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Wall LL, Brown D. Personhood Begins at Birth: The Rational Foundation for Abortion Policy in a Secular State. JOURNAL OF BIOETHICAL INQUIRY 2024:10.1007/s11673-024-10352-0. [PMID: 39172346 DOI: 10.1007/s11673-024-10352-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 03/03/2024] [Indexed: 08/23/2024]
Abstract
The struggle over legal abortion access in the United States is a religious controversy, not a scientific debate. Religious activists who believe that meaningful individual life (i.e., "personhood") begins at a specific "moment-of-conception" are attempting to pass laws that force this view upon all pregnant persons, irrespective of their medical circumstances, individual preferences, or personal religious beliefs. This paper argues that such actions promote a constitutionally prohibited "establishment of religion." Abortion policy in a secular state must be based upon scientifically accurate biology, not unprovable theological presuppositions. The scientific facts regarding human pregnancy do not support the position that personhood begins with fertilization-at which point a pregnancy does not yet even exist. Abortion policy should regard the embryo/fetus as part of the pregnant individual's body until delivery. We argue that individual "personhood" only begins when the latent potentialities of the fetal nervous system are actualized in the newborn after delivery. The paper argues that instantiating non-scientific beliefs concerning embryonic/fetal "personhood" into the law as the basis for abortion policy establishes a state-sponsored religion. The protection of religious liberty requires that abortion be decriminalized. Abortion should be treated like any other medical procedure and regulated similarly. To protect both religious freedom and sound medical practice, individual legal personhood should be recognized as beginning only at birth.
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Affiliation(s)
- L Lewis Wall
- Departments of Obstetrics & Gynecology and Anthropology, Washington University in St. Louis, St. Louis, MO, United States.
| | - Douglas Brown
- Department of Surgery, Washington University in St. Louis, St. Louis, MO, United States
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Barrow A, Cohen C, Serpico J, Goodman M, Grossman D, Raifman S, Upadhyay U. Brief of over 300 reproductive health researchers as Amici Curiae in FDA v. Alliance for Hippocratic Medicine. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2024. [PMID: 39074980 DOI: 10.1111/psrh.12281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
On January 30, 2024, over 300 researchers filed an amicus brief in FDA v. Alliance for Hippocratic Medicine, a United States (US) Supreme Court case that could have severely impacted access to mifepristone, one of the two drugs commonly used in medication abortion. The researchers summarize the legal challenges to the US Food and Drug Administration's (FDA's) original approval of mifepristone in 2000 and its 2016 and 2021 decisions modifying mifepristone's Risk Evaluation and Mitigation Strategy (REMS) Program and label, the responses from the FDA and drug manufacturer to the challenges, and the potential implications of the Court's decision on access to mifepristone in the US. The researchers detail how the FDA relied on a robust scientific record analyzing tens of thousands of patient experiences that conclusively demonstrated the safety and effectiveness of the changes to the mifepristone REMS Program and label and urge the Supreme Court to rely on the clear scientific record and preserve access to mifepristone without reimposing restrictions. What follows is a reprint of this brief.
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Affiliation(s)
- Amanda Barrow
- University of California Los Angeles Center on Reproductive Health, Law, and Policy, Los Angeles, California, USA
| | - Cathren Cohen
- University of California Los Angeles Center on Reproductive Health, Law, and Policy, Los Angeles, California, USA
| | - Jaclyn Serpico
- University of California Los Angeles Center on Reproductive Health, Law, and Policy, Los Angeles, California, USA
| | - Melissa Goodman
- University of California Los Angeles Center on Reproductive Health, Law, and Policy, Los Angeles, California, USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California San Francisco, Oakland, California, USA
| | - Sarah Raifman
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California San Francisco, Oakland, California, USA
| | - Ushma Upadhyay
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California San Francisco, Oakland, California, USA
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Moulton JE, Arefadib N, Botfield JR, Freilich K, Tomnay J, Bateson D, Black KI, Norman WV, Mazza D. A nurse-led model of care to improve access to contraception and abortion in rural general practice: Co-design with consumers and providers. J Adv Nurs 2024. [PMID: 38953531 DOI: 10.1111/jan.16299] [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: 01/09/2024] [Revised: 05/17/2024] [Accepted: 06/06/2024] [Indexed: 07/04/2024]
Abstract
AIM To describe key features of a co-designed nurse-led model of care intended to improve access to early medication abortion and long-acting reversible contraception in rural Australian general practice. DESIGN Co-design methodology informed by the Experience-Based Co-Design Framework. METHODS Consumers, nurses, physicians and key women's health stakeholders participated in a co-design workshop focused on the patient journey in seeking contraception or abortion care. Data generated at the workshop were analysed using Braun and Clarkes' six-step process for thematic analysis. RESULTS Fifty-two participants took part in the co-design workshop. Key recommendations regarding setting up the model included: raising awareness of the early medication abortion and contraceptive implant services, providing flexible booking options, ensuring appointment availability, providing training for reception staff and fostering good relationships with relevant local services. Recommendations for implementing the model were also identified, including the provision of accessible information, patient-approved communication processes that ensure privacy and safety, establishing roles and responsibilities, supporting consumer autonomy and having clear pathways for referrals and complications. CONCLUSION Our approach to experience-based co-design ensured that consumer experiences, values and priorities, together with practitioner insights, were central to the development of a nurse-led model of care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE The co-designed nurse-led model of care for contraception and medication abortion is one strategy to increase access to these essential reproductive health services, particularly in rural areas, while providing an opportunity for nurses to work to their full scope of practice. IMPACT Nurse-led care has gained global recognition as an effective strategy to promote equitable access to sexual and reproductive healthcare. Still, nurse-led contraception and abortion have yet to be implemented andevaluated in Australian general practice. This study will inform the model of care to be implemented and evaluated as part of the ORIENT trial to be completed in 2025. REPORTING METHOD Reported in line with the Standards for Reporting Qualitative Research (SRQR) checklist. PATIENT OR PUBLIC CONTRIBUTION Two consumer representatives contributed to the development of the co-design methodology as members of the ORIENT Intervention Advisory Group Governance Committee.
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Affiliation(s)
- Jessica E Moulton
- SPHERE, NHMRC Centre of Research Excellence in Sexual and Reproductive Health for Women in Primary Care, Melbourne, Victoria, Australia
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Noushin Arefadib
- SPHERE, NHMRC Centre of Research Excellence in Sexual and Reproductive Health for Women in Primary Care, Melbourne, Victoria, Australia
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jessica R Botfield
- SPHERE, NHMRC Centre of Research Excellence in Sexual and Reproductive Health for Women in Primary Care, Melbourne, Victoria, Australia
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Family Planning NSW, Sydney, New South Wales, Australia
| | - Karen Freilich
- SPHERE, NHMRC Centre of Research Excellence in Sexual and Reproductive Health for Women in Primary Care, Melbourne, Victoria, Australia
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jane Tomnay
- Centre for Excellence in Rural Sexual Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Deborah Bateson
- Daffodil Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten I Black
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Wendy V Norman
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Public Health and Policy, Public Health, Environments & Society, London School of Hygiene and Tropical Medicine, London, UK
| | - Danielle Mazza
- SPHERE, NHMRC Centre of Research Excellence in Sexual and Reproductive Health for Women in Primary Care, Melbourne, Victoria, Australia
- Department of General Practice, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Witt LB, Wolff S, Shih G, French V. Abortion and Contraception in Medical School Curricula: A Survey of North American Family Medicine Clinical Curriculum Directors. TEACHING AND LEARNING IN MEDICINE 2024; 36:174-182. [PMID: 36636862 DOI: 10.1080/10401334.2022.2163399] [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: 06/14/2022] [Revised: 12/01/2022] [Accepted: 12/16/2022] [Indexed: 06/17/2023]
Abstract
Phenomenon: Contraception and abortion care are commonly accessed health services, and physicians in training will encounter patients seeking this care. Curricula that teach contraception and abortion provision during medical school equip medical students with valuable skills and may influence their intention to provide these services during their careers. Family planning is nevertheless understood to be underrepresented in most medical curricula, including in North American medical schools where the laws on providing contraception and abortion have been consequentially changing. This study investigated the prevalence and predictors of contraception and abortion education in North American medical curricula in 2021. Approach: We asked family medicine clerkship directors from Canada and the United States (US) to report about contraception and abortion teaching in their clinical curricula and their school's whole curriculum and to report on associated factors. Survey questions were included in the 2021 Council of Academic Family Medicine's Educational Research Alliance (CERA) survey of Family Medicine Clerkship Directors at accredited North American medical schools. Surveys were distributed between April 29 and May 28, 2021, to the 160 clerkship directors listed in the CERA organization database. Findings: Seventy-eight directors responded to the survey (78/160, 48%). 47% of responding directors reported no contraception teaching in the family medicine clerkship. 81.7% of responding directors reported no abortion teaching in the clerkship, and 66% indicated abortion was not being taught in their school's whole curriculum. Medical school region correlated with the presence of abortion curricula, and schools with high graduation rates into the family medicine specialty reported abortion teaching more frequently. Fewer than 40% of responding directors had received training on both contraception and abortion care themselves. Insights: Contraception and abortion are both underrepresented in North American medical curricula. Formal abortion education may be absent from most family medicine clerkships and whole program curricula. To enhance family planning teaching in North American medical schools, we recommend that national curriculum resources be revised to include specific contraception and abortion learning objectives and for increased development and support for clinical curricula directors to universally include family planning teaching in whole program and family medicine clerkship curricula.
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Affiliation(s)
- Laurel B Witt
- Department of Family Medicine and Community Health, University of Kansas, Kansas City, Kansas, USA
| | - Sharon Wolff
- Department of Population Health, University of Kansas, Kansas City, Kansas, USA
| | - Grace Shih
- Department of Family Medicine, University of Washington, Seattle, Washington DC, USA
| | - Valerie French
- Department of Obstetrics and Gynecology, University of Kansas, Medical Center, Kansas City, Kansas, USA
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Velez MP, Fell DB, Shellenberger JP, Kwong JC, Ray JG. Miscarriage after SARS-CoV-2 vaccination: A population-based cohort study. BJOG 2024; 131:415-422. [PMID: 37973606 DOI: 10.1111/1471-0528.17721] [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: 08/23/2023] [Revised: 10/23/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To evaluate the risk of miscarriage following SARS-CoV-2 vaccination, while accounting for the competing risk of induced abortion. DESIGN Population-based cohort study. SETTING Ontario, Canada. PARTICIPANTS Women aged 15-50 years with a confirmed pregnancy at ≤19 completed weeks' gestation. METHODS Exposure to first SARS-CoV-2 vaccination, handled in a time-varying manner, was defined as (i) unvaccinated, (ii) remotely vaccinated >28 days before the estimated conception date or (iii) recently vaccinated ≤28 days before conception and up to 120 days after conception. MAIN OUTCOME MEASURES The outcome was miscarriage, occurring between the estimated date of conception and up to 19 completed weeks of pregnancy. Fine-Grey hazard models, accounting for the competing risk of induced abortion, generated hazard ratios (aHR), adjusted for socio-demographic factors, comorbidities, and biweekly periods. RESULTS Included were 246 259 pregnant women, of whom 34% received a first SARS-CoV-2 vaccination. Miscarriage occurred at a rate of 3.6 per 10 000 person-days among remotely vaccinated women and 3.2 per 10 000 person-days among those recently vaccinated, in contrast to a rate of 1.9 per 10 000 person-days among unvaccinated women, with corresponding aHR of 0.98 (95% confidence interval [CI] 0.91-1.07) and 1.00 (95% CI 0.93-1.08). CONCLUSIONS SARS-CoV-2 vaccination was not associated with miscarriage while accounting for the competing risk of induced abortion. This study reiterates the importance of including pregnant women in new vaccine clinical trials and registries, and the rapid dissemination of vaccine safety data.
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Affiliation(s)
- Maria P Velez
- Department of Obstetrics and Gynaecology, Queen's University, Kingston, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Deshayne B Fell
- ICES, Toronto, Ontario, Canada
- Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Ontario, Canada
| | | | - Jeffrey C Kwong
- ICES, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Joel G Ray
- ICES, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
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Lai SXL, Cohn A. Efficacy and safety of medical termination of pregnancy in a regional primary care setting. Aust N Z J Obstet Gynaecol 2024; 64:42-47. [PMID: 37528652 DOI: 10.1111/ajo.13738] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 07/09/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Australia has demonstrated high efficacy and safety of medical termination of pregnancy (MToP) using a mifepristone-buccal misoprostol regime. The provision of medical termination services in primary care has the potential to alleviate access barriers, particularly in rural and regional populations. Large-scale data are needed to support the expansion of this model. AIM The aim was to determine the efficacy and safety of nurse-led MToP within a regional general practice clinic. METHODS A retrospective cohort study of patients prescribed MToP from October 2014 to April 2020. Clinic nurses assessed patient eligibility and provided information, non-directive counselling and instructions. The general practitioner then confirmed eligibility, obtained informed consent and prescribed. Patients were administered 200 mg of mifepristone orally in a pharmacy and then self-administered 800-μg buccal misoprostol 36-48 h later at home. RESULTS A total of 998 patients were included in this study, with the median patient age being 27.3 years and 30.3% of patients travelling over 100 km to access the service. MToP was successful in 965 (96.7%) patients. There were 36 (3.6%) complications, of which 33 were incomplete MToP. Haemorrhage requiring transfusion, pain requiring hospital treatment and suspected infection were rare, each having a frequency of one (0.1%). Our follow-up rate was 74.8%, with a strong correlation identified between increased gestational age and decreased follow-up (P < 0.001). CONCLUSION This study is a large Australian example demonstrating high efficacy and safety of nurse-led MToP within regional general practice. The establishment of similar services in rural and regional Australia may address geographical and financial barriers to termination access.
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Affiliation(s)
- Sara Xiao-Li Lai
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Amanda Cohn
- Gateway Health, Wodonga, Victoria, Australia
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Ferketa M, Moore A, Klein-Barton J, Stulberg D, Hasselbacher L. Pharmacists' experiences dispensing misoprostol and readiness to dispense mifepristone. J Am Pharm Assoc (2003) 2024; 64:245-252.e1. [PMID: 37913990 DOI: 10.1016/j.japh.2023.10.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/21/2023] [Accepted: 10/25/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Mifepristone, followed by misoprostol, is commonly used for medication abortion and early miscarriage care. Since mifepristone's approval in 2000, the Food and Drug Administration (FDA) has placed restrictions on where and how it could be dispensed, including applying a Risk Evaluation and Mitigation Strategy in 2011. In December 2021, the FDA removed the in-person dispensing requirement and, in January 2023, began allowing certified pharmacies to dispense the drug directly to patients. OBJECTIVES To explore pharmacist knowledge about misoprostol and mifepristone, experience dispensing misoprostol, as well as comfort and readiness to dispense mifepristone should federal regulations allow. METHODS We conducted in-depth interviews with 21 U.S.-based pharmacists and pharmacy trainees between June and December of 2021, a time when few pharmacists were allowed to dispense mifepristone. RESULTS Participants reported varied knowledge about medications for miscarriage and abortion but described themselves as generally knowledgeable about medications and reported strategies for learning about new medications. Most said they would feel ready to dispense mifepristone, and many described dispensing misoprostol without difficulty. Potential challenges specific to mifepristone dispensing included employer hesitation and colleague refusals. To assure successful dispensing, participants recommended basic training and fact sheets; relationships with prescribers for follow-up; and policies for prescription transfers in the event of refusal. CONCLUSIONS We found that nearly all participants would feel ready to dispense mifepristone with some basic training. Pharmacists self-report having the skills and resources to learn about new medications quickly. Our findings support the FDA's rule change allowing pharmacist dispensing of mifepristone and suggest that most challenges would stem from individual or institutional refusals.
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Renner R, Ennis M, Kean L, Brooks M, Dineley B, Pymar H, Norman WV, Guilbert E. First and Second-Trimester Surgical Abortion Providers and Services in 2019: Results From the Canadian Abortion Provider Survey. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102188. [PMID: 37558165 DOI: 10.1016/j.jogc.2023.08.001] [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: 12/09/2022] [Revised: 07/11/2023] [Accepted: 08/02/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVE Our objective was to explore the workforce and clinical care of first and second-trimester surgical abortion (FTSA, STSA) providers following the publication of the updated Society of Obstetricians and Gynaecologists of Canada (SOGC) surgical abortion guidelines. METHODS We conducted a national, cross-sectional, online, self-administered survey of physicians who provided abortion care in 2019. This anonymized survey collected participant demographics, types of abortion services, and characteristics of FTSA and STSA clinical care. Through healthcare organizations using a modified Dillman technique, we recruited from July to December 2020. Descriptive statistics were generated by R Statistical Software. RESULTS We present the data of 222 surgical abortion provider respondents, of whom 219 provided FTSA, 109 STSA, and 106 both. Respondents practiced in every Canadian province and territory. Most were obstetrician-gynaecologists (56.8%) and family physicians (36.0%). The majority of FTSA and STSA respondents were located in urban settings, 64.8% and 79.8%, respectively, and more than 80% practiced in hospitals. More than 1 in 4 respondents reported <5 years' experience with surgical abortion care and 93.2% followed SOGC guidelines. Noted guideline deviations included that prophylactic antibiotic use was not universal, and more than half of respondents used sharp curettage in addition to suction. Fewer than 5% of STSA respondents used mifepristone for cervical preparation. CONCLUSION The surgical abortion workforce is multidisciplinary and rejuvenating. Education, training, and practice support, including SOGC guideline implementation, are required to optimize care and to ensure equitable FTSA and STSA access in both rural and urban regions. GESTATIONAL AGE NOTATION: weeks, weeks' gestation, gestational age (GA), e.g., 116 weeks.
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Affiliation(s)
- Regina Renner
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC; Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC.
| | - Madeleine Ennis
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC; Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC
| | - Lauren Kean
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC; Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC
| | - Melissa Brooks
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC; Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC
| | - Brigid Dineley
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC; Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC
| | - Helen Pymar
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC; Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC
| | - Wendy V Norman
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC; Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC; Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Edith Guilbert
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC; Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC
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Guarna G, Kotait M, Blair R, Vu N, Yakoub D, Davis R, Costescu D. Approved but Unavailable: A Mystery-Caller Survey of Mifepristone Access in a Large Ontario City. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102178. [PMID: 37390983 DOI: 10.1016/j.jogc.2023.06.009] [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: 04/07/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVES Mifepristone/misoprostol (mife/miso) has been approved in Canada since 2017, and is available since 2018. Mife/miso does not require witnessed administration in Canada, and therefore most patients obtain a prescription for home use. We sought to determine the proportion of pharmacies in Hamilton, Ontario, Canada, a city of over 500 000, that had combination mife/miso in stock at any given time. METHODS A mystery-caller approach was used to survey all pharmacies (n = 218) in Hamilton, Ontario, Canada between June 2022 and September 2022. RESULTS Of the 208 pharmacies that were successfully contacted, only 13 (6%) pharmacies had mife/miso in stock. The most commonly cited reasons for the medication being unavailable were low patient demand (38%), cost (22%), lack of familiarity with medication (13%), supplier issues (9%), training requirements (8%), and medication expiry (7%). CONCLUSIONS These findings suggest that while mife/miso has been available in Canada since 2017, significant barriers remain to patients accessing this medication. This study clearly demonstrates a need for further advocacy and clinician education to ensure mife/miso is accessible to the patients who require it.
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Affiliation(s)
- Giuliana Guarna
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, ON.
| | - Maryam Kotait
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, ON
| | - Rachel Blair
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, ON
| | - Nancy Vu
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, ON
| | - Donika Yakoub
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON
| | - Rhianna Davis
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON
| | - Dustin Costescu
- Department of Obstetrics and Gynaecology, McMaster University, Hamilton, ON
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Wahl K, Norman WV, Van Esch K, Williams A, Wylie A, Munro S. The Medical Abortion Prescriber Checklist and Resource Guide: Tools for Prescribers. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102135. [PMID: 37201581 DOI: 10.1016/j.jogc.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Kate Wahl
- Department of Obstetrics and Gynaecology, The University of British Columbia, Vancouver, BC; Contraception and Abortion Research Team, Women's Health Research Institute, BCWomen's Hospital and Health Centre, Vancouver, BC
| | - Wendy V Norman
- Contraception and Abortion Research Team, Women's Health Research Institute, BCWomen's Hospital and Health Centre, Vancouver, BC; Department of Family Practice, The University of British Columbia, Vancouver, BC; Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristen Van Esch
- Contraception and Abortion Research Team, Women's Health Research Institute, BCWomen's Hospital and Health Centre, Vancouver, BC; Department of Family Practice, The University of British Columbia, Vancouver, BC
| | - Aleyah Williams
- Department of Obstetrics and Gynaecology, The University of British Columbia, Vancouver, BC; Contraception and Abortion Research Team, Women's Health Research Institute, BCWomen's Hospital and Health Centre, Vancouver, BC; Centre for Health Evaluation and Outcome Sciences, The University of British Columbia, Vancouver, BC
| | | | - Sarah Munro
- Department of Obstetrics and Gynaecology, The University of British Columbia, Vancouver, BC; Contraception and Abortion Research Team, Women's Health Research Institute, BCWomen's Hospital and Health Centre, Vancouver, BC; Centre for Health Evaluation and Outcome Sciences, The University of British Columbia, Vancouver, BC.
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Mazer-Amirshahi M, Stolbach AI, Ye P. ACMT Position Statement: Position on the Recent Judicial Challenge of U.S. Food and Drug Administration Approval of Mifepristone. J Med Toxicol 2023; 19:414-415. [PMID: 37548894 PMCID: PMC10522555 DOI: 10.1007/s13181-023-00960-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 07/19/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023] Open
Affiliation(s)
- Maryann Mazer-Amirshahi
- Georgetown University School of Medicine, Washington, DC, USA
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | | | - Peggy Ye
- Georgetown University School of Medicine, Washington, DC, USA
- Department of Obstetrics and Gynecology, Medstar Washington Hospital Center, Washington, DC, USA
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12
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Rowlands S, Harrison-Woolrych M. Improving access to medicines for early medical abortion: learning from experiences of medicines licensing and service delivery. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:234-237. [PMID: 37640520 DOI: 10.1136/bmjsrh-2023-201949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Sam Rowlands
- Department of Medical Science & Public Health, Bournemouth University, Poole, UK
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Neill S, Mokashi M, Goldberg A, Fortin J, Janiak E. Mifepristone use for early pregnancy loss: A qualitative study of barriers and facilitators among OB/GYNS in Massachusetts, USA. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2023; 55:210-217. [PMID: 37394759 DOI: 10.1363/psrh.12237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
CONTEXT Early pregnancy loss (EPL) affects 1 million patients in the United States (US) annually, but integration of mifepristone into EPL care may be complicated by regulatory barriers, practice-related factors, and abortion stigma. METHODS We conducted qualitative, semi-structured interviews among obstetrician-gynecologists in independent practice in Massachusetts, US on mifepristone use for EPL. We recruited participants via professional networks and purposively sampled for mifepristone use, practice type, time in practice, and geographic location within Massachusetts until we reached thematic saturation. We analyzed interviews using inductive and deductive coding under a thematic analysis framework to identify facilitators of and barriers to mifepristone use. RESULTS We interviewed 19 obstetrician-gynecologists; 12 had used mifepristone for EPL and 7 had not. Participants were in private practice (n = 12), academic practice (n = 6), or worked at a federally qualified health center (n = 1). Seven had fellowship training, including four in complex family planning. The most common facilitators of mifepristone use for EPL were access to the expertise or protocols of local-regional experts, leadership from a "champion," prior experience with abortion care, and hospital capacity constraints during the COVID-19 pandemic. The most common barriers were related to the Mifepristone Risk Evaluation and Mitigation Strategy (REMS) Program imposed by the US Food and Drug Administration (FDA). Additionally, mifepristone's affiliation with abortion was a barrier to its use in EPL for some obstetrician-gynecologists. CONCLUSION The FDA Mifepristone REMS Program presents substantial barriers to obstetrician-gynecologists incorporating mifepristone into their EPL care.
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Affiliation(s)
- Sara Neill
- Department of Obstetrics, Gynecology, & Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Alisa Goldberg
- Department of Obstetrics, Gynecology, & Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| | - Jennifer Fortin
- ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| | - Elizabeth Janiak
- Department of Obstetrics, Gynecology, & Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
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14
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Paynter M, Heggie C. Distance between institutions of incarceration and procedural abortion facilities in Canada. Contraception 2023; 124:110079. [PMID: 37245785 DOI: 10.1016/j.contraception.2023.110079] [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: 01/23/2023] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 05/30/2023]
Abstract
OBJECTIVES People incarcerated in facilities for women and girls face barriers to accessing abortion, including unclear legislation, operational procedures, and distance. While medication abortion could mitigate distance barriers, prison is not a hospitable environment for medication abortion. Considering this limitation, this paper aimed to identify the distance from institutions of incarceration designated for women and girls to procedural abortion facilities in Canada. STUDY DESIGN This study builds on an inventory of the 67 institutions of incarceration designated for women and girls across 13 provinces and territories in Canada, previously created by the authors. Procedural abortion facilities were identified using publicly available directories. Distances were calculated using Google Maps. The closest procedural abortion facility was identified for each institution, as well as the gestational age limit of each facility. RESULTS Of the 67 institutions, 23 (34%) were located 0 to 10km from a procedural abortion facility. Fourteen (21%) were located 10.1 to 20km away. Ten (15%) were located 20.1 to 100km away. Eleven were located 100.1 to 300km away (16%). The remaining 9 (13%) were located between 300.1 and 738km away. Distances ranged from 0.1 to 738km. The greatest distances were among institutions in northern Canada. CONCLUSIONS This paper identified a large range of distances between institutions of incarceration and procedural abortion facilities in Canada. Physical distance is only one measure of accessibility of abortion services. For incarcerated people, contextual factors including carceral policies and procedures present barriers to care, with significant impact on health equity. IMPLICATIONS Distance between carceral institutions and procedural abortion facilities reduces equitable access to reproductive health services for incarcerated populations. Pregnant people should be protected from imprisonment to ensure reproductive autonomy.
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Affiliation(s)
- Martha Paynter
- Faculty of Nursing, University of New Brunswick, Fredericton, NB, Canada.
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15
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Ennis M, Renner RM, Olure B, Norman WV, Begun S, Martin L, Harris LH, Kean L, Seewald M, Munro S. Experience of stigma and harassment among respondents to the 2019 Canadian abortion provider survey. Contraception 2023; 124:110083. [PMID: 37263373 DOI: 10.1016/j.contraception.2023.110083] [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: 02/03/2023] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVE We conducted a national survey to assess the experiences of stigma and harassment among physicians and nurse practitioners providing abortions and abortion service administrators in Canada. STUDY DESIGN We conducted an exploratory, cross-sectional, national, anonymized, online survey between July and December 2020. Subsections of the survey explored stigma and harassment experienced by respondents, including the 35-item Revised Abortion Providers Stigma Scale and open-ended responses. We analyzed the quantitative data to generate descriptive statistics and employed a reflexive thematic analysis to interpret open-ended responses. RESULTS Three hundred fifty-four participants started the stigma and harassment section of the survey. Among low-volume clinicians (<30 abortions/year, 60%, n = 180) 8% reported harassment; 21% among higher volume clinicians (≥30 abortions/year, 40%, n = 119) and 47% among administrators (n = 39), most commonly picketing. The mean stigma score was 67.8 (standard deviation 17.2; maximum score 175). Our qualitative analysis identified five themes characterizing perceptions of stigma and harassment: concerns related to harassment from picketing, protestors, and the public; wanting protestor "bubble zones"; aiming to be anonymous to avoid being a target; not providing an abortion service; but also witnessing a safe and positive practice environment. CONCLUSIONS Being a low-volume clinician compared to higher volume clinician and administrator appears to be associated with less harassment. Clinicians providing abortion care in Canada reported mid-range abortion-related stigma scores, and expressed strong concerns that stigma interfered with their abortion provision. Our results indicate that further de-stigmatization and protection of abortion providers in Canada is needed through policy and practice interventions including bubble zones. IMPLICATIONS While Canadian abortion care clinicians and administrators reported relatively low incidence of harassment, our results indicate that they are concerned about stigma and harassment. However, as this was an exploratory survey, these data may not be representative of all Canadian abortion providers. Our data identify a need to support abortion clinicians and to bolster protections for dedicated abortion services.
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Affiliation(s)
- Madeleine Ennis
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; Contraception and Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada
| | - Regina M Renner
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; Contraception and Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada.
| | - Bimbola Olure
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; Contraception and Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada; Centre for Health Evaluation and Outcome Sciences (CHÉOS), St. Paul's Hospital Vancouver, Vancouver, BC, Canada
| | - Wendy V Norman
- Contraception and Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada; Department of Family Practice, University of British Columbia, Vancouver, BC, Canada; Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Stephanie Begun
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Lisa Martin
- Department of Health and Human Services, University of Michigan-Dearborn, Dearborn, MI, United States
| | - Lisa H Harris
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
| | - Lauren Kean
- Contraception and Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Meghan Seewald
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
| | - Sarah Munro
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; Contraception and Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada; Centre for Health Evaluation and Outcome Sciences (CHÉOS), St. Paul's Hospital Vancouver, Vancouver, BC, Canada
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16
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Haas M, Church J, Street DJ, Bateson D, Mazza D. How can we encourage the provision of early medical abortion in primary care? Results of a best-worst scaling survey. Aust J Prim Health 2023; 29:252-259. [PMID: 36473159 DOI: 10.1071/py22130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 11/15/2022] [Indexed: 07/20/2023]
Abstract
BACKGROUND Almost onein four women in Australia experience an unintended pregnancy during their lifetime; of these, approximately 30% currently end in abortion. Although early medical abortion (EMA) up to 9weeks gestation is becoming more widely available in Australia, it is still not commonly offered in primary care. The aim of this study was to investigate the barriers and facilitators to the provision of EMA in primary care. METHODS A sample of 150 general practitioners (GPs) and 150 registered nurses (RNs) working in Australia responded to a best-worst scaling survey designed to answer the following question: what are the most important facilitators and barriers to the provision of EMA in primary care? RESULTS GPs believe that the lack of clinical guidelines, the amount of information provision and counselling required, and the fact that women who are not their patients may not return for follow-up are the most important barriers. For RNs, these three barriers, together with the stigma of being known as being involved in the provision of EMA, are the most important barriers. The formation of a community of practice to support the provision of EMA was identified by both professions as the most important facilitator. CONCLUSIONS Having access to a community of practice, enhanced training and reducing stigma will encourage the provision of EMA. Although clinical guidelines are available, they need to be effectively disseminated, implemented and endorsed by peak bodies. Primary care practices should consider using task sharingand developing patient resources to facilitate the provision of information and counselling.
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Affiliation(s)
- Marion Haas
- Centre for Health Economics Research and Evaluation, Faculty of Health, University of Technology Sydney, Broadway, NSW 2007, Australia
| | - Jody Church
- Centre for Health Economics Research and Evaluation, Faculty of Health, University of Technology Sydney, Broadway, NSW 2007, Australia
| | - Deborah J Street
- Centre for Health Economics Research and Evaluation, Faculty of Health, University of Technology Sydney, Broadway, NSW 2007, Australia
| | - Deborah Bateson
- Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia
| | - Danielle Mazza
- Department of General Practice, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Notting Hill, Vic. 3168, Australia
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17
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Zusman EZ, Munro S, Norman WV, Soon JA. Dispensing mifepristone for medical abortion in Canada: Pharmacists' experiences of the first year. Can Pharm J (Ott) 2023; 156:204-214. [PMID: 37435503 PMCID: PMC10331362 DOI: 10.1177/17151635231176270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 07/13/2023]
Abstract
Background Mifepristone for medical abortion was first dispensed by community pharmacists in Canada directly to patients in January 2017. We asked about pharmacists' experiences over their first year dispensing mifepristone in order to evaluate the frequency of the new practice and assess availability in urban/rural pharmacies. Methods From August to December 2019, we invited 433 community pharmacists who had completed a baseline survey at least 1 year prior to participate in a follow-up online survey. We summarized categorical data using counts and proportions and conducted a qualitative thematic analysis of open-ended responses. Results Among 122 participants, 67.2% had dispensed the product, and 48.4% routinely stocked mifepristone. Pharmacists reported a mean of 26 and median of 3 (interquartile range, 1, 8) mifepristone prescriptions filled in their pharmacies in the previous year. Participants perceived that the benefits of making mifepristone available in pharmacies included increased abortion access for patients (n = 115; 94.3%), reduced pressure on the health care system (n = 104; 85.3%), increased rural and remote abortion access (n = 103; 84.4%) and increased interprofessional collaborations (n = 48; 39.3%). Few participants reported challenges to maintaining adequate stock of mifepristone, but these challenges included low demand (n = 24; 19.7%), short expiry dating (n = 12; 9.8%) and drug shortages (n = 8; 6.6%). The overwhelming majority, 96.7%, reported that their communities did not resist the provision of mifepristone by their pharmacy. Interpretation Participating pharmacists reported many benefits and very few barriers to stocking and dispensing mifepristone. Both urban and rural communities responded positively to enhanced access to mifepristone in their community. Conclusions Mifepristone is well accepted by pharmacists within the primary care system in Canada.
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Affiliation(s)
- Enav Z. Zusman
- Contraception and Abortion Research Team of the Women’s Health Research Institute, UBC, and of the Collaboration for Outcomes Research and Evaluation
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver
| | - Sarah Munro
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research, Vancouver, British Columbia
| | - Wendy V. Norman
- Department of Family Practice, University of British Columbia, Vancouver
| | - Judith A. Soon
- Contraception and Abortion Research Team of the Women’s Health Research Institute, UBC, and of the Collaboration for Outcomes Research and Evaluation
- Department of Family Practice, University of British Columbia, Vancouver
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
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18
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Mazza D. Reimagining medical abortion in Australia: what do we need to do to meet women's needs and ensure ongoing access? Med J Aust 2023; 218:496-498. [PMID: 37330996 DOI: 10.5694/mja2.51979] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 06/20/2023]
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19
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Eckstein SM, von Felten S, Perotto L, Brun R, Vorburger D. First trimester abortion protocols by facility type in Switzerland and potential barriers to accessing the service. Sci Rep 2023; 13:6814. [PMID: 37100827 PMCID: PMC10131519 DOI: 10.1038/s41598-023-34101-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 04/24/2023] [Indexed: 04/28/2023] Open
Abstract
Simplified first-trimester abortion protocols are well established. However, data on the use of medical or surgical abortion protocols across Switzerland is lacking. We report protocol characteristics in abortion care for two different facility types, hospital vs private practices (office-based) in Switzerland. Furthermore, we investigate an association between protocol characteristics and the likelihood of following through with the abortion at the same facility. We also report abortion outcomes of an office-based cohort where doctors use simplified abortion protocols. This study consists of two parts. (i) Between April and July, 2019, we collected data regarding medical and surgical abortion protocols of institutions offering abortions, in a nationwide survey. We assessed whether the proportion of patients who followed through with the abortion (primary outcome) after first appointment was associated with predefined protocol characteristics, considered to complicate access to abortion services, using generalised estimating equations. (ii) We analysed abortion outcomes of six selected office-based facilities from January, 2008, to December, 2018, using simplified abortion protocols in accordance with the Worlds Health Organisation (WHO) guidelines. (i) We included a total of 39 institutions. Hospitals showed more protocol-based barriers to abortion access compared with office-based facilities. The odds of undergoing an abortion after the first appointment were increased using protocols with minimal barriers. Overall, office-based facilities applied higher gestational age limits, required fewer appointments, and administered mifepristone more often after the first visit than did hospitals. (ii) We included a total of 5274 patients with an incidence of complications requiring surgery of 2.5% in line with rates reported in published literature. Only a few hospitals provide abortion care with easy access to medical and surgical abortion, whereas most office-based facilities do. Access to abortion services is generally crucial, and should be provided in a single visit whenever clinically permissible.
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Affiliation(s)
| | - Stefanie von Felten
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Laura Perotto
- Department of Gyaecology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Romana Brun
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Denise Vorburger
- Department of Gynaecology, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
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20
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Guilbert E, Bois G. Évaluation de l'accès à l'avortement médicamenteux dans les cliniques d'avortement du Québec en 2021 - Partie I. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:116-124. [PMID: 36567051 DOI: 10.1016/j.jogc.2022.11.013] [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: 07/11/2022] [Revised: 11/14/2022] [Accepted: 11/14/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE In 2020, 11.9% of abortions in Quebec were medication abortions, compared with 32.4% in Ontario. The objective of this evaluation was to assess the quality of access to medication abortion in Quebec abortion clinics, where 91% of these abortions are performed. METHODS Quebec abortion clinics were contacted by 2 mystery client clinical profiles between October 8 and November 17, 2021. Descriptive analyses and statistical tests were performed, as well as a qualitative analysis of collected comments. RESULTS Medication abortion up to 63 days of gestational age or less was available in 39/47 abortion clinics, more in rural and remote areas than in urban or suburban areas (P = 0.013). The mean time from first call to first appointment was 6.2 calendar days (standard deviation [SD] 4.0), shorter in rural and remote areas (P = 0.005) and in clinics affiliated with a hospital or local community service center (P = 0.010). The mean number of visits required for medication abortion was higher than for surgical abortion (2.9 [SD] 0.9 vs. 2.3 [SD] 1.1) (P < 0.001). For one in three clinical profiles (26/78, 33%), a telemedicine visit was possible. Medication abortion entirely accessible through telemedicine was not available. Unfavorable comments about medication abortion were frequent. CONCLUSION Access to medication abortion is difficult in Quebec and access through telemedicine is almost non existent. Restrictions imposed by the Collège des médecins du Québec (CMQ) and constraints imposed on patients limit access.
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Affiliation(s)
- Edith Guilbert
- Département d'obstétrique, gynécologie et reproduction, Université Laval, Québec, Québec, Canada.
| | - Geneviève Bois
- Département de médecine familiale et de médecine d'urgence, Université de Montréal, Montréal, Québec, Canada
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21
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Liu N, Ray JG. Short-Term Adverse Outcomes After Mifepristone-Misoprostol Versus Procedural Induced Abortion : A Population-Based Propensity-Weighted Study. Ann Intern Med 2023; 176:145-153. [PMID: 36592459 DOI: 10.7326/m22-2568] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Prior studies comparing first-trimester pharmaceutical induced abortion (IA) with procedural IA were prone to selection bias, were underpowered to assess serious adverse events (SAEs), and did not account for confounding by indication. Starting in 2017, mifepristone-misoprostol was dispensed at no cost in outpatient pharmacies across Ontario, Canada. OBJECTIVE To compare short-term risk for adverse outcomes after early IA by mifepristone-misoprostol versus by procedural IA. DESIGN Population-based cohort study. SETTING Ontario, Canada. PATIENTS All women who had first-trimester IA. MEASUREMENTS A total of 39 856 women dispensed mifepristone-misoprostol as outpatients were compared with 65 176 women undergoing procedural IA at 14 weeks' gestation or earlier within nonhospital outpatient clinics (comparison 1). A total of 39 856 women prescribed mifepristone-misoprostol were compared with 8861 women undergoing ambulatory hospital-based procedural IA at an estimated 9 weeks' gestation or less (comparison 2). The primary composite outcome was any SAE within 42 days after IA, including severe maternal morbidity, end-organ damage, intensive care unit admission, or death. A coprimary broader outcome comprised any SAE, hemorrhage, retained products of conception, infection, or transfusion. Stabilized inverse probability of treatment weighting accounted for confounding between exposure groups. RESULTS Mean age at IA was about 29 years (SD, 7); 33% were primigravidae. Six percent resided in rural areas, and 25% resided in low-income neighborhoods. In comparison 1, SAEs occurred among 133 women after mifepristone-misoprostol IA (3.3 per 1000) versus 114 after procedural IA (1.8 per 1000) (relative risk [RR], 1.87 [95% CI, 1.44 to 2.43]; absolute risk difference [ARD], 1.5 per 1000 [CI, 0.9 to 2.2]). The respective rates of any adverse event were 28.9 versus 12.4 per 1000 (RR, 2.33 [CI, 2.11 to 2.57]; ARD, 16.5 per 1000 [CI, 14.5 to 18.4]). In comparison 2, SAEs occurred among 133 (3.4 per 1000) and 27 (3.3 per 1000) women, respectively (RR, 1.04 [CI, 0.61 to 1.78]). The respective rates of any adverse event were 31.2 versus 24.9 per 1000 (RR, 1.25 [CI, 1.04 to 1.51]). LIMITATION A woman prescribed mifepristone-misoprostol may not have taken the medication, and the exact gestational age at IA was not always known. CONCLUSION Although rare, short-term adverse events are more likely after mifepristone-misoprostol IA than procedural IA, especially for less serious adverse outcomes. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research.
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Affiliation(s)
- Ning Liu
- ICES and University of Toronto, Toronto, Ontario, Canada (N.L.)
| | - Joel G Ray
- Departments of Medicine and Obstetrics and Gynecology, St. Michael's Hospital, ICES, and University of Toronto, Toronto, Ontario, Canada (J.G.R.)
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22
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Carson A, Cameron ES, Paynter M, Norman WV, Munro S, Martin-Misener R. Nurse practitioners on 'the leading edge' of medication abortion care: A feminist qualitative approach. J Adv Nurs 2023; 79:686-697. [PMID: 36369652 PMCID: PMC10100085 DOI: 10.1111/jan.15487] [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: 05/25/2022] [Revised: 10/09/2022] [Accepted: 10/19/2022] [Indexed: 11/15/2022]
Abstract
AIMS To explore nurse practitioners' experiences of medication abortion implementation in Canada and to identify ways to further support the implementation of medication abortion by nurse practitioners in Canada. DESIGN A qualitative approach informed by feminist theory and integrated knowledge translation. METHODS Qualitative interviews with stakeholders and nurse practitioners between January 2020 and May 2021. Data were analysed using critical feminist theory. RESULTS Participants included 20 stakeholders, 16 nurse practitioner abortion providers, and seven nurse practitioners who did not provide abortions. We found that nurse practitioners conduct educational, communication and networking activities in the implementation of medication abortion in their communities. Nurse practitioners navigated resistance to abortion care in the health system from employers, colleagues and funders. Participants valued making abortion care more accessible to their patients and indicated that normalizing medication abortion in primary care was important to them. CONCLUSION When trained in abortion care and supported by employers, nurse practitioners are leaders of abortion care in their communities and want to provide accessible, inclusive services to their patients. We recommend nursing curricula integrate abortion services in education, and that policymakers and health administrators partner with nurses, physicians, midwives, social workers and pharmacists, for comprehensive provincial/territorial sexual and reproductive health strategies for primary care. IMPACT The findings from this study may inform future policy, health administration and curriculum decisions related to reproductive health, and raise awareness about the crucial role of nurse practitioners in abortion care and contributions to reproductive health equity. PATIENT OR PUBLIC CONTRIBUTION This study focused on provider experiences. In-kind support was provided by Action Canada for Sexual Health & Rights, an organization that provides direct support and resources to the public and is committed to advocating on behalf of patients and the public seeking sexual and reproductive health services.
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Affiliation(s)
- Andrea Carson
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Martha Paynter
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Wendy V Norman
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada.,Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Sarah Munro
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
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23
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Beshar I, Liu SM, Shaw KA, Henkel A. Discovery of an Ectopic Pregnancy after Attempted Self-Managed Abortion. N Engl J Med 2023; 388:278-279. [PMID: 36652361 DOI: 10.1056/nejmc2214213] [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: 01/19/2023]
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24
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Carson A, Stirling-Cameron E, Paynter M, Munro S, Norman WV, Kilpatrick K, Begun S, Martin-Misener R. Barriers and enablers to nurse practitioner implementation of medication abortion in Canada: A qualitative study. PLoS One 2023; 18:e0280757. [PMID: 36701296 PMCID: PMC9879445 DOI: 10.1371/journal.pone.0280757] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 01/06/2023] [Indexed: 01/27/2023] Open
Abstract
In this study we explored nurse practitioner-provided medication abortion in Canada and identified barriers and enablers to uptake and implementation. Between 2020-2021, we conducted 43 semi-structured interviews with 20 healthcare stakeholders and 23 nurse practitioners who both provided and did not provide medication abortion. Data were analyzed using interpretive description. We identified five overarching themes: 1) Access and use of ultrasound for gestational dating; 2) Advertising and anonymity of services; 3) Abortion as specialized or primary care; 4) Location and proximity to services; and 5) Education, mentorship, and peer support. Under certain conditions, ultrasound is not required for medication abortion, supporting nurse practitioner provision in the absence of access to this technology. Nurse practitioners felt a conflict between wanting to advertise their abortion services while also protecting their anonymity and that of their patients. Some nurse practitioners perceived medication abortion to be a low-resource, easy-to-provide service, while some not providing medication abortion continued to refer patients to specialized clinics. Some participants in rural areas felt unable to provide this service because they were too far from emergency services in the event of complications. Most nurse practitioners did not have any training in abortion care during their education and desired the support of a mentor experienced in abortion provision. Addressing factors that influence nurse practitioner provision of medication abortion will help to broaden access. Nurse practitioners are well-suited to provide medication abortion care but face multiple ongoing barriers to provision. We recommend the integration of medication abortion training into nurse practitioner education. Further, widespread communication from nursing organizations could inform nurse practitioners that medication abortion is within their scope of practice and facilitate public outreach campaigns to inform the public that this service exists and can be provided by nurse practitioners.
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Affiliation(s)
- Andrea Carson
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
- * E-mail:
| | | | - Martha Paynter
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sarah Munro
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wendy V. Norman
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kelley Kilpatrick
- Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
| | - Stephanie Begun
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
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Baraitser P, Free C, Norman WV, Lewandowska M, Meiksin R, Palmer MJ, Scott R, French R, Wellings K, Ivory A, Wong G. Improving experience of medical abortion at home in a changing therapeutic, technological and regulatory landscape: a realist review. BMJ Open 2022; 12:e066650. [PMID: 36385017 PMCID: PMC9670095 DOI: 10.1136/bmjopen-2022-066650] [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] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To inform UK service development to support medical abortion at home, appropriate for person and context. DESIGN Realist review SETTING/PARTICIPANTS: Peer-reviewed literature from 1 January 2000 to 9 December 2021, describing interventions or models of home abortion care. Participants included people seeking or having had an abortion. INTERVENTIONS Interventions and new models of abortion care relevant to the UK. OUTCOME MEASURES Causal explanations, in the form of context-mechanism-outcome configurations, to test and develop our realist programme theory. RESULTS We identified 12 401 abstracts, selecting 944 for full text assessment. Our final review included 50 papers. Medical abortion at home is safe, effective and acceptable to most, but clinical pathways and user experience are variable and a minority would not choose this method again. Having a choice of abortion location remains essential, as some people are unable to have a medical abortion at home. Choice of place of abortion (home or clinical setting) was influenced by service factors (appointment number, timing and wait-times), personal responsibilities (caring/work commitments), geography (travel time/distance), relationships (need for secrecy) and desire for awareness/involvement in the process. We found experiences could be improved by offering: an option for self-referral through a telemedicine consultation, realistic information on a range of experiences, opportunities to personalise the process, improved pain relief, and choice of when and how to discuss contraception. CONCLUSIONS Acknowledging the work done by patients when moving medical abortion care from clinic to home is important. Patients may benefit from support to: prepare a space, manage privacy and work/caring obligations, decide when/how to take medications, understand what is normal, assess experience and decide when and how to ask for help. The transition of this complex intervention when delivered outside healthcare environments could be supported by strategies that reduce surprise or anxiety, enabling preparation and a sense of control.
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Affiliation(s)
| | - Caroline Free
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Wendy V Norman
- Department of Family Practice, The University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Maria Lewandowska
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Rebecca Meiksin
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Melissa J Palmer
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Rachel Scott
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Rebecca French
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Kaye Wellings
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Alice Ivory
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
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Munro SB, Dunn S, Guilbert ER, Norman WV. Advancing Reproductive Health through Policy-Engaged Research in Abortion Care. Semin Reprod Med 2022; 40:268-276. [PMID: 36746159 DOI: 10.1055/s-0042-1760213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Mifepristone medication abortion was first approved in China and France more than 30 years ago and is now used in more than 60 countries worldwide. It is a highly safe and effective method that has the potential to increase population access to abortion in early pregnancy, closer to home. In both Canada and the United States, the initial regulations for distribution, prescribing, and dispensing of mifepristone were highly restricted. However, in Canada, where mifepristone was made available in 2017, most restrictions on the medication were removed in the first year of its availability. The Canadian regulation of mifepristone as a normal prescription makes access possible in community primary care through a physician or nurse practitioner prescription, which any pharmacist can dispense. In this approach, people decide when and where to take their medication. We explore how policy-maker-engaged research advanced reproductive health policy and facilitated this rapid change in Canada. We discuss the implications of these policy advances for self-management of abortion and demonstrate how in Canada patients "self-manage" components of the abortion process within a supportive health care system.
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Affiliation(s)
- Sarah B Munro
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sheila Dunn
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Edith R Guilbert
- Department of Obstetrics, Gynecology and Reproduction, Laval University, Québec City, Québec, Canada
| | - Wendy V Norman
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada.,Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Renner RM, Ennis M, Kyeremeh A, Norman WV, Dunn S, Pymar H, Guilbert E. Telemedicine for First-Trimester Medical Abortion in Canada: Results of a 2019 Survey. Telemed J E Health 2022; 29:686-695. [PMID: 36126299 PMCID: PMC10171945 DOI: 10.1089/tmj.2022.0245] [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: 11/13/2022] Open
Abstract
Introduction: Telemedicine has the potential to improve abortion access disparities in Canada. We aimed to explore the provision of telemedicine for first-trimester medical abortion and related barriers in 2019. Methods: We conducted a national, cross-sectional, anonymized, web-based survey of clinicians who provided abortion care in 2019 in Canada. We distributed our survey through professional health organizations to maximize identification of possible eligible respondents and used a modified Dillman technique to foster responses. Questions elicited provider demographics, clinical characteristics, including telemedicine first-trimester medical abortion and perceived related barriers. Descriptive statistics were analyzed using R software. Results: Among 465 respondents, 388 reported providing first-trimester medical abortion across Canada; 44.0% reported experience using telemedicine for some components of care: 49.3% of primary care clinicians and 28.7% of specialists. Telemedicine was used for initial consultation (86.0%), prescription (82.2%), or follow-up (92.2%). The median percentage of telemedicine providers' patients who underwent a dating ultrasound was 90.0. The majority usually followed up with patients through quantitative human chorionic gonadotropin (hCG) (84.2%). Seventy-eight percent perceived barriers to telemedicine; the most common being inability to confirm gestational age with ultrasound (43.0%), and lack of provincial telemedicine abortion fee code to pay practitioners (30.2%), timely access to serum hCG testing (24.6%), and nearby emergency services (23.3%). Discussion: In 2019, fewer than half of respondents reported providing some aspects of first-trimester medical abortion through telemedicine and the majority perceived barriers. Our results can inform knowledge translation activities to reduce barriers and increase telemedicine abortion care in Canada.
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Affiliation(s)
- Regina M Renner
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada.,Contraception and Abortion Research Team, Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, Canada
| | - Madeleine Ennis
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada.,Contraception and Abortion Research Team, Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, Canada
| | - Ama Kyeremeh
- Contraception and Abortion Research Team, Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, Canada
| | - Wendy V Norman
- Contraception and Abortion Research Team, Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, Canada.,Department of Family Practice, University of British Columbia, Vancouver, Canada.,Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sheila Dunn
- Contraception and Abortion Research Team, Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, Canada.,Department of Family and Community Medicine, University of Toronto, Ontario, Canada
| | - Helen Pymar
- Contraception and Abortion Research Team, Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, Canada.,Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Manitoba, Canada
| | - Edith Guilbert
- Contraception and Abortion Research Team, Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, Canada.,Department of Obstetrics, Gynecology and Reproduction, Université Laval, Québec City, Canada
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Janiak E, Belizaire C, Liu J, Fulcher IR. The association of U.S. state-level abortion restrictions with medication abortion service delivery innovations during the early COVID-19 pandemic. Contraception 2022; 113:26-29. [PMID: 35430237 PMCID: PMC9010011 DOI: 10.1016/j.contraception.2022.04.003] [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: 11/24/2021] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To assess whether state-level abortion restrictions resulted in differential uptake of innovative medication abortion practices such as changing ultrasound requirements, offering telehealth, or dispensing medications without a physical exam during the early COVID-19 pandemic. METHODS We used data from a prospective national survey of abortion providers to assess the association between a novel index of state-level abortion hostility and adoption of medication abortion services innovations during the pandemic. RESULTS Clinics in states with low or medium hostility were more likely to adopt innovative practices than those in high or extreme hostility states. CONCLUSIONS Clinics in abortion hostile states were less likely to adopt clinical recommendations and public health best practices for abortion care during the COVID-19 pandemic.
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Affiliation(s)
- Elizabeth Janiak
- Brigham and Women's Hospital, Boston, MA, United States,Harvard Medical School, Boston, MA, United States,Planned Parenthood League of Massachusetts, Boston, MA, United States,Corresponding author
| | - Carmela Belizaire
- Planned Parenthood League of Massachusetts, Boston, MA, United States,Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States
| | - Jessie Liu
- Planned Parenthood League of Massachusetts, Boston, MA, United States,Harvard College, Cambridge, MA, United States
| | - Isabel R. Fulcher
- Harvard Medical School, Boston, MA, United States,Planned Parenthood League of Massachusetts, Boston, MA, United States
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Renner RM, Ennis M, Contandriopoulos D, Guilbert E, Dunn S, Kaczorowski J, Darling EK, Albert A, Styffe C, Norman WV. Abortion services and providers in Canada in 2019: results of a national survey. CMAJ Open 2022; 10:E856-E864. [PMID: 36167421 PMCID: PMC9578753 DOI: 10.9778/cmajo.20210232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Since 2016, abortion care has undergone several important changes, particularly related to the provision of medical abortion using mifepristone. We aimed to document characteristics of the abortion care workforce in Canada after the update of clinical practice guidelines of mifepristone use for medical abortion. METHODS We conducted a national, web-based, anonymized, bilingual (English/French) survey. We collected demographics and clinical care characteristics of physicians and nurse practitioners who provided abortion care in 2019. Between July and December 2020, we distributed the survey through professional organizations, including The College of Family Physicians of Canada and The Society of Obstetricians and Gynaecologists of Canada. We present descriptive statistics. RESULTS Overall, 465 respondents representing all 10 provinces and 3 territories in Canada completed the survey. Of these, 388 (83.4%), including 30 nurse practitioners, provided first-trimester medical abortion, of which 350 (99.4%) used mifepristone. Two hundred and nineteen (47.1%) respondents provided first-trimester surgical abortion, 109 (23.4%) provided second-trimester surgical abortion and 115 (24.7%) provided second- or third-trimester medical abortion. Half of respondents reported fewer than 5 years of experience with any abortion care. Respondents reported providing a total of 48 509 abortions in 2019, including 32 345 (66.7%) first-trimester surgical abortions and 13 429 (27.7%) first-trimester medical abortions. In Quebec, only 1918 (12.5%) of reported abortions were first-trimester medical abortions. Primary care providers provided 34 540 (71.2%) of the total abortions. First-trimester medical abortions represented 44.4% (n = 2334) of all abortions in rural areas, as opposed to 25.6% (n = 11 067) in urban areas. INTERPRETATION The increased availability of medical abortion facilitates abortion access, especially in primary care and rural settings, and where surgical abortion is not available. Rejuvenation of the workforce is a critical contributor to equitable access to abortion services.
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Affiliation(s)
- Regina M Renner
- Department of Obstetrics and Gynaecology (Renner, Ennis), University of British Columbia, Vancouver, BC; Contraception and Abortion Research Team (Renner, Ennis, Contandriopoulos, Guilbert, Dunn, Kaczorowski, Darling, Albert, Styffe, Norman), Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC; School of Nursing (Contandriopoulos), University of Victoria, Victoria, BC; Department of Obstetrics Gynecology and Reproduction (Guilbert), Laval University, Québec City, Que.; Department of Family & Community Medicine (Dunn), University of Toronto, Toronto, Ont.; Women's College Research Institute (Dunn), Women's College Hospital, Toronto, Ont.; Department of Family and Emergency Medicine (Kaczorowski), Université de Montréal, Montréal, Que.; Department of Obstetrics & Gynecology (Darling), McMaster University, Hamilton, Ont.; School of Population and Public Health (Styffe) and Department of Family Practice (Norman), University of British Columbia, Vancouver, BC; Faculty of Public Health and Policy (Norman), London School of Hygiene & Tropical Medicine, London, UK
| | - Madeleine Ennis
- Department of Obstetrics and Gynaecology (Renner, Ennis), University of British Columbia, Vancouver, BC; Contraception and Abortion Research Team (Renner, Ennis, Contandriopoulos, Guilbert, Dunn, Kaczorowski, Darling, Albert, Styffe, Norman), Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC; School of Nursing (Contandriopoulos), University of Victoria, Victoria, BC; Department of Obstetrics Gynecology and Reproduction (Guilbert), Laval University, Québec City, Que.; Department of Family & Community Medicine (Dunn), University of Toronto, Toronto, Ont.; Women's College Research Institute (Dunn), Women's College Hospital, Toronto, Ont.; Department of Family and Emergency Medicine (Kaczorowski), Université de Montréal, Montréal, Que.; Department of Obstetrics & Gynecology (Darling), McMaster University, Hamilton, Ont.; School of Population and Public Health (Styffe) and Department of Family Practice (Norman), University of British Columbia, Vancouver, BC; Faculty of Public Health and Policy (Norman), London School of Hygiene & Tropical Medicine, London, UK
| | - Damien Contandriopoulos
- Department of Obstetrics and Gynaecology (Renner, Ennis), University of British Columbia, Vancouver, BC; Contraception and Abortion Research Team (Renner, Ennis, Contandriopoulos, Guilbert, Dunn, Kaczorowski, Darling, Albert, Styffe, Norman), Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC; School of Nursing (Contandriopoulos), University of Victoria, Victoria, BC; Department of Obstetrics Gynecology and Reproduction (Guilbert), Laval University, Québec City, Que.; Department of Family & Community Medicine (Dunn), University of Toronto, Toronto, Ont.; Women's College Research Institute (Dunn), Women's College Hospital, Toronto, Ont.; Department of Family and Emergency Medicine (Kaczorowski), Université de Montréal, Montréal, Que.; Department of Obstetrics & Gynecology (Darling), McMaster University, Hamilton, Ont.; School of Population and Public Health (Styffe) and Department of Family Practice (Norman), University of British Columbia, Vancouver, BC; Faculty of Public Health and Policy (Norman), London School of Hygiene & Tropical Medicine, London, UK
| | - Edith Guilbert
- Department of Obstetrics and Gynaecology (Renner, Ennis), University of British Columbia, Vancouver, BC; Contraception and Abortion Research Team (Renner, Ennis, Contandriopoulos, Guilbert, Dunn, Kaczorowski, Darling, Albert, Styffe, Norman), Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC; School of Nursing (Contandriopoulos), University of Victoria, Victoria, BC; Department of Obstetrics Gynecology and Reproduction (Guilbert), Laval University, Québec City, Que.; Department of Family & Community Medicine (Dunn), University of Toronto, Toronto, Ont.; Women's College Research Institute (Dunn), Women's College Hospital, Toronto, Ont.; Department of Family and Emergency Medicine (Kaczorowski), Université de Montréal, Montréal, Que.; Department of Obstetrics & Gynecology (Darling), McMaster University, Hamilton, Ont.; School of Population and Public Health (Styffe) and Department of Family Practice (Norman), University of British Columbia, Vancouver, BC; Faculty of Public Health and Policy (Norman), London School of Hygiene & Tropical Medicine, London, UK
| | - Sheila Dunn
- Department of Obstetrics and Gynaecology (Renner, Ennis), University of British Columbia, Vancouver, BC; Contraception and Abortion Research Team (Renner, Ennis, Contandriopoulos, Guilbert, Dunn, Kaczorowski, Darling, Albert, Styffe, Norman), Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC; School of Nursing (Contandriopoulos), University of Victoria, Victoria, BC; Department of Obstetrics Gynecology and Reproduction (Guilbert), Laval University, Québec City, Que.; Department of Family & Community Medicine (Dunn), University of Toronto, Toronto, Ont.; Women's College Research Institute (Dunn), Women's College Hospital, Toronto, Ont.; Department of Family and Emergency Medicine (Kaczorowski), Université de Montréal, Montréal, Que.; Department of Obstetrics & Gynecology (Darling), McMaster University, Hamilton, Ont.; School of Population and Public Health (Styffe) and Department of Family Practice (Norman), University of British Columbia, Vancouver, BC; Faculty of Public Health and Policy (Norman), London School of Hygiene & Tropical Medicine, London, UK
| | - Janusz Kaczorowski
- Department of Obstetrics and Gynaecology (Renner, Ennis), University of British Columbia, Vancouver, BC; Contraception and Abortion Research Team (Renner, Ennis, Contandriopoulos, Guilbert, Dunn, Kaczorowski, Darling, Albert, Styffe, Norman), Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC; School of Nursing (Contandriopoulos), University of Victoria, Victoria, BC; Department of Obstetrics Gynecology and Reproduction (Guilbert), Laval University, Québec City, Que.; Department of Family & Community Medicine (Dunn), University of Toronto, Toronto, Ont.; Women's College Research Institute (Dunn), Women's College Hospital, Toronto, Ont.; Department of Family and Emergency Medicine (Kaczorowski), Université de Montréal, Montréal, Que.; Department of Obstetrics & Gynecology (Darling), McMaster University, Hamilton, Ont.; School of Population and Public Health (Styffe) and Department of Family Practice (Norman), University of British Columbia, Vancouver, BC; Faculty of Public Health and Policy (Norman), London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth K Darling
- Department of Obstetrics and Gynaecology (Renner, Ennis), University of British Columbia, Vancouver, BC; Contraception and Abortion Research Team (Renner, Ennis, Contandriopoulos, Guilbert, Dunn, Kaczorowski, Darling, Albert, Styffe, Norman), Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC; School of Nursing (Contandriopoulos), University of Victoria, Victoria, BC; Department of Obstetrics Gynecology and Reproduction (Guilbert), Laval University, Québec City, Que.; Department of Family & Community Medicine (Dunn), University of Toronto, Toronto, Ont.; Women's College Research Institute (Dunn), Women's College Hospital, Toronto, Ont.; Department of Family and Emergency Medicine (Kaczorowski), Université de Montréal, Montréal, Que.; Department of Obstetrics & Gynecology (Darling), McMaster University, Hamilton, Ont.; School of Population and Public Health (Styffe) and Department of Family Practice (Norman), University of British Columbia, Vancouver, BC; Faculty of Public Health and Policy (Norman), London School of Hygiene & Tropical Medicine, London, UK
| | - Arianne Albert
- Department of Obstetrics and Gynaecology (Renner, Ennis), University of British Columbia, Vancouver, BC; Contraception and Abortion Research Team (Renner, Ennis, Contandriopoulos, Guilbert, Dunn, Kaczorowski, Darling, Albert, Styffe, Norman), Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC; School of Nursing (Contandriopoulos), University of Victoria, Victoria, BC; Department of Obstetrics Gynecology and Reproduction (Guilbert), Laval University, Québec City, Que.; Department of Family & Community Medicine (Dunn), University of Toronto, Toronto, Ont.; Women's College Research Institute (Dunn), Women's College Hospital, Toronto, Ont.; Department of Family and Emergency Medicine (Kaczorowski), Université de Montréal, Montréal, Que.; Department of Obstetrics & Gynecology (Darling), McMaster University, Hamilton, Ont.; School of Population and Public Health (Styffe) and Department of Family Practice (Norman), University of British Columbia, Vancouver, BC; Faculty of Public Health and Policy (Norman), London School of Hygiene & Tropical Medicine, London, UK
| | - Claire Styffe
- Department of Obstetrics and Gynaecology (Renner, Ennis), University of British Columbia, Vancouver, BC; Contraception and Abortion Research Team (Renner, Ennis, Contandriopoulos, Guilbert, Dunn, Kaczorowski, Darling, Albert, Styffe, Norman), Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC; School of Nursing (Contandriopoulos), University of Victoria, Victoria, BC; Department of Obstetrics Gynecology and Reproduction (Guilbert), Laval University, Québec City, Que.; Department of Family & Community Medicine (Dunn), University of Toronto, Toronto, Ont.; Women's College Research Institute (Dunn), Women's College Hospital, Toronto, Ont.; Department of Family and Emergency Medicine (Kaczorowski), Université de Montréal, Montréal, Que.; Department of Obstetrics & Gynecology (Darling), McMaster University, Hamilton, Ont.; School of Population and Public Health (Styffe) and Department of Family Practice (Norman), University of British Columbia, Vancouver, BC; Faculty of Public Health and Policy (Norman), London School of Hygiene & Tropical Medicine, London, UK
| | - Wendy V Norman
- Department of Obstetrics and Gynaecology (Renner, Ennis), University of British Columbia, Vancouver, BC; Contraception and Abortion Research Team (Renner, Ennis, Contandriopoulos, Guilbert, Dunn, Kaczorowski, Darling, Albert, Styffe, Norman), Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC; School of Nursing (Contandriopoulos), University of Victoria, Victoria, BC; Department of Obstetrics Gynecology and Reproduction (Guilbert), Laval University, Québec City, Que.; Department of Family & Community Medicine (Dunn), University of Toronto, Toronto, Ont.; Women's College Research Institute (Dunn), Women's College Hospital, Toronto, Ont.; Department of Family and Emergency Medicine (Kaczorowski), Université de Montréal, Montréal, Que.; Department of Obstetrics & Gynecology (Darling), McMaster University, Hamilton, Ont.; School of Population and Public Health (Styffe) and Department of Family Practice (Norman), University of British Columbia, Vancouver, BC; Faculty of Public Health and Policy (Norman), London School of Hygiene & Tropical Medicine, London, UK
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La SOGC plaide en faveur de l'accès aux soins d'avortement de haute qualité. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:948-950. [PMID: 36109103 DOI: 10.1016/j.jogc.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Norman WV, Wilson RD, Francoeur D. The SOGC Supports High-Quality, Accessible Abortion Care. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:945-947. [PMID: 36109102 DOI: 10.1016/j.jogc.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Wendy V Norman
- Department of Family Practice, University of British Columbia, Vancouver, BC; Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - R Douglas Wilson
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB; Society of Obstetricians and Gynaecologists of Canada, Ottawa, ON
| | - Diane Francoeur
- Society of Obstetricians and Gynaecologists of Canada, Ottawa, ON; Department of Obstetrics and Gynecology, University of Montreal, Montréal, QC
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Kaller S, Ma M, Gurazada T, Baba CF, Rafie S, Raine-Bennett T, Averbach S, Chen M, Berry E, Meckstroth KR, Grossman D. "No Big Deal": A Qualitative Study of Pharmacists' Perspectives on Dispensing Mifepristone for Medication Abortion. Womens Health Issues 2022; 32:571-577. [PMID: 35918240 DOI: 10.1016/j.whi.2022.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/15/2022] [Accepted: 06/22/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Until December 2021, the United States Food and Drug Administration impeded abortion access by restricting pharmacists from dispensing mifepristone, one of two drugs used in medication abortion. This study aimed to explore pharmacists' perspectives on dispensing mifepristone. METHODS We conducted semistructured interviews with pharmacists before and after participating in a pilot project where mifepristone was dispensed from their pharmacies. We thematically coded all interview transcripts, then summarized emergent themes related to pharmacists' support, comfort, experiences, and concerns around dispensing mifepristone. RESULTS Between May 2018 and July 2020, we interviewed 29 pharmacists (22 at baseline and 15 at follow-up, with 8 completing both interviews) from 5 pharmacies. At both baseline and follow-up, interviewees strongly supported pharmacists dispensing mifepristone, feeling it would improve quality of care by providing more convenient medication abortion access and streamlined service delivery and take advantage of pharmacists' expertise and availability. All pharmacists interviewed at follow-up reported dispensing mifepristone except two who were willing but did not have the opportunity. Pharmacists experienced few challenges dispensing mifepristone. Their main concern was perceived discomfort that other pharmacists and pharmacy staff may experience, particularly in conservative areas or small pharmacies where pharmacists' refusal to dispense mifepristone could impede abortion access. CONCLUSIONS Most pharmacists supported dispensing mifepristone and were comfortable doing so after education on mifepristone and medication abortion. They dispensed mifepristone without difficulty, in a similar process as dispensing other medications. With the recent removal of U.S. Food and Drug Administration restrictions prohibiting it, our findings support the feasibility of pharmacists dispensing mifepristone.
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Affiliation(s)
- Shelly Kaller
- Advancing New Standards in Reproductive Health (ANISRH), University of California, Oakland, California.
| | - Melanie Ma
- Department of Obstetrics and Gynecology, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California
| | - Tanvi Gurazada
- Advancing New Standards in Reproductive Health (ANISRH), University of California, Oakland, California
| | - C Finley Baba
- Advancing New Standards in Reproductive Health (ANISRH), University of California, Oakland, California
| | - Sally Rafie
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego Health, San Diego, California
| | - Tina Raine-Bennett
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Sarah Averbach
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, California
| | - Melissa Chen
- Department of Obstetrics and Gynecology, University of California, Sacramento, California
| | - Erin Berry
- Planned Parenthood Great Northwest, Hawai'i, Alaska, Indiana, Kentucky, Seattle, Washington
| | - Karen R Meckstroth
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANISRH), University of California, Oakland, California
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Ennis M, Renner R, Guilbert E, Norman WV, Pymar H, Kean L, Carson A, Martin-Misener R, Dunn S. Provision of First-trimester Medication Abortion in 2019: Results from the Canadian Abortion Provider Survey. Contraception 2022; 113:19-25. [PMID: 35351448 DOI: 10.1016/j.contraception.2022.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To explore the Canadian first-trimester medication abortion (MA) workforce and their clinical care following the introduction of mifepristone in 2017, updated national clinical practice guidelines and government approval of nurse practitioners (NPs) as first-trimester MA providers. STUDY DESIGN We conducted a national, self-administered, cross-sectional survey of abortion providers in 2019. Our bilingual (French/English) survey collected information on demographics, abortion number, and clinical care characteristics. The true number of abortion providers is unknown thus we cannot calculate a survey response rate. To maximize identification of possibly eligible respondents, we widely distributed the survey between July and December 2020 through health professional organizations, using a modified Dillman technique. We used descriptive statistics to characterize the workforce and clinical practices. RESULTS Four-hundred-sixty-five clinicians responded, of whom 388 provided first-trimester MA. Physicians (n=358) and NPs (n=30) reported providing 13,429 first-trimester MAs in 2019 which represented 27.7% of all reported abortions in the survey. The majority of first-trimester MA respondents were primary care physicians (n=245, 63.1%), had less than five years' experience (n=223, 61.3%) and practiced outside of hospitals (n=228, 66.5%). Forty-three percent (n=165) practiced rurally, and 44.0% (n=136) used telemedicine for some abortion care. Ninety-nine percent (n=350) used a guideline-recommended mifepristone/misoprostol regimen while 14.5% (n=51) sometimes used methotrexate. Patients most commonly received mifepristone/misoprostol at community pharmacies (median 100.0%; interquartile range 50.0-100.0%). CONCLUSION Our results suggest that there are many new first-trimester MA providers, an increase in the proportion of MAs since 2012 and a shift to primary care settings. Respondents widely adopted mifepristone. IMPLICATIONS STATEMENT Our results highlight that, following mifepristone introduction, many new primary care practitioners started providing first-trimester medication abortion throughout Canada, including the first non-physicians. This increased access to abortion particularly in rural and underserved communities. These results could inform future directions in policy, guidelines, and abortion access initiatives.
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Affiliation(s)
- Madeleine Ennis
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada
| | - Regina Renner
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada.
| | - Edith Guilbert
- Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada; Department of Obstetrics, Gynecology and Reproduction, Laval University, Quebec City, Quebec, Canada
| | - Wendy V Norman
- Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada; Department of Family Practice, University of British Columbia, Vancouver, BC, Canada; Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Helen Pymar
- Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Lauren Kean
- Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Andrea Carson
- Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada; School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ruth Martin-Misener
- Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada; School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Sheila Dunn
- Contraception Abortion Research Team, Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, BC, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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Tanne JH. US drugs agency approves abortion pill by mail but many states limit access. BMJ 2021; 375:n3120. [PMID: 34930761 DOI: 10.1136/bmj.n3120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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