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Ralph LJ, Baba CF, Biggs MA, McNicholas C, Hagstrom Miller A, Grossman D. Comparison of No-Test Telehealth and In-Person Medication Abortion. JAMA 2024; 332:898-905. [PMID: 38913394 PMCID: PMC11197442 DOI: 10.1001/jama.2024.10680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/17/2024] [Indexed: 06/25/2024]
Abstract
Importance In the US, access to medication abortion using history-based (no-test) eligibility assessment, including through telehealth and mailing of mifepristone, has grown rapidly. Additional evidence on the effectiveness and safety of these models is needed. Objective To evaluate whether medication abortion with no-test eligibility assessment and mailing of medications is as effective as in-person care with ultrasonography and safe overall. Design, Setting, and Participants Prospective, observational study with noninferiority analysis. Sites included 4 abortion-providing organizations in Colorado, Illinois, Maryland, Minnesota, Virginia, and Washington from May 2021 to March 2023. Eligible patients were seeking medication abortion up to and including 70 days' gestation, spoke English or Spanish, and were aged 15 years or older. Exposure Study groups reflected the model of care selected by the patient and clinicians and included: (1) no-test (telehealth) eligibility assessment and mailing of medications (no-test + mail) (n = 228); (2) no-test eligibility assessment and pickup of medications (no-test + pickup) (n = 119); or (3) in-person with ultrasonography (n = 238). Main Outcomes and Measures Effectiveness, defined as a complete abortion without the need for repeating the mifepristone and misoprostol regimen or a follow-up procedure, and safety, defined as an abortion-related serious adverse event, including overnight hospital admission, surgery, or blood transfusion. Outcomes were derived from patient surveys and medical records. Primary analysis focused on the comparison of the no-test + mail group with the in-person with ultrasonography group. Results The mean age of the participants (N = 585) was 27.3 years; most identified as non-Hispanic White (48.6%) or non-Hispanic Black (28.1%). Median (IQR) gestational duration was 45 days (39-53) and comparable between study groups (P = .30). Outcome data were available for 91.8% of participants. Overall effectiveness was 94.4% (95% CI, 90.7%-99.2%) in the no-test + mail group and 93.3% (95% CI, 88.3%-98.2%) in the in-person with ultrasonography group in adjusted models (adjusted risk difference, 1.2 [95% CI, -4.1 to 6.4]), meeting the prespecified 5% noninferiority margin. Serious adverse events included overnight hospitalization (n = 4), blood transfusion (n = 2), and emergency surgery (n = 1) and were reported by 1.1% (95% CI, 0.4%-2.4%) of participants, with 3 in the no-test + mail group, 3 in the in-person with ultrasonography group, and none in the no-test + pickup group. Conclusions and Relevance This prospective, observational study found that medication abortion obtained following no-test telehealth screening and mailing of medications was associated with similar rates of complete abortion compared with in-person care with ultrasonography and met prespecified criteria for noninferiority, with a low prevalence of adverse events.
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Affiliation(s)
- Lauren J. Ralph
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco
| | - C. Finley Baba
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco
| | - M. Antonia Biggs
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco
| | - Colleen McNicholas
- Planned Parenthood of the St. Louis Region and Southwest Missouri, St Louis
| | - Amy Hagstrom Miller
- Whole Woman’s Health & Whole Woman’s Health Alliance, Charlottesville, Virginia
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco
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Kimport K, McReynolds-Pérez J, Bercu C, Cisternas C, Wilkinson Salamea E, Zurbriggen R, Moseson H. The pleasure, joy and positive emotional experiences of abortion accompaniment after 17 weeks' gestation. CULTURE, HEALTH & SEXUALITY 2024; 26:1028-1043. [PMID: 38056488 DOI: 10.1080/13691058.2023.2287720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 11/21/2023] [Indexed: 12/08/2023]
Abstract
Research documents how abortion can be emotionally difficult and stigmatising, but generally has not considered whether and how involvement in abortion may be a source of positive emotions, including pleasure, belonging and even joy. The absence of explorations that start from the possibility of abortion pleasure and joy represents an epistemic foreclosure. Moreover, it highlights how social science literature has tended to emphasise the negative aspects of abortion care in ways that produce or amplify normative negative associations. In this paper, we investigate the positive emotions, pleasure and joy of abortion involvement by drawing on interviews conducted in 2019 with 28 abortion accompaniers in Argentina, Chile, and Ecuador about their experiences accompanying abortions after 17 weeks' gestation. Abortion accompaniment is a response to unsafe and/or inaccessible abortion whereby volunteer activists guide abortion seekers through a medication abortion. Interviewees described how the practice of accompaniment generated positive emotions by building a feminist community, shared intimacy among women, and witnessing aborting people claim their strength. Importantly, these positive emotional experiences of involvement with abortion were not distinct from the broader marginalisation of abortion but were, instead, rooted in its marginalisation.
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Affiliation(s)
- Katrina Kimport
- Advancing New Standards in Reproductive Health, University of California, San Francisco, Oakland, CA, USA
| | | | | | | | | | - Ruth Zurbriggen
- La Colectiva Feminista La Revuelta, Neuquén, Patagonia, Argentina
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Dethier D, Tschann M, Roman M, Chen JJ, Soon R, Kaneshiro B. Self-performed Rh typing: a cross-sectional study. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024:bmjsrh-2024-202349. [PMID: 39004443 DOI: 10.1136/bmjsrh-2024-202349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVE To evaluate whether patients are capable and willing to self-administer and interpret an EldonCard test to determine their Rh status. METHODS This was a cross-sectional study in Honolulu, HI, USA of pregnancy-capable people aged 14-50 years who did not know their blood type and had never used an EldonCard. Participants independently completed EldonCard testing, determined their Rh type and answered a survey on feasibility and acceptability. Separately, a blinded clinician recorded their interpretation of the participant's EldonCard. When available, we obtained blood type from the electronic health record (EHR). We measured Rh type agreement between participant, clinician and EHR, as well as participant comfort and acceptability of testing. RESULTS Of the 330 total participants, 288 (87.3%) completed testing. Patients and clinicians had 94.0% agreement in their interpretation of the EldonCard for Rh status. Patient interpretation had 83.5% agreement with EHR while clinician and EHR had 92.3% agreement. Sensitivity of EldonCard interpretation by patient and clinician was 100%. Specificity was 83.2% for patients and 92.2% for clinicians. Two patients (of 117) had Rh-negative blood type in the EHR. The vast majority of participants found the EldonCard testing easy (94.4%) and felt comfortable doing the testing (93.7%). Participants with lower education levels felt less confident (p=0.003) and less comfortable with testing (p=0.038); however, their ability to interpret results was similar to others (p=0.051). CONCLUSIONS Patient-performed Rh typing via the EldonCard is an effective and acceptable option for patients, and could be used as a primary screening test for Rh status.
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Affiliation(s)
- Divya Dethier
- Department of Obstetrics and Gynecology, University of Hawai'i at Manoa John A Burns School of Medicine, Honolulu, Hawaii, USA
| | - Mary Tschann
- Department of Obstetrics and Gynecology, University of Hawai'i at Manoa John A Burns School of Medicine, Honolulu, Hawaii, USA
| | - Meliza Roman
- Department of Quantitative Health Sciences, University of Hawai'i at Manoa John A Burns School of Medicine, Honolulu, Hawaii, USA
| | - John J Chen
- Department of Quantitative Health Sciences, University of Hawai'i at Manoa John A Burns School of Medicine, Honolulu, Hawaii, USA
| | - Reni Soon
- Department of Obstetrics and Gynecology, University of Hawai'i at Manoa John A Burns School of Medicine, Honolulu, Hawaii, USA
| | - Bliss Kaneshiro
- Department of Obstetrics and Gynecology, University of Hawai'i at Manoa John A Burns School of Medicine, Honolulu, Hawaii, USA
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4
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Pleasants EA, Jayaweera RT, Egwuatu I, Nmezi S, Kristianingrum IA, Zurbriggen R, Grosso B, Bercu C, Motana R, Gerdts C, Moseson H. Self-managed medication abortion trajectories: results from a prospective observational study in Argentina, Nigeria and Southeast Asia. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024; 50:155-164. [PMID: 37907254 DOI: 10.1136/bmjsrh-2023-201979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/11/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVES Time is a crucial factor in abortion-seeking because options for care change with pregnancy duration, and most people prefer to access abortion care early in pregnancy. We aimed to collect data on the timing of steps in accompanied self-managed abortion-seeking experiences in legally restrictive settings. METHODS In this prospective, observational, cohort study we recruited callers from three abortion accompaniment groups in Argentina, Nigeria and a country in Southeast Asia. Participants completed a baseline survey before starting a self-managed medication abortion (SMA) and two follow-up surveys (approximately 1 and 3 weeks after taking medication). Primary outcomes of interest included: (1) time from abortion decision to contacting the hotline, (2) time from contacting the hotline to obtaining pills and (3) time from obtaining pills to taking the first dose. We explored relationships between participant characteristics and each of these outcomes and evaluated differences in overall abortion time using survival analyses. RESULTS Between July 31, 2019 and October 01, 2020 we enrolled 1352 eligible callers; 1148 provided data for this analysis. After deciding to have an abortion, participants took 12.2 days on average (95% CI: 11.6, 12.9) to start medications for abortion. On average, participants at later pregnancy durations progressed through the SMA process more quickly (<4 weeks: 20.9 days, 4 weeks: 11 days, 5-6 weeks: 10.1 days, 7-9 weeks, 10.4 days, 10+ weeks: 9.1 days; p<0.001). CONCLUSIONS Overall, participants accessed accompaniment group support and started abortion regimens quickly and at relatively early pregnancy durations. SMA with accompaniment provided a time-efficient route for obtaining abortions.
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Affiliation(s)
- Elizabeth A Pleasants
- School of Public Health, University of California Berkeley, Berkeley, California, USA
| | | | - Ijeoma Egwuatu
- Generation Initiative for Women and Youth, Lagos, Nigeria
| | - Sybil Nmezi
- Generation Initiative for Women and Youth, Lagos, Nigeria
| | | | | | - Belén Grosso
- La Revuelta Colectiva Feminista, Neuquén, Argentina
| | - Chiara Bercu
- Ibis Reproductive Health, Oakland, California, USA
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5
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Kapp N, Bawah AA, Agula C, Menzel JL, Antobam SK, Asuming PO, Eckersberger E, Pearson EE. Medical abortion in Ghana: A non-randomized, non-inferiority study of access through pharmacies compared with clinics. Contraception 2024:110538. [PMID: 39002625 DOI: 10.1016/j.contraception.2024.110538] [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: 04/22/2024] [Revised: 07/03/2024] [Accepted: 07/09/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVES To compare self-reported clinical outcomes following medical abortion with mifepristone and misoprostol sourced from either a pharmacy or health clinic. STUDY DESIGN We conducted a prospective, non-randomized, non-inferiority cohort study across four regions in Ghana, from high-volume pharmacies and health clinics. Participants seeking medical abortion (less than nine weeks' gestation) who met usual medical abortion eligibility criteria were recruited. Data collection included baseline surveys, follow-up phone interviews, and self-reported assessments of medical abortion outcomes. The study aimed to enroll 2000 medical abortion users (1000 from each source). RESULTS Complete outcome data was available and analyzed from 1958 participants (of 2208 enrolled), with the adjusted risk difference of need for additional treatment to complete the abortion indicating non-inferiority of the pharmacy group compared to the clinic group [-2.3% (95% CI -5.3% to 0.7%)]. Both groups reported low rates of additional treatment (4.9%) and adhered similarly to the abortion regimen. Secondary outcomes showed no significant differences, with moderate acceptability in both groups (65.4% pharmacy, 52.3% facility). Adverse outcomes were rare: one ectopic pregnancy, one blood transfusion and no deaths or other major complications were reported. CONCLUSIONS Accessing medical abortion pills directly from pharmacies without prior consultation from a provider demonstrated non-inferior self-reported clinical outcomes compared to seeking care from health clinics. The findings align with the growing global evidence supporting the safety and effectiveness of medical abortion self-care. IMPLICATIONS This study contributes data which support future registration of over-the-counter use of medical abortion drugs up to nine weeks' gestation. Such measures could expand options for safe abortion care, especially in regions where unsafe abortion poses a substantial maternal health risk. TRIAL REGISTRATION ClinicalTrials.gov (NCT03727308).
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Affiliation(s)
| | - Ayaga A Bawah
- Regional Institute for Population Studies (RIPS), University of Ghana, Accra, Ghana
| | - Caesar Agula
- Regional Institute for Population Studies (RIPS), University of Ghana, Accra, Ghana
| | | | - Samuel K Antobam
- Regional Institute for Population Studies (RIPS), University of Ghana, Accra, Ghana
| | - Patrick O Asuming
- University of Ghana Business School (UGBS), University of Ghana, Accra, Ghana
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6
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Gerdts C, Sunderlin K, Cárdenas-Peña N. Self-Managed Abortion and Criminalization in the Post-Dobbs US. JAMA Netw Open 2024; 7:e2424298. [PMID: 39078636 DOI: 10.1001/jamanetworkopen.2024.24298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/31/2024] Open
Affiliation(s)
| | - Kylee Sunderlin
- Legal and Policy Department, If/When/How, Ypsilanti, Michigan
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7
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Hoggart L, Purcell C, Bloomer F, Newton V, Oluseye A. Social connectedness and supported self-management of early medication abortion in the UK: experiences from the COVID-19 pandemic and learning for the future. CULTURE, HEALTH & SEXUALITY 2024; 26:855-870. [PMID: 37830180 DOI: 10.1080/13691058.2023.2258189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 09/08/2023] [Indexed: 10/14/2023]
Abstract
Medication abortion has been established globally as safe and effective. This modality has increased accessibility and the opportunity to centre individual autonomy at the heart of abortion care, by facilitating self-managed abortion. Previous research has shown how self-managed abortion is beneficial in myriad settings ranging from problematic to (relatively) unproblematic contexts of access. In this paper we explore the relationship between self-management and sources of support (including health professionals, family, and friends); as well as considering issues of reproductive control and autonomy. Drawing on qualitative, experience-centred interviews, we utilise the concept of social connectedness to examine how supported self-managed abortion was experienced in the United Kingdom during the COVID-19 pandemic. Overall, self-management was welcomed, with participants speaking positively about managing their own abortion at home. However, a sense of connectedness was crucial in helping participants deal with difficult experiences; and functioned to support individual autonomy in self-care. This paper is the first to examine factors of connection, support, and isolation, as experienced by those undergoing self-managed abortion in the UK in detail. Our research suggests a continued need to advocate for high quality support for self-managed abortion, as well as for choice of abortion method, to support patient-centered care.
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Affiliation(s)
- Lesley Hoggart
- Faculty of Wellbeing, Education & Language Studies, Open University, Milton Keynes, UK
| | - Carrie Purcell
- Faculty of Wellbeing, Education & Language Studies, Open University, Milton Keynes, UK
| | - Fiona Bloomer
- School of Applied Social and Policy Sciences, Ulster University, Belfast, UK
| | - Victoria Newton
- Faculty of Wellbeing, Education & Language Studies, Open University, Milton Keynes, UK
| | - Ayomide Oluseye
- Faculty of Wellbeing, Education & Language Studies, Open University, Milton Keynes, UK
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8
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Luchetti G, Albardonedo V, Alfonso MV. [Women's rescuers network: Community support for self-managed abortion in Argentina]. Salud Colect 2024; 20:e4810. [PMID: 38992339 DOI: 10.18294/sc.2024.4810] [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: 02/17/2024] [Accepted: 05/30/2024] [Indexed: 07/13/2024] Open
Abstract
The availability of medications to induce abortion, especially in contexts of restricted access, has transformed practices and allowed women and/or their community organizations to assist other women in obtaining abortions, whether or not they interact with the healthcare system. This study recovers the experience of a feminist community organization that, from the province of Neuquén, extends throughout the country, creating a network of community care. An exploratory descriptive study with a qualitative approach was conducted to analyze the experiences of women who facilitate access to permitted abortion in Argentina. Through in-depth interviews with three leaders of the feminist collective La Revuelta and semi-structured interviews with 33 members of the socorrista groups, conducted between November 2019 and December 2020, we describe their history and processes of work and growth; we explore their motivations and feelings and characterize the interactions of these organizations with public and private health systems. The results of this work align with the international conversation and bibliographic production about these organizations and their particularities, and with the need to incorporate these forms of care into institutional health systems.
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Affiliation(s)
- Gabriela Luchetti
- Médica, ginecóloga-obstetra. Magíster en Genero Sociedad y Políticas. Profesora adjunta, Facultad de Medicina, Universidad Nacional del Comahue, Neuquén, Argentina
| | - Valeria Albardonedo
- Licenciada en Comunicación Social. Magíster en Ciencias Sociales. Asistente Docencia, Facultad de Medicina, Universidad Nacional del Comahue, Neuquén, Argentina
| | - María Victoria Alfonso
- Licenciada en Comunicación Social. Magíster en Política y Gestión de la Ciencia y la Tecnología. Secretaria, Consejo Superior, Universidad Nacional del Comahue, Neuquén, Argentina
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9
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Keefe-Oates B, Filippa S, Janiak E, Zurbriggen R, Grosso B, Chen JT, Gerdts C, Gottlieb B. Seeking abortion accompaniment: experiences and self-managed abortion preferences of hotline callers after abortion legalisation in Argentina. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024:bmjsrh-2023-202209. [PMID: 38889960 DOI: 10.1136/bmjsrh-2023-202209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 05/16/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Until the legalisation of abortion in Argentina in 2021, the Socorristas en Red, a network of feminist collectives, provided support and information ('accompaniment') to people self-managing their abortion with medications. Following legalisation, the Socorristas continued accompanying people self-managing or accessing abortion through the healthcare system. We conducted a cross-sectional study to understand preferences, experiences and choices about abortion when contacting a Socorristas hotline after legalisation of abortion in Argentina. METHODS We surveyed callers to the Socorristas' hotline in Neuquén, Argentina about their demographics, pregnancy history, reasons for calling, and experiences seeking abortion through the hotline and the healthcare system. We assessed overall prevalence of these experiences, and analysed differences between people who contacted the health system before calling the hotline and those who first called the hotline for services. RESULTS Of the 755 callers in the study, the majority (63.3%) contacted the Socorristas because they trusted them, and 21.7% called because they both trusted the Socorristas and did not want to go to the healthcare system. At the end of the call, most people (95.4%) chose to self-manage their abortion with accompaniment outside the healthcare system. People who called the healthcare system prior to contacting the hotline frequently reported being referred to the Socorristas, as well as challenges scheduling appointments. CONCLUSIONS After legalisation of abortion in Argentina there is continued demand for accompaniment. Globally, ensuring that accompaniment and self-management of abortion is legal and protected will provide individuals with the support and facilitated access to the abortion care they desire.
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Affiliation(s)
- Brianna Keefe-Oates
- Department of Social and Behavioral Sciences, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Sofia Filippa
- Ibis Reproductive Health, Cambridge, Massachusetts, USA
| | - Elizabeth Janiak
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Belén Grosso
- La Revuelta Colectiva Feminista, Neuquén, Argentina
| | - Jarvis T Chen
- Department of Social and Behavioral Sciences, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Barbara Gottlieb
- Department of Social and Behavioral Sciences, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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10
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Upadhyay UD, Adkins CE. Deception by obfuscation: Studnicki et al.'s retracted longitudinal cohort study of emergency room utilization following abortion. Contraception 2024; 134:110417. [PMID: 38494149 DOI: 10.1016/j.contraception.2024.110417] [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: 12/12/2023] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVES In November 2022, the anti-abortion advocacy group Alliance for Hippocratic Medicine filed a lawsuit against the U.S. Food and Drug Administration challenging the initial 2000 approval of mifepristone and its subsequent approvals, which removed unnecessary restrictions on its use, by disputing the medication's safety record. Such challenges relied on a study examining the incidence of emergency room visits following medication abortion with mifepristone and procedural abortion using Medicaid claims data from 1999-2015. In February 2024 that study was retracted by its publisher. In this paper, we analyzed the methods and presentations of the data used in the study. STUDY DESIGN We drew upon commonly accepted principles in responsible epidemiologic and scientific research to evaluate the methods and presentations of the data and organized our findings into themes. RESULTS We found multiple instances of methodological flaws, mischaracterizations, and obfuscations of data in this study, including use of a misleading research question and framing, analytic flaws, inappropriate use of an unvalidated proxy measure for outcomes of interest, and inappropriate and deceptive visualizations of data. In each instance, the resulting effect obfuscated and misrepresented the safety of medication abortion with mifepristone. CONCLUSIONS The misrepresentation and exaggeration of data promoted and exacerbated misinterpretations about the study's findings, resulting in substantial harm before it was retracted. Recognizing that ongoing judicial proceedings threaten access to conventional reproductive health care in the United States, public health policies must be informed by scientific and medical literature that is comprehensive, methodologically sound, and absent any obfuscations or misrepresentations. IMPLICATIONS Studnicki et al.'s study of emergency room visits after abortion misrepresented the safety of mifepristone with multiple instances of methodological flaws and obfuscations of data. While the study has now been retracted, it led to irrevocable harm, threatening access to medication abortion, which has an established safety record.
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Affiliation(s)
- Ushma D Upadhyay
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, United States.
| | - Chris E Adkins
- Department of Pharmaceutical Sciences, School of Pharmacy, South University, Savannah, GA, United States
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11
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Littell JH, Young S, Pigott TD, Biggs MA, Munk‐Olsen T, Steinberg JR. PROTOCOL: Abortion and mental health outcomes: A systematic review and meta-analysis. CAMPBELL SYSTEMATIC REVIEWS 2024; 20:e1410. [PMID: 38779333 PMCID: PMC11109527 DOI: 10.1002/cl2.1410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 04/17/2024] [Accepted: 04/23/2024] [Indexed: 05/25/2024]
Abstract
This is a protocol for a systematic review and meta-analysis of research on mental health outcomes of abortion. Does abortion increase the risk of adverse mental health outcomes? That is the central question for this review. Our review aims to inform policy and practice by locating, critically appraising, and synthesizing empirical evidence on associations between abortion and subsequent mental health outcomes. Given the controversies surrounding this topic and the complex social, political, legal, and ideological contexts in which research and reviews on abortion are conducted, it is especially important to conduct this systematic review and meta-analysis with comprehensive, rigorous, unbiased, and transparent methods. We will include a variety of study designs to enhance understanding of studies' methodological strengths and weaknesses and to identify potential explanations for conflicting results. We will follow open science principles, providing access to our methods, measures, and results, and making data available for re-analysis.
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Affiliation(s)
- Julia H. Littell
- Graduate School of Social Work and Social ResearchBryn Mawr CollegeBryn MawrPennsylvaniaUSA
| | - Sarah Young
- Hunt LibraryCarnegie Mellon UniversityPittsburghPennsylvaniaUSA
| | - Therese D. Pigott
- College of Education and Human DevelopmentGeorgia State UniversityAtlantaGeorgiaUSA
| | - M. Antonia Biggs
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, School of MedicineUniversity of California San FranciscoOaklandCaliforniaUSA
| | - Trine Munk‐Olsen
- Department of PsychiatryUniversity of Southern DenmarkOdenseDenmark
| | - Julia R. Steinberg
- Department of Family Science, School of Public HealthUniversity of MarylandCollege ParkMarylandUSA
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Aiken ARA, Wells ES, Gomperts R, Scott JG. Provision of Medications for Self-Managed Abortion Before and After the Dobbs v Jackson Women's Health Organization Decision. JAMA 2024; 331:1558-1564. [PMID: 38526865 PMCID: PMC10964154 DOI: 10.1001/jama.2024.4266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/06/2024] [Indexed: 03/27/2024]
Abstract
Importance The Supreme Court decision in Dobbs v Jackson Women's Health Organization overturned the right to choose abortion in the US, with at least 16 states subsequently implementing abortion bans or 6-week gestational limits. Prior research indicates that in the 6 months following Dobbs, approximately 32 360 fewer abortions were provided within the US formal health care setting. However, trends in the provision of medications for self-managed abortion outside the formal health care setting have not been studied. Objective To determine whether the provision of medications for self-managed abortion outside the formal health care setting increased in the 6 months after Dobbs. Design, Setting, and Participants Cross-sectional study using data from sources that provided abortion medications outside the formal health care setting to people in the US between March 1 and December 31, 2022, including online telemedicine organizations, community networks, and online vendors. Using a hierarchical bayesian model, we imputed missing values from sources not providing data. We estimated the change in provision of medications for self-managed abortion after the Dobbs decision. We then estimated actual use of these medications by accounting for the possibility that not all provided medications are used by recipients. Exposure Abortion restrictions following the Dobbs decision. Main Outcomes and Measures Provision and use of medications for a self-managed abortion. Results In the 6-month post-Dobbs period (July 1 to December 31, 2022), the total number of provisions of medications for self-managed abortion increased by 27 838 (95% credible interval [CrI], 26 374-29 175) vs what would have been expected based on pre-Dobbs levels. Excluding imputed data changes the results only slightly (27 145; 95% CrI, 25 747-28 246). Accounting for nonuse of medications, actual self-managed medication abortions increased by an estimated 26 055 (95% CrI, 24 739-27 245) vs what would have been expected had the Dobbs decision not occurred. Conclusions and Relevance Provision of medications for self-managed abortions increased in the 6 months following the Dobbs decision. Results suggest that a substantial number of abortion seekers accessed services despite the implementation of state-level bans and restrictions.
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Affiliation(s)
| | | | | | - James G. Scott
- McCombs School of Business, University of Texas at Austin
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13
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Atienzo EE, Cruz V, Garduño S, Lomelí S, Meza M, Zurbriggen R, Carbone SL, Wollum A. Safe abortion in Latin America: a look at abortion accompaniment collectives from the perspective of their activists. CULTURE, HEALTH & SEXUALITY 2024; 26:588-604. [PMID: 37504892 DOI: 10.1080/13691058.2023.2233589] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 07/03/2023] [Indexed: 07/29/2023]
Abstract
Over the last decade, activists in Latin America have expanded access to safe abortion through processes of accompaniment. Abortion accompaniment is characterised by activism and community-based strategies to facilitate access to, and safe use of, medication abortion, mainly outside clinical contexts. Drawing on findings from a survey of 515 activists who were part of Accompaniment Collectives in Latin America, this study describes the organisation of these collectives, barriers and facilitators to their activism, and how accompaniers perceive the impact and future of abortion accompaniment. Accompaniment Collectives are organised and flexible and operate in diverse social and legal contexts. The main goals of accompaniment are the normalisation and social decriminalisation of abortion culturally (84%); the social construction of autonomy (79%); and the protection of people's freedom (73%), life (71%) and health (67%). Activists in legally restrictive settings identified limited access to abortion medication (73%) and restrictive laws (71%) as the main barriers to accompaniment, while health care personnel objecting to abortion provision on grounds of conscience was most common in legally permissive settings (64%). Collectives have developed strategies to overcome such barriers to and expanding access to abortion care. Activists expect accompaniment to continue regardless of the legal status of abortion.
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Affiliation(s)
| | | | - Sofía Garduño
- Fondo de Aborto para la Justicia Social MARIA, Ciudad de México, México
| | - Stephanie Lomelí
- Fondo de Aborto para la Justicia Social MARIA, Ciudad de México, México
| | - Milena Meza
- Con las Amigas y en la Casa, Santiago, Chile
| | - Ruth Zurbriggen
- Colectiva Feminista La Revuelta en Socorristas en Red, Neuquén, Argentina
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14
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Upadhyay UD, Koenig LR, Meckstroth K, Ko J, Valladares ES, Biggs MA. Effectiveness and safety of telehealth medication abortion in the USA. Nat Med 2024; 30:1191-1198. [PMID: 38361123 PMCID: PMC11031403 DOI: 10.1038/s41591-024-02834-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/24/2024] [Indexed: 02/17/2024]
Abstract
Telehealth abortion has become critical to addressing surges in demand in states where abortion remains legal but evidence on its effectiveness and safety is limited. California Home Abortion by Telehealth (CHAT) is a prospective study that follows pregnant people who obtained medication abortion via telehealth from three virtual clinics operating in 20 states and Washington, DC between April 2021 and January 2022. Individuals were screened using a standardized no-test protocol, primarily relying on their medical history to assess medical eligibility. We assessed effectiveness, defined as complete abortion after 200 mg mifepristone and 1,600 μg misoprostol (or lower) without additional intervention; safety was measured by the absence of serious adverse events. We estimated rates using multivariable logistic regression and multiple imputation to account for missing data. Among 6,034 abortions, 97.7% (95% confidence interval (CI) = 97.2-98.1%) were complete without subsequent known intervention or ongoing pregnancy after the initial treatment. Overall, 99.8% (99.6-99.9%) of abortions were not followed by serious adverse events. In total, 0.25% of patients experienced a serious abortion-related adverse event, 0.16% were treated for an ectopic pregnancy and 1.3% abortions were followed by emergency department visits. There were no differences in effectiveness or safety between synchronous and asynchronous models of care. Telehealth medication abortion is effective, safe and comparable to published rates of in-person medication abortion care.
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Affiliation(s)
- Ushma D Upadhyay
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
| | - Leah R Koenig
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Karen Meckstroth
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer Ko
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | | | - M Antonia Biggs
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
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15
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Dutton-Kenny M, Ojanen-Goldsmith A, Dwyer E, Horner D, Prager SW. Supported at-home abortion: An exploratory study of methods, outcomes, and motivations of community-led abortion care in the United States and Canada. Contraception 2024; 132:110368. [PMID: 38232941 DOI: 10.1016/j.contraception.2024.110368] [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: 05/29/2022] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVES This an exploratory study aimed to describe methods and outcomes of comprehensive community-led abortion care in the United States and Canada. STUDY DESIGN This community-based participatory research study recruited community abortion providers from the United States and Canada through existing confidential networks. They participated through in-person and online collaboration to design and implement a data collection tool for abortion methods, outcomes, and motivations from clients. We implemented significant security measures to protect participant confidentiality. RESULTS Thirty community providers were recruited, five withdrew, and 12 provided data for 167 at-home abortions. Most abortions occurred between 6 and 10 weeks (104 [62%]). Abortions between 13 and 21 weeks represent 39 cases (23%). Misoprostol only was the most common method (n = 125 [75%]), followed by herbs alone (n = 12 [7%]) and aspiration (n = 12 [7%]). Complications were rare (n = 3 [1.8%]), with 163 complete abortions (98%). The primary motivation for seeking community-led abortion care was avoiding a clinic. CONCLUSIONS Community providers employed various abortion methods with safety and effectiveness profiles comparable to those reported for clinical and community-based abortion care. Clients wanting a different model of abortion care seek out community-led abortions, regardless of whether clinics are legal and accessible. IMPLICATIONS Community-led abortion is a viable choice for patients. Community providers should be recognized for their contributions to abortion access and high-quality, person-centered care. This study demonstrates a broader range of abortion providers and diverse options meeting the need for individualized abortion care.
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Affiliation(s)
| | | | - Erin Dwyer
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, United States
| | | | - Sarah Ward Prager
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, United States.
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16
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McMahon HV, McMahon BD. Automating untruths: ChatGPT, self-managed medication abortion, and the threat of misinformation in a post- Roe world. Front Digit Health 2024; 6:1287186. [PMID: 38419805 PMCID: PMC10900507 DOI: 10.3389/fdgth.2024.1287186] [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: 09/01/2023] [Accepted: 01/26/2024] [Indexed: 03/02/2024] Open
Abstract
Background ChatGPT is a generative artificial intelligence chatbot that uses natural language processing to understand and execute prompts in a human-like manner. While the chatbot has become popular as a source of information among the public, experts have expressed concerns about the number of false and misleading statements made by ChatGPT. Many people search online for information about self-managed medication abortion, which has become even more common following the overturning of Roe v. Wade. It is likely that ChatGPT is also being used as a source of this information; however, little is known about its accuracy. Objective To assess the accuracy of ChatGPT responses to common questions regarding self-managed abortion safety and the process of using abortion pills. Methods We prompted ChatGPT with 65 questions about self-managed medication abortion, which produced approximately 11,000 words of text. We qualitatively coded all data in MAXQDA and performed thematic analysis. Results ChatGPT responses correctly described clinician-managed medication abortion as both safe and effective. In contrast, self-managed medication abortion was inaccurately described as dangerous and associated with an increase in the risk of complications, which was attributed to the lack of clinician supervision. Conclusion ChatGPT repeatedly provided responses that overstated the risk of complications associated with self-managed medication abortion in ways that directly contradict the expansive body of evidence demonstrating that self-managed medication abortion is both safe and effective. The chatbot's tendency to perpetuate health misinformation and associated stigma regarding self-managed medication abortions poses a threat to public health and reproductive autonomy.
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Affiliation(s)
- Hayley V. McMahon
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, GA, United States
- The Center forReproductive Health Research in the Southeast, Emory University Rollins School of Public Health, Atlanta, GA, United States
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17
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McGovern T, Favier M, Gil L, Kitaba-Gaviglio B, Bencomo C, Memaj I, Garbers S, Maier M. Applying global lessons to protect abortion access in the United States. BMJ 2024; 384:e073833. [PMID: 38171571 DOI: 10.1136/bmj-2022-073833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Affiliation(s)
- Terry McGovern
- CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | | | - Laura Gil
- Grupo Médico por el Derecho a Decidir, Colombia
| | | | - Clarisa Bencomo
- CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | - Ira Memaj
- CUNY Graduate School of Public Health and Health Policy, New York, NY, USA
| | - Samantha Garbers
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Malia Maier
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, NY, USA
- Program on Global Health Justice and Governance, Columbia University Mailman School of Public Health, New York, NY, USA
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18
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Fleurant E, McCloskey L. Medication Abortion: A Comprehensive Review. Clin Obstet Gynecol 2023; 66:706-724. [PMID: 37910067 DOI: 10.1097/grf.0000000000000812] [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
This chapter provides an overview of evidence-based guidelines for medication abortion in the first trimester. We discuss regimens, both FDA-approved and other clinical-based protocols, and will briefly discuss novel self-managed abortion techniques taking place outside the formal health care system. Overview of patient counseling and pain management are presented with care to include guidance on "no touch" regimens that have proven both feasible and effective. We hope that this comprehensive review helps the health care community make strides to increase access to abortion in a time when reproductive health care is continuously restricted.
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Affiliation(s)
- Erin Fleurant
- Department of Obstetrics and Gynecology, Northwestern McGaw Medical Center, Chicago, Illinois
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19
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Willis B, Church K, Perttu E, Thompson H, Weerasinghe S, Macias-Konstantopoulos W. The preventable burden of mortality from unsafe abortion among female sex workers: a Community Knowledge Approach survey among peer networks in eight countries. Sex Reprod Health Matters 2023; 31:2250618. [PMID: 37712508 PMCID: PMC10506426 DOI: 10.1080/26410397.2023.2250618] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
Previous studies have found high levels of unintended pregnancy among female sex workers (FSW), but less attention has been paid to their abortion practices and outcomes. This study is the first to investigate abortion-related mortality among FSW across eight countries: Angola, Brazil, Democratic Republic of Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa. The Community Knowledge Approach (CKA) was used to survey a convenience sample of FSW (n = 1280). Participants reported on the deaths of peer FSW in their social networks during group meetings convened by non-governmental organisations (n = 165 groups, conducted across 24 cities in 2019). Details on any peer FSW deaths in the preceding five years were recorded. The circumstances of abortion-related deaths are reported here. Of the 1320 maternal deaths reported, 750 (56.8%) were due to unsafe abortion. The number of abortion-related deaths reported was highest in DRC (304 deaths reported by 270 participants), Kenya (188 deaths reported by 175 participants), and Nigeria (216 deaths reported by 312 participants). Among the abortion-related deaths, mean gestational age was 4.6 months and 75% occurred outside hospital. Unsafe abortion methods varied by country, but consumption of traditional or unknown medicines was most common (37.9% and 29.9%, respectively). The 750 abortion-related deaths led to 1207 children being left motherless. The CKA successfully recorded a stigmatised practice among a marginalised population, identifying very high levels of abortion-related mortality. Urgent action is now needed to deliver comprehensive sexual and reproductive healthcare to this vulnerable population, including contraption, safe abortion, and post-abortion care.
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Affiliation(s)
- Brian Willis
- Director, Global Health Promise, Portland, OR, USA
| | - Kathryn Church
- Independent Consultant, London, UK; Honorary Assistant Professor, Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Emily Perttu
- Director of Data Analysis, Global Health Promise, Portland, OR, USA
| | - Heather Thompson
- Maternal Health Advisor, Global Health Promise, Portland, OR, USA; Adjunct Professor, Schulich School of Medicine, McMaster Faculty of Medicine; & Obstetrician/Gynecologist, Grey Bruce Health Services, Hamilton, Ontario, Canada
| | - Swarna Weerasinghe
- Biostatistician, Global Health Promise, Portland, OR, USA; Associate Professor, Department of Community Health and Epidemiology, Dalhousie University, Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Wendy Macias-Konstantopoulos
- Global Policy Advisor, Global Health Promise, Portland, OR, USA; Director, Center for Social Justice and Health Equity, Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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20
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Lerma K, Coplon L, Goyal V. Travel for abortion care: implications for clinical practice. Curr Opin Obstet Gynecol 2023; 35:476-483. [PMID: 37916900 DOI: 10.1097/gco.0000000000000915] [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
PURPOSE OF REVIEW Traveling long distances to obtain abortion care due to restrictions and scarce availability is associated with significant obstacles. We review clinical strategies that can facilitate abortion access and outline considerations to ensure person-centered and equitable care. RECENT FINDINGS Establishing a patient's gestational duration prior to travel may be beneficial to ensure they are eligible for their desired abortion method at the preferred facility or to determine if a multiday procedure is required. If a local ultrasound cannot be obtained prior to travel, evidence demonstrates people can generally estimate their gestational duration accurately. If unable to provide care, clinicians should make timely referrals for abortion. Integration of telemedicine into abortion care is safe and well regarded by patients and should be implemented into service delivery where possible to reduce obstacles to care. Routine in-person follow-up care is not necessary. However, for those who want reassurance, formalized pathways to care should be established to ensure people have access to care in their community. To further minimize travel-related burdens, facilities should routinely offer information about funding and practical support, emotional support, and legal resources. SUMMARY There are many opportunities to optimize clinical practice to support those traveling for abortion care.
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Affiliation(s)
- Klaira Lerma
- Population Research Center, The University of Texas at Austin, Austin, Texas
| | - Leah Coplon
- Abortion On Demand, Seattle, Washington, USA
| | - Vinita Goyal
- Population Research Center, The University of Texas at Austin, Austin, Texas
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21
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Acre VN, Küng SA, Arce C, Yapu A, Iriondo D, Morales M. Reach, experience, and acceptability of an abortion self-care intervention in Bolivia: a mixed-methods evaluation. Sex Reprod Health Matters 2023; 31:2139888. [PMID: 36867125 PMCID: PMC9987779 DOI: 10.1080/26410397.2022.2139888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
In 2018, Ipas Bolivia launched an abortion self-care (ASC) community intervention with the goal of increasing access to supportive, well-informed abortion support provided by community agents (CAs). Between September 2019 and July 2020, Ipas conducted a mixed-methods evaluation to assess the reach, outcomes, and acceptability of the intervention. We used logbook data maintained by CAs to capture demographic characteristics and ASC outcomes of people supported. We also conducted in-depth interviews with 25 women who had received support and 22 CAs who had provided support. 530 people accessed ASC support through the intervention, most of whom were young, single, educated women accessing abortion in the first trimester. Among the 302 people who self-managed their abortions, 99% reported having a successful abortion. No women reported adverse events. All women interviewed expressed satisfaction with the support provided by the CA and, in particular, with the information, lack of judgement, and respect they felt from CAs. CAs spoke highly about their experience and viewed their participation as a way to increase people's ability to exercise their reproductive rights. Obstacles included experiences of stigma, fears of legal repercussions, and difficulties dispelling misconceptions around abortion. Legal restrictions and abortion stigma continue to complicate access to safe abortion, and findings from this evaluation highlight important avenues for the effectiveness and expansion of ASC interventions, including legal support to people who have abortions and those who provide abortion support, building capacity of people as informed buyers, and ensuring that interventions reach rural and other often under-served people.
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Affiliation(s)
- Valerie N Acre
- Senior Research, Monitoring and Evaluation Advisor, Ipas, Chapel Hill, NC, USA. Correspondence:
| | | | | | - Adela Yapu
- Program Manager, Ipas Bolivia, La Paz, Bolivia
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22
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Wulf S, Vinekar K, Dehlendorf C, Srinivasulu S, Steinauer J, Carvajal DN. Implications of Overturning Roe v Wade on Abortion Training in US Family Medicine Residency Programs. Ann Fam Med 2023; 21:545-548. [PMID: 38012041 PMCID: PMC10681702 DOI: 10.1370/afm.3042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 11/29/2023] Open
Abstract
In June 2022, the US Supreme Court overturned Roe v Wade, opening the door to state-level abortion bans. By August 2023, 17 states banned abortion or instituted early gestational age bans. We performed an analysis to assess the proportion of accredited US family medicine residency programs and trainees in states with abortion restrictions. Twenty-nine percent of family medicine residency programs (n = 201) and residents (n = 3,930) are in states with bans or very restrictive policies. Family medicine residency programs must optimize training and exposure to abortion within their contexts, so graduates are able to care for patients seeking abortions or needing follow-up care.
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Affiliation(s)
- Sarah Wulf
- Person-Centered Reproductive Health Program, Department of Family and Community Medicine, University of California, San Francisco, California
| | - Kavita Vinekar
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christine Dehlendorf
- Person-Centered Reproductive Health Program, Department of Family and Community Medicine, University of California, San Francisco, California
| | | | - Jody Steinauer
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California
| | - Diana N Carvajal
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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23
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Raymond EG, Weaver MA, Shochet T. Effectiveness and safety of misoprostol-only for first-trimester medication abortion: An updated systematic review and meta-analysis. Contraception 2023; 127:110132. [PMID: 37517447 DOI: 10.1016/j.contraception.2023.110132] [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: 03/22/2023] [Revised: 07/20/2023] [Accepted: 07/26/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES This study aimed to update our 2019 systematic review of data on the effectiveness and safety of misoprostol-only for first-trimester abortion. STUDY DESIGN We searched PubMed on December 18, 2022, to find published articles describing the outcomes of treatment with misoprostol-only for abortion of viable intrauterine pregnancy at ≤91 days of gestation. From each article identified, two authors independently abstracted relevant data about each group of patients treated with a distinct regimen. We assessed the risk of bias using four defined indicators. We estimated the proportion of patients with treatment failure using meta-analytic methods as well as the proportion hospitalized or transfused after treatment. We examined associations between treatment failure and selected characteristics of the groups. RESULTS We identified 49 papers with 66 groups that collectively included 16,354 evaluable patients, of whom 2960 (meta-analytic estimate 15%, 95% CI 12%, 19%) had treatment failures. Of 9228 patients assessed for ongoing pregnancy after treatment, 521 (meta-analytic estimate 6%, 95% CI 5%, 8%) had that condition. Failure risk was significantly associated with misoprostol dose, the total allowed number of doses, the maximum duration of dosing, and certain indicators of risk of bias. Among 11,007 patients allowed to take at least three misoprostol doses, the first consisting of misoprostol 800 mcg administered vaginally, sublingually, or buccally, the meta-analytic estimate of the failure risk was 11% (95% CI 8%, 14%). At most, 0.2% of 15,679 evaluable patients were hospitalized or received transfusions. CONCLUSIONS Although some studies in this updated review were adjudicated to have a high risk of bias, the results continue to support the key conclusion of our 2019 analysis: misoprostol-only is effective and safe for the termination of first-trimester intrauterine pregnancy. IMPLICATIONS Misoprostol-only is a safe and effective option for medication abortion in the first trimester if mifepristone is unavailable or inaccessible.
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Affiliation(s)
| | - Mark A Weaver
- Elon University, Department of Mathematics and Statistics, Elon, NC, United States
| | - Tara Shochet
- Gynuity Health Projects, New York, NY, United States
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24
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Jayaweera R, Egwuatu I, Nmezi S, Kristianingrum IA, Zurbriggen R, Grosso B, Bercu C, Gerdts C, Moseson H. Medication Abortion Safety and Effectiveness With Misoprostol Alone. JAMA Netw Open 2023; 6:e2340042. [PMID: 37889485 PMCID: PMC10611991 DOI: 10.1001/jamanetworkopen.2023.40042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/12/2023] [Indexed: 10/28/2023] Open
Abstract
Importance Misoprostol-alone regimens for abortion may be more effective than previously thought. Objective To estimate the effectiveness of medication abortion with misoprostol alone among individuals self-managing their abortion. Design, Setting, and Participants For this prospective observational cohort study of callers to safe abortion hotlines and accompaniment groups in Argentina, Nigeria, and Southeast Asia, participants were recruited between July 31, 2019, and October 1, 2020, prior to starting their medication abortion. Eligible participants were 13 years or older, had no contraindications to medication abortion, and were not currently bleeding. Participants completed a baseline and 2 follow-up surveys. The analysis was restricted to participants who reported using misoprostol alone and was performed between January 6, 2022 and September 8, 2023. Exposure Self-managed medication abortion using misoprostol alone. Main Outcomes and Measures The primary outcome was effectiveness, defined as participant self-report of complete abortion without procedural intervention, measured at 1 week and 3 weeks after taking misoprostol. Secondary outcomes included method safety, measured by self-report of experiencing warning signs (eg, heavy bleeding, pain, fever, discharge) indicative of a potential complication and by medical treatment (eg, blood transfusion, intravenous fluids, overnight hospital stay) indicative of a potential adverse event. Additional outcomes included length of bleeding and cramping, time to expulsion, and experience of adverse effects. Results Among 1352 enrolled participants, 637 used misoprostol-alone regimens for abortion and were included in the analysis (591 [92.8%] from Nigeria, 45 [7.1%] from Southeast Asia, and 1 [0.2%] from Argentina; 384 [60.2%] aged 20-29 years; 317 [49.8%] with pregnancy durations <7 weeks and 205 [32.2%] with pregnancy durations between 7 and <9 weeks). At last follow-up after taking medication (median, 22 days; IQR, 21-26 days), 625 participants (98.1%; 95% CI, 96.7%-98.9%) had a complete abortion without procedural intervention. Potential adverse events were reported by 6 participants (0.9%; 95% CI, 0.4%-2.1%). Most participants experienced bleeding for less than 1 week (median, 4 days; IQR, 3-6 days) and expelled their pregnancy within 24 hours of starting the abortion process (median, 12 hours; IQR, 9-15 hours). Common side effects included nausea (335 participants [52.6%]), fever (232 [36.4%]), and diarrhea (181 [28.4%]). Conclusions and Relevance The findings suggest that misoprostol alone is a highly effective method of pregnancy termination. Future research should explore strategies to maximize the effectiveness of misoprostol alone in clinical and nonclinical settings.
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Affiliation(s)
| | - Ijeoma Egwuatu
- Generation Initiative Women and Youth Network, Lagos, Nigeria
| | - Sybil Nmezi
- Generation Initiative Women and Youth Network, Lagos, Nigeria
| | | | | | - Belén Grosso
- La Revuelta Colectiva Feminista, Neuquén, Argentina
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25
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Kapp N, Mao B, Menzel J, Eckersberger E, Saphonn V, Rathavy T, Pearson E. A prospective, comparative study of clinical outcomes following clinic-based versus self-use of medical abortion. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:300-307. [PMID: 36894309 PMCID: PMC10579469 DOI: 10.1136/bmjsrh-2022-201722] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/12/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND To determine whether clinical outcomes differ among women accessing a combined medical abortion regimen from a health clinic when compared with those accessing it from a pharmacy. METHODS We conducted a multicentre, prospective, comparative, non-inferiority study of participants aged ≥15 years seeking medical abortion from five clinics and five adjacent pharmacy clusters in three provinces of Cambodia. Participants were recruited in-person at the point of purchase (clinic or pharmacy). Follow-up for self-reported pill use, acceptability, and clinical outcomes occurred by telephone at days 10 and 30 after mifepristone administration. RESULTS Over 10 months, we enrolled 2083 women with 1847 providing outcome data: 937 from clinics and 910 from pharmacies. Most were early in their pregnancy (mean gestational age of 6.3 and 6.1 weeks, respectively) and almost all took the pills correctly (98% and 96%,). Additional treatment needed to complete the abortion was non-inferior for the pharmacy group (9.3%) compared with the clinic group (12.7%). More from the clinic group received additional care from a provider, such as antibiotics or diagnostics tests, than those from the pharmacy group (11.5% and 3.2%,), and one ectopic pregnancy (pharmacy group) was successfully treated. Most said they felt prepared for what happened after taking the pills (90.9% and 81.3%, respectively, p=0.273). CONCLUSIONS Self-use of a combined medical abortion product resulted in comparable clinical outcomes as use following a clinical visit, consistent with existing literature on its safety and efficacy. Registration and availability of medical abortion as an over-the-counter product would likely increase women's access to safe abortion.
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Affiliation(s)
| | - Bunsoth Mao
- University of Health Sciences, Phnom Penh, Cambodia
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26
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Goemans S, Singh A, Yadav AK, McDougal L, Raj A, Averbach SH. The Association Between Self-Managed versus Clinician-Managed Abortion and Self-Reported Abortion Complications: A Cross-Sectional Analysis in India. Int J Womens Health 2023; 15:1467-1473. [PMID: 37795194 PMCID: PMC10545903 DOI: 10.2147/ijwh.s414599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/15/2023] [Indexed: 10/06/2023] Open
Abstract
Purpose To examine the association between self-managed abortion and the self-reported experience of abortion complications in India, a country with a high incidence of self-managed abortion. Patients and Methods The study used a cross-sectional multivariable logistic regression analysis of data from the National Family Health Survey (NFHS-4) of 2015-2016 to compare the odds of self-reported complications experienced during abortion between self-managed and clinician-managed abortions in India. Results On average, self-managed abortions occurred earlier in gestation than clinician-managed abortions, 7.8 weeks and 11.3 weeks, respectively (p < 0.001). Self-managed abortion was associated with fewer self-reported abortion-related complications than clinician-managed abortions when adjusted for covariates not including gestational age (Adjusted Odds Ratio (aOR) 0.82, 95% confidence interval (CI) 0.69, 0.97). However, once adjusted for gestational age, there was no longer a clinically meaningful or statistically significant difference in the odds of self-reported complications between self-managed and clinician-managed abortions (aOR = 0.98, 95% CI 0.81, 1.18). Conclusion These findings suggest that people in India are using safe methods to self-manage abortions and support the hypothesis that self-managed abortion can improve access to abortion and reproductive choice without increasing risk.
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Affiliation(s)
- Sophie Goemans
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA
| | - Abhishek Singh
- Department of Public Health & Mortality Studies, International Institute for Population Sciences, Mumbai, Maharashtra, India
- Centre of Demography of Gender, International Institute for Population Sciences, Mumbai, Maharashtra, India
| | - Ajit Kumar Yadav
- GENDER Project, International Institute for Population Sciences, Mumbai, Maharashtra, India
| | - Lotus McDougal
- Center on Gender Equity and Health, University of California San Diego, La Jolla, CA, USA
| | - Anita Raj
- Center on Gender Equity and Health, University of California San Diego, La Jolla, CA, USA
| | - Sarah H Averbach
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA
- Center on Gender Equity and Health, University of California San Diego, La Jolla, CA, USA
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Erhardt-Ohren B, Pier E, Arroyo D, Cole W, Hilliard M, Otero-Gonzalez A, Hidalgo-Mora O, Ospina-Henao S, Rochat R, Newton-Levinson A. Extra-legal abortion and post-abortion care knowledge, attitudes, and practices among obstetrician-gynecologist clinicians and medical residents in San José, Costa Rica: a qualitative study. BMC Womens Health 2023; 23:503. [PMID: 37735400 PMCID: PMC10512472 DOI: 10.1186/s12905-023-02639-y] [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: 06/01/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Induced abortion in Costa Rica is illegal in all cases except to save the life of the pregnant person. Despite severe restrictions to legal abortion, individuals in Costa Rica still induce abortions outside of the formal healthcare system. These individuals and those with spontaneous abortions, also known as miscarriages, occasionally need medical care for complications. In Costa Rica, an estimated 41% of unintended pregnancies end in abortion, yet there is very little published literature exploring the perspectives of healthcare providers on abortion in Costa Rica. METHODS We interviewed ten obstetrician-gynecologist clinicians and five obstetrician-gynecologist medical residents in San José, Costa Rica about their beliefs and practices related to extra-legal abortion and post-abortion care (PAC) using a Spanish language in-depth semi-structured interview guide. After transcription and translation into English, analysis team pairs used a combination of deductive and inductive coding to identify themes and sub-themes within the data. RESULTS Obstetrician-gynecologist clinicians and medical residents were aware of the presence of extra-legal abortion, and particularly, medication abortion, in their communities, but less familiar with dosing for induction. They expressed the desire to provide non-judgmental care and support their patients through extra-legal abortion and PAC journeys. Study participants were most familiar with providing care to individuals with spontaneous abortions. When discussing PAC, they often spoke about a policy of reporting individuals who seek PAC following an extra-legal abortion, without commenting on whether or not they followed the guidance. CONCLUSIONS This study contributes to a gap in research about the knowledge, attitudes, and practices of Costa Rican obstetrician-gynecologist clinicians and medical residents around extra-legal abortion and PAC. The results reveal an opportunity to train these healthcare providers as harm reduction experts, who are able to accurately counsel individuals who are seeking abortion services outside of the healthcare system, and to provide training to improve care for individuals needing PAC.
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Affiliation(s)
| | - Ellyn Pier
- Rollins School of Public Health, Emory University, Atlanta, USA
| | - Daniel Arroyo
- Faculty of Medicine, Universidad de Ciencias Médicas, San José, Costa Rica
| | - Whitney Cole
- Rollins School of Public Health, Emory University, Atlanta, USA
| | | | | | - Oscar Hidalgo-Mora
- Faculty of Medicine, Universidad de Ciencias Médicas, San José, Costa Rica
| | | | - Roger Rochat
- Rollins School of Public Health, Emory University, Atlanta, USA
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Giorgio M, Makumbi F, Kibira SPS, Shiferaw S, Seme A, Bell SO, Sully E. Self-reported abortion experiences in Ethiopia and Uganda, new evidence from cross-sectional community-based surveys. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002340. [PMID: 37682781 PMCID: PMC10490852 DOI: 10.1371/journal.pgph.0002340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 08/08/2023] [Indexed: 09/10/2023]
Abstract
Unsafe abortion is a major contributor to maternal morbidity and mortality. To gain insight into the ways in which abortion restrictions and stigma may shape reproductive health outcomes, we present self-reported data on abortions in Ethiopia and Uganda and compare these findings across the two varying legal contexts. W investigate differences in sociodemographic characteristics by whether or not a woman self-reported an abortion, and we describe the characteristics of women's most recent self-reported abortion. In Ethiopia only, we classified abortions as being either safe, less safe, or least safe. Finally, we estimate minimum one-year induced abortion incidence rates using the Network Scale-Up Method (NSUM). We find that women who self-reported abortions were more commonly older, formerly married, or had any children compared to women who did not report an abortion. While three-quarters of women in both settings accessed their abortion in a health facility, women in Ethiopia more commonly used public facilities as compared to in Uganda (23.0% vs 12.6%). In Ethiopia, 62.4% of self-reported abortions were classified as safe, and treated complications were more commonly reported among least and less safe abortions compared to safe abortions (21.4% and 23.1% vs. 12.4%, respectively). Self-reported postabortion complications were more common in Uganda (37.2% vs 16.0%). The NSUM estimate for the minimum one-year abortion incidence rate was 4.7 per 1000 in Ethiopia (95% CI 3.9-5.6) and 19.4 per 1000 in Uganda (95% C 16.2-22.8). The frequency of abortions and low levels of contraception use at the time women became pregnant suggest a need for increased investments in family planning services in both settings. Further, it is likely that the broadly accessible nature of abortion in Ethiopia has made abortions safer and less likely to result in complications in Ethiopia as compared to Uganda.
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Affiliation(s)
| | - Fredrick Makumbi
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Assefa Seme
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Suzanne O. Bell
- Johns Hopkins Bloomberg School of Public Health, Department of Population, Family, and Reproductive Health, Baltimore, MD, United States of America
| | - Elizabeth Sully
- Guttmacher Institute, New York, NY, United States of America
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Moseson H, Jayaweera R, Egwuatu I, Grosso B, Kristianingrum IA, Nmezi S, Zurbriggen R, Bercu C, Motana R, Gerdts C. Effectiveness of Self-Managed Medication Abortion Between 9 and 16 Weeks of Gestation. Obstet Gynecol 2023; 142:330-338. [PMID: 37411022 DOI: 10.1097/aog.0000000000005266] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/04/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE To evaluate abortion completion after self-managed medication abortion in pregnancies at or beyond 9 weeks of gestation. METHODS We conducted a prospective observational cohort study in which we recruited callers to three abortion-accompaniment groups in Argentina, Nigeria, and Southeast Asia who were initiating a self-managed medication abortion. Participants completed a baseline survey over the phone before taking pills and then two follow-up phone surveys 1 and 3 weeks after taking pills. The primary outcome was abortion completion; secondary outcomes included physical experiences and health care seeking and treatment. RESULTS Between 2019 and 2020, we enrolled 1,352 participants, 19.5% (264/1,352) of whom self-managed a medication abortion at 9 or more weeks of gestation: 75.0% (198/264) at 9-11 weeks, 19.3% (51/264) at 12-14 weeks, and 5.7% (15/264) at 15-22 weeks. Participants were aged 26 years on average (SD 5.6 years); 56.4% (149/264) used the combined regimen (mifepristone+misoprostol), and 43.6% (115/264) used misoprostol only. At the last follow-up, 89.4% (236/264) had a complete abortion without procedural intervention, 5.3% (14/264) had a complete abortion with manual vacuum aspiration or dilation and curettage procedure, 4.9% (13/264) had an incomplete abortion, and 0.4% (1/264) participants did not report an abortion outcome. Some participants (23.5%, 62/264) sought health care during or after the self-managed medication abortion, most commonly to confirm completion (15.9%, 42/264); 9.1% (24/264) needed further medical intervention (procedural evacuation, antibiotics, additional misoprostol, intravenous fluids, blood transfusion, or overnight stay in the facility). Those who were 12 or more weeks pregnant were more likely to seek care at a clinic or hospital than those who were 9-11 weeks pregnant (adjusted relative risk 1.62, 95% CI 1.3-2.1). CONCLUSION People who self-managed an abortion with medication between 9 and 16 weeks of gestation had high levels of abortion completion and accessed health care to confirm completion or to treat potential complications. CLINICALTRIALREGISTRATION ISRCTN, ISRCTN95769543.
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Affiliation(s)
- Heidi Moseson
- Ibis Reproductive Health, Oakland, California; the Generation Initiative for Women and Youth, Lagos, Nigeria; La Revuelta Colectiva Feminista, Neuquén, Argentina; Samsara, Southeast Asia; and Ibis Reproductive Health, Johannesburg, South Africa
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Mirian Z, AbdiShahshahani M, Noroozi M, Mostafavi F, Beigi M. Effect of intervention based on the 5A self-management model on the improvement of behaviors related to women's reproductive health after legal abortion. Sci Rep 2023; 13:11316. [PMID: 37443384 PMCID: PMC10345094 DOI: 10.1038/s41598-023-38521-y] [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: 08/31/2022] [Accepted: 07/10/2023] [Indexed: 07/15/2023] Open
Abstract
Legal abortion has adopted many beneficial measures to prevent the birth of fetuses with congenital anomalies and maintain the health of high-risk mothers. However, abortion has its own complications and, thus, most mothers need care in this regard. The aim of this study was to determine the effect of self-management model on behaviors related to the reproductive health of mothers after legal abortion. This clinical trial study was conducted on 72 women who had legal abortion with the permission from Isfahan forensic medicine. The intervention was conducted using the 5A self-management model. The control group received the usual health system cares. Data collection tool was a researcher-made questionnaire of behaviors related to reproductive health, which was completed before and two months after the intervention by the two groups. The total mean score of the behavior (P < 0.001) and its dimensions (Prevention of post-abortion complications with P = 0.01, Prevention of sexually transmitted infections, satisfactory sexual function and family planning with P < 0.001) in the intervention group two months after the outset of the intervention was significantly higher than before the intervention. The total mean score of the behavior (P < 0.001) and its dimensions (Prevention of post-abortion complications with P = 0.002, Prevention of sexually transmitted infections, satisfactory sexual function and family planning with P < 0.001) two months after the outset of the intervention in the intervention group was significantly higher than the control group. Based on the results, this educational model can be emphasized to promote reproductive health behaviors of women after abortion.Clinical trial protocol link: https://www.irct.ir/user/trial/55184/view .
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Affiliation(s)
- Zahra Mirian
- Student Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahshid AbdiShahshahani
- Department of Midwifery and Reproductive Health, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahnaz Noroozi
- Department of Midwifery and Reproductive Health, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Firozeh Mostafavi
- Department of Health Education and Health Promotion, Faculty of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Marjan Beigi
- Department of Midwifery and Reproductive Health, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran.
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Pizzarossa LB, Maziwisa M, Durojaye E. Self-Managed Abortion in Africa: The Decriminalization Imperative in Regional Human Rights Standards. Health Hum Rights 2023; 25:171-183. [PMID: 37397422 PMCID: PMC10309143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Self-managed abortion holds particular promise for revolutionizing people's access to quality reproductive care in Africa, where the burden of abortion-related mortality is the highest globally and where abortion remains criminalized, in violation of various internationally and regionally recognized human rights. Increasingly safe and effective, self-managed medication abortion is still subject to many restrictions, including criminal laws, across the continent. Drawing on recent evidence and human rights developments around self-managed abortion, this paper explores whether and to what extent Africa's regional legal framework builds a normative basis for the decriminalization of self-managed abortion. We conclude that the region's articulation of the rights to dignity, to freedom from cruel, inhuman, and degrading treatment, and to nondiscrimination, among others, provides strong grounds for decriminalization, both concerning individuals who need abortions and concerning the constellation of actors who enable self-management.
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Affiliation(s)
- Lucía Berro Pizzarossa
- Postdoctoral fellow at the O’Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, United States
| | - Michelle Maziwisa
- Senior postdoctoral fellow and program manager for human rights and democratization in Africa at the Centre for Human Rights, University of Pretoria, South Africa
| | - Ebenezer Durojaye
- Head of the Socio-Economic Rights Project at the Dullah Omar Institute, University of the Western Cape, Cape Town, South Africa
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Calderón-Villarreal A, Carrasco BIV, Friedman J, Schiavon R. Accompaniment on the edge: What can the US learn from Latin America about contested abortion care? PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001922. [PMID: 37216338 DOI: 10.1371/journal.pgph.0001922] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The US has stood as a reference point for abortion rights in the Americas since 1973, however in 2022, the US Supreme Court revoked the constitutional right to abortion. Facing similar circumstances, a huge number of grass roots accompanist networks have arisen throughout Latin America. These collectives are typically organized loosely within state and national networks that provide training and medication/supplies and promote advocacy and the expansion of new collectives. Extensive evidence and lived experience support the safety and effectiveness of self-managed medication abortion. Much can be learned from the Latin American accompanist model in the modern struggle for reproductive justice in the US. Accompaniment networks in Mexico have provided transborder abortion services-via misoprostol delivery-to US-based women living in states that required long travel or high costs to access services. Now, these transborder services will take on a new level of significance. Guaranteeing safe and low-cost access to abortion services is a key tenet of reproductive justice. Instead of relying on the political process alone to eventually provide abortion access through legal channels, an accompanist model provides an icon of resistance to oppressive legal shifts, and directly provides services to women.
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Affiliation(s)
- Alhelí Calderón-Villarreal
- Department of Family and Preventive Medicine, University of California, San Diego (UCSD), San Diego, California, United States of America
- School of Public Health, San Diego State University (SDSU), San Diego, California, United States of America
- Facultad de Medicina, Universidad Autónoma de Coahuila (UAdeC), Torreon, Mexico
| | - Bianka Itzel Verduzco Carrasco
- Colectiva Feminista de Malas Estudiantes, Tijuana, Mexico
- Facultad de Humanidades y Ciencias Sociales, Universidad Autónoma de Baja California (UABC), Tijuana, Mexico
- Facultad de Filosofía y Letras, Universidad Autónoma de Sinaloa (UAS), Tijuana, Mexico
| | - Joseph Friedman
- University of California, Los Angeles (UCLA), Los Angeles, California, United States of America
| | - Raffaela Schiavon
- Former Director of Ipas-Mexico, Mexico City, Mexico
- Independent Consultant in Sexual and Reproductive Health, Mexico City, Mexico
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Single dose letrozole and misoprostol for termination of pregnancy through 63 days' gestation: A pilot study. Contraception 2023; 120:109924. [PMID: 36529240 DOI: 10.1016/j.contraception.2022.109924] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/23/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES We conducted a pilot study to evaluate a single dose of letrozole 30 mg prior to misoprostol 800 mcg buccally for medication abortion STUDY DESIGN: We enrolled 40 participants seeking medication abortion up to 63 days' gestation at a site in Salt Lake City, UT. Participants received a single dose of letrozole 30 mg in-clinic followed 2 days later by misoprostol 800 mcg buccally at home. They took a second dose of misoprostol if they had no bleeding within 24 hours of the first. Participants returned 7 to 10 days later for assessment of abortion outcome and side effects RESULTS: Thirty-seven participants (93%) returned for follow-up and 2 (5%) went to another facility from which research staff obtained outcome data. Three-fourths (29/39, 74%, 95% CI: 60%-89%) had a complete abortion; 4 (10%, 95% CI: 0.3%-20%) had an incomplete abortion and opted for aspiration, and 6 (15%, 95% CI: 4%-27%) had an ongoing pregnancy. All subjects with follow-up reported taking the first dose of misoprostol. Ten (27%) took the second dose as well; only three did so due to no bleeding. Nineteen participants (51%) reported side effects after letrozole prior to misoprostol and two people (5%) rated these effects as severe. Side effects following misoprostol occurred in 33 participants (89%) and were as expected based on previous literature. No serious adverse events were reported CONCLUSION: A single dose of letrozole 30 mg followed by misoprostol had lower than desirable efficacy and does not warrant further study. IMPLICATIONS A single dose of letrozole does not appear to be an effective adjunct to misoprostol for medication abortion.
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Verma N, Grossman D. Self-Managed Abortion in the United States. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2023; 12:70-75. [PMID: 37305376 PMCID: PMC9989574 DOI: 10.1007/s13669-023-00354-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
Purpose of Review This review aims to provide up-to-date information about self-managed abortion in the USA. Recent Findings Evidence indicates that there is growing demand for self-managed abortion in the USA as obstacles to facility-based care increase, especially since the Supreme Court overturned Roe v. Wade. Self-managed abortion with medications is safe and effective. Summary Based on a nationally representative survey, the lifetime prevalence of self-managed abortion in the USA in 2017 was estimated to be 7%. People experiencing barriers to abortion care, including people of color, people with lower incomes, people in states that have restrictive abortion laws, and those living farther from facilities providing abortion care are more likely to attempt self-managed abortion. While people may use a range of methods to self-manage abortion, there is growing use of safe and effective medications, including mifepristone used together with misoprostol and misoprostol used alone; use of traumatic and dangerous methods is rare. While many people attempt to self-manage their abortion because of barriers to facility-based care, others have a preference for self-care because it is convenient, accessible, and private. While the medical risks of self-managed abortion may be few, the legal risks may be significant. Sixty-one people have been criminally investigated or arrested between 2000 and 2020 for allegedly self-managing their abortion or helping someone else do so. Clinicians play an important role in providing evidence-based information and care to patients considering or attempting self-managed abortion, as well as minimizing legal risks.
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Affiliation(s)
- Nisha Verma
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco (UCSF), 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
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Lenharo M. US lawsuit threatens access to abortion drug: the science behind the case. Nature 2023; 615:16-17. [PMID: 36823274 DOI: 10.1038/d41586-023-00529-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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Raymond EG, Mark A, Grossman D, Beasley A, Brandi K, Castle J, Creinin MD, Gerdts C, Gil L, Grant M, Lockley A, Perritt J, Shochet T, Truan D, Upadhyay UD. Medication abortion with misoprostol-only: A sample protocol. Contraception 2023; 121:109998. [PMID: 36849033 DOI: 10.1016/j.contraception.2023.109998] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 02/22/2023] [Accepted: 02/22/2023] [Indexed: 02/27/2023]
Affiliation(s)
| | - Alice Mark
- National Abortion Federation, Washington, DC, USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, Oakland, CA, USA
| | - Anitra Beasley
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | | | - Jen Castle
- Planned Parenthood Federation of America, New York, NY, USA
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | | | - Laura Gil
- Grupo Médico por el Derecho a Decidir-Colombia, Bogota, Colombia
| | | | - April Lockley
- Miscarriage and Abortion Hotline, Washington, DC, USA
| | | | | | | | - Ushma D Upadhyay
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, Oakland, CA, USA
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Shochet T, Berro Pizzarossa L, Larrea S, Blum J, Jelinska K, Comendant R, Sagaidac I. Self-managed abortion via the internet: Analysis of one year of service delivery data from Women Help Women. Gates Open Res 2023; 7:41. [PMID: 37123048 PMCID: PMC10130357 DOI: 10.12688/gatesopenres.14369.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 02/15/2023] Open
Abstract
Background: To better comprehend the demand for online medication abortion and to inform service delivery practice, we conducted an analysis of Women Help Women (WHW) service delivery statistics. The primary goals were to understand their user profile, evaluate self-reported outcomes and use of other medical services, and assess the overall experience both with the abortion itself and with the counseling and care provided by WHW. Methods: We retrospectively evaluated user characteristics, abortion outcomes, and acceptability of both the medication abortion and WHW’s services, using consultation data and corresponding evaluation data from a one-year period. For users who did not complete the evaluation form, WHW staff reviewed email correspondences to identify key outcomes. Results: From August 2016-July 2017, 3,307 individuals received abortion pills from WHW. Users were geographically located in thirty countries and correspondence was conducted in seven languages. Most reported their gestational age to be less than eight weeks. Of the 2,295 who took the pills and provided outcome information, almost all (99.1%, n=2275) reported that they were no longer pregnant. The majority (84.1%, n=1576/1875) used symptoms to confirm outcome; one fourth (22.8%, n=428) sought an ultrasound and one sixth (18.0%, n=338) used urine and/or serum testing. One in eight users (12.6%, n=292/2317) reported seeking additional medical care after taking the abortion pills. Most (87.5%, n=1551/1773) reported being satisfied or very satisfied with the abortion. Conclusions: Our study confirms that self-managed abortion is a process that people can do safely and effectively with community support and without medical supervision. In the context of a global backlash against abortion rights, self-managed abortion is an integral part of a spectrum of options for abortion care that must be made available to all.
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Affiliation(s)
| | | | - Sara Larrea
- Women Help Women, Amsterdam, The Netherlands
- Independent Researcher, Amstersdam, The Netherlands
| | | | | | - Rodica Comendant
- Women Help Women, Amsterdam, The Netherlands
- Reproductive Health Training Center, Chisinau, Moldova
| | - Irina Sagaidac
- Women Help Women, Amsterdam, The Netherlands
- Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Moldova
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Skuster P, Moseson H, Perritt J. Self-managed abortion: Aligning law and policy with medical evidence. Int J Gynaecol Obstet 2023; 160:720-725. [PMID: 36458802 DOI: 10.1002/ijgo.14607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
People have always and will always find ways to try to end their pregnancies when necessary. Many do so safely without the involvement or direct supervision of healthcare professionals by self-managing their abortions. In 2022, the well-established safety and efficacy of abortion medications prompted WHO to fully endorse self-managed medication abortion as part of a comprehensive range of safe, effective options for abortion care. But despite robust evidence supporting the safety and effectiveness of the self-use of medications for abortion, abortion laws and policies around the world remain at odds with clinical evidence and with the realities of self-managed medication abortion in the present day. The present article considers legal issues related to self-managed abortion and addresses the role of obstetricians, gynecologists, and other healthcare professionals in promoting clinical and legal safety in abortion care through support of self-managed abortion.
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Affiliation(s)
- Patty Skuster
- Temple University Beasley School of Law, Pennsylvania, Philadelphia, USA
| | | | - Jamila Perritt
- Physicians for Reproductive Health, New York, New York, USA
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Fay KE, Alemu H, Perritt J. Self-managed abortion: Toxic legislation, non-toxic medication. Am J Emerg Med 2023; 64:193-194. [PMID: 36344352 PMCID: PMC9845147 DOI: 10.1016/j.ajem.2022.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Kathryn E. Fay
- Harvard Medical School, Department of Obstetrics, Gynecology, and Reproductive Biology, 25 Shattuck Street, Boston, MA 02115, United States of America
| | - Hanney Alemu
- Northeastern University, 360 Huntington Ave, Boston, MA 02115, United States of America
| | - Jamila Perritt
- Physicians for Reproductive Health, 1430 Broadway, Suite 1614, New York, NY 10018, United States of America
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No-Test Medication Abortion: A Systematic Review. Obstet Gynecol 2023; 141:23-34. [PMID: 36701607 DOI: 10.1097/aog.0000000000005016] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/22/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To summarize the effectiveness and safety outcomes of medication abortion performed without prior pelvic examination or ultrasonogram ("no-test medication abortion"). DATA SOURCES We searched the MEDLINE, Scopus, Web of Science, Cochrane (including ClinicalTrials.gov), CINAHL, Global Index Medicus, and CAB Direct databases to identify relevant studies published before April 2022 using a peer-reviewed search strategy including terms such as "medication abortion" and "ultrasonography." We contacted experts in the field for unpublished data and ongoing studies. METHODS OF STUDY SELECTION We reviewed 2,423 studies using Colandr. We included studies if they presented clinical outcomes of medication abortion performed with mifepristone and misoprostol and without prior pelvic examination or ultrasonogram. We excluded studies with duplicate data. We abstracted successful abortion rates overall, as well as rates by gestational age through 63 days, 70 days and past 84 days. We abstracted complication rates, including the need for surgical evacuation, additional medications, blood transfusion, and ectopic pregnancy. TABULATION, INTEGRATION AND RESULTS We included 21 studies with a total of 10,693 patients with outcome data reported. The overall efficacy of no-test medication abortion was 96.4%; 93.8% (95% CI 92.8-94.6%) through 63 days of gestation and 95.2% (95% CI 94.7-95.7%) through 70 days of gestation. The overall rate of surgical evacuation was 4.4% (95% CI 4.0-4.9), need for additional misoprostol 2.2% (95% CI 1.8-2.6), blood transfusion 0.5% (95% CI 0.3-0.6), and ectopic pregnancy 0.06% (95% CI 0.02-0.15). CONCLUSION Medication abortion performed without prior pelvic examination or ultrasonogram is a safe and effective option for pregnancy termination. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021240739.
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Ethical Care for Patients with Self-Managed Abortion After Roe. Am J Nurs 2023; 123:38-44. [PMID: 36546386 DOI: 10.1097/01.naj.0000911524.68698.ea] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
ABSTRACT The 2022 Supreme Court decision leaving the regulation of abortion to the states is sure to result in a complex regulatory environment for patients and nurses. In states where abortion is illegal, patients may self-manage abortions using medications they obtain through the mail or by other means. Nurses may care for these patients in multiple settings and may wonder about their own legal and ethical obligations. This article reviews patient privacy as it relates to self-managed abortion, ethical reporting requirements for nurses, and best practices for treating complications of self-managed abortion using a harm reduction framework, with a focus on protecting patients' rights. Recommendations for ethical patient care are also provided.
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Accounting for Misclassification and Selection Bias in Estimating Effectiveness of Self-managed Medication Abortion. Epidemiology 2023; 34:140-149. [PMID: 36455250 DOI: 10.1097/ede.0000000000001546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Studies on the effectiveness of self-managed medication abortion may suffer from misclassification and selection bias due to self-reported outcomes and loss of follow-up. Monte Carlo sensitivity analysis can estimate self-managed abortion effectiveness accounting for these potential biases. METHODS We conducted a Monte Carlo sensitivity analysis based on data from the Studying Accompaniment model Feasibility and Effectiveness Study (the SAFE Study), to generate bias-adjusted estimates of the effectiveness of self-managed abortion with accompaniment group support. Between July 2019 and April 2020, we enrolled a total of 1051 callers who contacted accompaniment groups in Argentina and Nigeria for self-managed abortion information; 961 took abortion medications and completed at least one follow-up. Using these data, we calculated measures of effectiveness adjusted for ineligibility, misclassification, and selection bias across 50,000 simulations with bias parameters drawn from pre-specified Beta distributions in R. RESULTS After accounting for the potential influence of various sources of bias, bias-adjusted estimates of effectiveness were similar to observed estimates, conditional on chosen bias parameters: 92.68% (95% simulation interval: 87.80%, 95.74%) for mifepristone in combination with misoprostol (versus 93.7% in the observed data) and 98.47% (95% simulation interval: 96.79%, 99.39%) for misoprostol alone (versus 99.3% in the observed data). CONCLUSIONS After adjustment for multiple potential sources of bias, estimates of self-managed medication abortion effectiveness remain high. Monte Carlo sensitivity analysis may be useful in studies measuring an epidemiologic proportion (i.e., effectiveness, prevalence, cumulative incidence) while accounting for possible selection or misclassification bias.
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Arnalsteen C, Jochum F, Hauss AS, Kiehl A, Deshaies A, Martel C, Koch A, Bettahar K. [Single dose of misoprostol for abortion until 9 weeks of gestation]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:41-45. [PMID: 36423881 DOI: 10.1016/j.gofs.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 11/13/2022] [Accepted: 11/13/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The primary objective was to compare the efficacy of a single-dose misoprostol for abortion before 7 weeks of gestation and between 7 and 9 weeks of gestation. The secondary objectives were to compare the amount of misoprostol required for complete expulsion, the need for endo-uterine aspiration, and to assess pain and patient experience in these two groups. METHODS This was a single-centre prospective observational study conducted at the University Hospitals of Strasbourg from 1st October 2019 to 31st December 2020. RESULTS A total of 306 patients were included, 150 in the group before 7 weeks of gestation and 156 in the group between 7 and 9 weeks of gestation. There was no significant difference in the success rate of the single dose of misoprostol between the two groups with 34.7 and 37.8% respectively (P=0.63). After taking painkillers, there is no difference in terms of pain relief (EN ≤ 4 for 92 et 95% of patients P=0.37). CONCLUSION The single dose of misoprostol for in-hospital abortion is as effective between 7 and 9 weeks of gestation as it is before 7. By extension, therefore, we would suggest that there should be no difference in efficacy between home abortions before 7 weeks of gestation and between 7 and 9 weeks of gestation and therefore suggest that home abortions can be performed up to 9 weeks of gestation without fear of a decrease in the rate of complete expulsion and the efficacy of analgesia, with potentially less use of misoprostol compared with the hospital setting.
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Affiliation(s)
- C Arnalsteen
- Pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, avenue Molière, Strasbourg, France.
| | - F Jochum
- Pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, avenue Molière, Strasbourg, France
| | - A-S Hauss
- Pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, avenue Molière, Strasbourg, France
| | - A Kiehl
- Pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, avenue Molière, Strasbourg, France
| | - A Deshaies
- Pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, avenue Molière, Strasbourg, France
| | - C Martel
- Pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, avenue Molière, Strasbourg, France
| | - A Koch
- Pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, avenue Molière, Strasbourg, France
| | - K Bettahar
- Pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, avenue Molière, Strasbourg, France
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Bercu C, Filippa S, Jayaweera R, Egwuatu I, Nmezi S, Zurbriggen R, Grosso B, Kristianingrum IA, Maneiro M, Liparelli MS, Sandoval S, Tapia I, Soria G, Moseson H. A qualitative exploration of how the COVID-19 pandemic shaped experiences of self-managed medication abortion with accompaniment group support in Argentina, Indonesia, Nigeria, and Venezuela. Sex Reprod Health Matters 2022; 30:2079808. [PMID: 35713531 PMCID: PMC9225659 DOI: 10.1080/26410397.2022.2079808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Globally, people self-manage their medication abortions without clinical assistance. Feminist activist collectives (accompaniment groups) support people through self-managed abortion with evidence-based guidance. We sought to understand the impact of COVID-19 and related restrictions on the need for and experiences of self-managed abortion with accompaniment support across varied legal and social contexts. Between May and October 2020, we conducted in-depth interviews with individuals who self-managed abortions with support from accompaniment groups during the pandemic in Argentina, Indonesia, Nigeria, and Venezuela. We conducted a thematic analysis to understand the impact of COVID-19 on participants’ experiences with accompanied self-managed abortions. Across 43 in-depth interviews, participants in all four countries described how the COVID-19 pandemic created challenges at each step of their abortion process, from confirming the pregnancy, accessing abortion pills, finding a private, comfortable place, and verifying abortion completion. For most people, conditions related to the pandemic made it harder to self-manage an abortion; for a minority, being at home made aspects of the experience somewhat easier. Nonetheless, all participants reported feeling supported by accompaniment groups, and COVID-19 and related lockdowns reinforced their preference for accompaniment-supported self-managed abortion. These findings highlight the essential role that accompaniment groups play in ensuring access to high-quality abortion care in a multiplicity of settings, particularly during the COVID-19 pandemic. Efforts are needed to expand the reach of accompaniment groups to increase access to the high-quality abortion support they provide, filling a critical gap left by health systems and legal infrastructure.
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Affiliation(s)
- Chiara Bercu
- Associate Project Director, Ibis Reproductive Health, Oakland, CA, USA
| | - Sofia Filippa
- Research Consultant, Ibis Reproductive Health, Oakland, CA, USA
| | | | - Ijeoma Egwuatu
- Data, Innovation and Communication Director, Generation Initiative for Women and Youth, Lagos State, Nigeria
| | - Sybil Nmezi
- Executive Director, Generation Initiative for Women and Youth, Lagos State, Nigeria
| | - Ruth Zurbriggen
- Activist and Researcher, Colectiva Feminista La Revuelta, Neuquén, Argentina
| | - Belen Grosso
- Activist and Researcher, Colectiva Feminista La Revuelta, Neuquén, Argentina
| | | | - Mariana Maneiro
- Member of the Feminist Collective, Feministas en Acción Libre y Directa por la Autonomía Sexual y Reproductiva (Faldas-R), Caracas, Venezuela
| | - María Soledad Liparelli
- Member of the Feminist Collective, Feministas en Acción Libre y Directa por la Autonomía Sexual y Reproductiva (Faldas-R), Caracas, Venezuela
| | - Stephhanie Sandoval
- Member of the Feminist Collective, Feministas en Acción Libre y Directa por la Autonomía Sexual y Reproductiva (Faldas-R), Caracas, Venezuela
| | - Isha Tapia
- Member of the Feminist Collective, Feministas en Acción Libre y Directa por la Autonomía Sexual y Reproductiva (Faldas-R), Caracas, Venezuela
| | - Guillermina Soria
- Member of the Feminist Collective, Feministas en Acción Libre y Directa por la Autonomía Sexual y Reproductiva (Faldas-R), Caracas, Venezuela
| | - Heidi Moseson
- Senior Research Scientist, Ibis Reproductive Health, Oakland, CA, USA
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Kristianingrum IA, Nmezi S, Zurbriggen R, Gerdts C, Jayaweera R, Moseson H. Overcoming challenges in research on self-managed medication abortion: lessons from a collaborative activist-researcher partnership. Sex Reprod Health Matters 2022; 30:2077282. [PMID: 35695259 PMCID: PMC9225767 DOI: 10.1080/26410397.2022.2077282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
| | - Sybil Nmezi
- Executive Director, Generation Initiative for Women and Youth Network, Lagos, Nigeria
| | - Ruth Zurbriggen
- Executive Director, Colectiva Feminista la Revuelta, Neuquen, Argentina
| | - Caitlin Gerdts
- Vice President for Research, Ibis Reproductive Health, Oakland, CA, USA
| | - Ruvani Jayaweera
- Research Scientist Research Scientist, Ibis Reproductive Health, Oakland, CA, USA
| | - Heidi Moseson
- Senior Research Scientist, Ibis Reproductive Health, Oakland, CA, USA. Correspondence:
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Abstract
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.
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Bazié F, Thomas HL, Byrne ME, Kindo B, Bell SO, Moreau C. Typologies of women's abortion trajectories in Burkina Faso: findings from a qualitative study. Reprod Health 2022; 19:212. [PMID: 36443828 PMCID: PMC9707265 DOI: 10.1186/s12978-022-01526-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/10/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Abortion is a legally restricted, yet common reproductive life event among women in Burkina Faso; however, women's abortion experiences vary greatly depending on their social and economic capital, partner involvement, and level of knowledge. We sought to classify women's abortion care-seeking experiences across the life course and social conditions into typologies using qualitative data. METHODS An initial quantitative survey among a nationally representative sample of women ages 15-49 years collected information on women's induced abortion experiences. Women who reported an abortion in the last 10 years were asked if they would agree to participate in a subsequent in-depth interview (IDI) to learn more about their abortion experience. Twenty-five women, identified via purposive sampling, completed an IDI. Using a process of typology construction, we identified attributes of each woman's condition at the time of her abortion and aspects of her abortion experience, created a matrix of attributes and cases, and identified emerging relationships. Three types were identified through this process. RESULTS Twenty-three IDIs were analyzed, and women's abortion experiences were grouped into three types: abortion to delay childbearing in adolescence; abortion to space childbirth among women in union; abortion to avoid childbearing among single mothers. Two cases were identified as outliers. Cases were grouped based on the context of their pregnancy, the reason for the abortion and involved decision-makers, and their patterns of care-seeking, including methods and sources used. CONCLUSION Structural inequities related to gender and wealth were prominent forces shaping women's abortion experiences. Comprehensive sexuality education coupled with community-based interventions to promote gender-equitable relationships and address social stigma related to women's sexuality could reduce reproductive coercion and unintended pregnancies.
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Affiliation(s)
- Fiacre Bazié
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso.
| | - Haley L Thomas
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Meagan E Byrne
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Boukary Kindo
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Soins Primaires et Prévention, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, 94800, Villejuif, France
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The influence of feminist abortion accompaniment on emotions related to abortion: A longitudinal observational study in Mexico. SSM Popul Health 2022; 19:101259. [PMID: 36238820 PMCID: PMC9552094 DOI: 10.1016/j.ssmph.2022.101259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/28/2022] [Accepted: 10/02/2022] [Indexed: 11/22/2022] Open
Abstract
Emotions can reflect how individuals internalize identities, social roles, and broader power structures, including abortion stigma. Abortion accompaniment, in the form of logistical, informational, and emotional support offered by individuals and organizations, takes a person-centered, feminist, and rights-based approach. We tested the extent to which abortion accompaniment may decrease negative and increase positive feelings an individual holds related to their abortion. Using observational longitudinal data collected between January 2017 and mid-2018, we compared negative and positive emotional responses to a personal abortion experience one month and six months following the abortion to emotions immediately prior to the abortion ("baseline"), among women travelling from outside of Mexico City to abortion clinics in Mexico City with and without support of the accompaniment organization, Fondo MARIA. We used doubly robust longitudinal mixed effects models with inverse probability weighting methods. At baseline, accompanied and unaccompanied participants experienced an average of 4.9 and 4.4 negative emotions out of eight respectively (i.e., anguish, nervousness, scared, anxious, sadness, guilt, anger, shame) and 1.7 and 1.9 positive emotions of out 4 respectively (happiness, calmness, decidedness, and relief). From our model results, women accompanied (n = 77) had larger decreases in negative feelings (p < .05) and larger increases in positive feelings (p < .01) toward their abortion compared to those who were not accompanied (n = 119) at six months. These changes led the majority of accompanied respondents to have primarily positive feelings about their abortion by endline. Abortion accompaniment through Fondo MARIA in Mexico City was associated with a larger decrease in negative feelings, particularly those related to stigma, and a larger increase in positive feelings six months after abortion. Accompaniment's focus on person-centered support, self-determination, and autonomy may enable people seeking abortion to view their decision as one that is valid and legitimate, and resist the predominant stigmatizing narratives framing abortion as something that is transgressive.
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McMahon HV, Karp C, Bell SO, Shiferaw S, Seme A, Yihdego M, Zimmerman LA. Availability of Postabortion Care Services in Ethiopia: Estimates from a 2020 National Sample of Public Facilities. Contracept X 2022; 4:100087. [DOI: 10.1016/j.conx.2022.100087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/27/2022] [Accepted: 10/09/2022] [Indexed: 11/07/2022] Open
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Sanchez-Morales JE, Rodriguez-Contreras JL, Ruiz-Lara L, Ochoa-Torres B, Zaragoza M, Padilla-Zuniga K. Cost Analysis of Surgical and Medical Uterine Evacuation Methods for First-Trimester Abortion Used in Public Hospitals in Mexico. Health Serv Insights 2022; 15:11786329221126347. [PMID: 36171763 PMCID: PMC9511298 DOI: 10.1177/11786329221126347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/28/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Data on abortion procedures costs are scarce in low- and middle-income countries. In Mexico, the only known study was conducted more than a decade ago, with data from years before the abortion legislation. This study estimated the costs, from the health system’s perspective, of surgical and medical abortion methods commonly used by women who undergo first-trimester abortion in Mexico. Methods: Data were collected on staff time, salaries, medications, consumables, equipment, imaging, and lab studies, at 5 public general hospitals. A bottom-up micro-costing approach was used. Results: Surgical abortion costs were US$201 for manual vacuum aspiration and US$298 for sharp curettage. The cost of medical abortion with misoprostol was US$85. The use of cervical ripening increases the costs by up to 18%. Staff comprised up to 72% of total costs in surgical abortions. Hospitalization was the area where most of the spending occurred, due to the staff and post-surgical surveillance required. Conclusions: Our estimates reflect the costs of “real-life” implementation and highlight the impact on costs of the overuse of resources not routinely recommended by clinical guidelines, such as cervical ripening for surgical abortion. This information will help decision-makers to generate policies that contribute to more efficient use of resources.
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Affiliation(s)
| | - Jose Luis Rodriguez-Contreras
- Division of Medical Equipment Management, Ministry of Health, Health Institute for Welfare (INSABI), Mexico City, Mexico
| | | | | | - Mara Zaragoza
- Ipas Central America and Mexico (Ipas CAM), Mexico City, Mexico
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