the procedure. For contemplation-stage physicians, the optimum approach may be one that helps to overcome barriers associated with FDA regulations and concerns about violence and protests.

Abortion in the United States

Abortion is an extremely safe and common medical procedure. In the United States, over one million women had an abortion in the year 2000. Advances in early abortion techniques have helped to increase the proportion of early procedures, the safest type. Abortion rates have been declining since the early nineties among adults and adolescents, but rates among poor, minority women remain high. State restrictions to abortion have a larger impact on poor women and young women. Restrictions and regulations have also resulted in the concentration of abortion services in specialized clinics. These clinics are subject to harassment. The expansion of abortion services to more types of providers could increase access, as well as integrate abortion into women's health care.

The epigenetic environment: secondary sex ratio depends on differential survival in embryogenesis

Live human births are usually more than half male, in spite of excess losses of males throughout fetal development. These observations together demand an excess of males near the beginning of pregnancy greater than that seen at birth. Reductions of the usual excess of males among human live births have widely been considered to represent consequences of untoward circumstances surrounding conception. Repeated competent research efforts have found no evidence for any bias in gametogenesis or fertilization in favour of Y-bearing sperm. Male embryogenesis is faster and more efficient, leaving females in excess among failures before the fetal period. Sex differences in speed and efficiency of embryogenesis, dependent for example on epigenetic differences such as genomic imprinting, produce an excess of males at the transition from embryogenesis to clinical pregnancy, that will survive the male excess of losses throughout the fetal period, to yield an excess of males among live births. Changes in, or mediated by, the epigenetic environment of embryogenesis provide the most plausible prospects for causes of changes in secondary sex ratio.