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Upadhyay UD, Koenig LR, Meckstroth K, Ko J, Valladares ES, Biggs MA. Effectiveness and safety of telehealth medication abortion in the USA. Nat Med 2024; 30:1191-1198. [PMID: 38361123 PMCID: PMC11031403 DOI: 10.1038/s41591-024-02834-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/24/2024] [Indexed: 02/17/2024]
Abstract
Telehealth abortion has become critical to addressing surges in demand in states where abortion remains legal but evidence on its effectiveness and safety is limited. California Home Abortion by Telehealth (CHAT) is a prospective study that follows pregnant people who obtained medication abortion via telehealth from three virtual clinics operating in 20 states and Washington, DC between April 2021 and January 2022. Individuals were screened using a standardized no-test protocol, primarily relying on their medical history to assess medical eligibility. We assessed effectiveness, defined as complete abortion after 200 mg mifepristone and 1,600 μg misoprostol (or lower) without additional intervention; safety was measured by the absence of serious adverse events. We estimated rates using multivariable logistic regression and multiple imputation to account for missing data. Among 6,034 abortions, 97.7% (95% confidence interval (CI) = 97.2-98.1%) were complete without subsequent known intervention or ongoing pregnancy after the initial treatment. Overall, 99.8% (99.6-99.9%) of abortions were not followed by serious adverse events. In total, 0.25% of patients experienced a serious abortion-related adverse event, 0.16% were treated for an ectopic pregnancy and 1.3% abortions were followed by emergency department visits. There were no differences in effectiveness or safety between synchronous and asynchronous models of care. Telehealth medication abortion is effective, safe and comparable to published rates of in-person medication abortion care.
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Affiliation(s)
- Ushma D Upadhyay
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
| | - Leah R Koenig
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Karen Meckstroth
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer Ko
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | | | - M Antonia Biggs
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
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Pickering S, Manze M, Losch J, Romero D. Delays in Obtaining Abortion and Miscarriage Care Among Pregnant Persons in New York State During the COVID-19 Pandemic: The CAP Study. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2024; 5:30-39. [PMID: 38249936 PMCID: PMC10797165 DOI: 10.1089/whr.2023.0128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/23/2024]
Abstract
Background We sought to investigate delays obtaining abortion and miscarriage care during the COVID-19 pandemic, compared with before the pandemic, among pregnant persons in New York State (NYS). Methods We administered a cross-sectional survey in June-July 2020 to NYS residents aged 18-44 years who identified as female or transgender male (N = 1,525). This analysis focused on a subsample who had an abortion or miscarriage during COVID-19, were seeking an abortion at the time of the survey, or had an abortion or miscarriage before COVID-19 (n = 116). We conducted bivariate analyses to determine differences in delays to seeking or obtaining an abortion or miscarriage during versus before the pandemic, as well as consideration of abortion among those pregnant during versus before the pandemic. We also asked open-ended questions about miscarriage and abortion experiences. Main Findings Of the 21 respondents who sought or were seeking an abortion during the COVID-19 pandemic, 76.2% (n = 16) reported experiencing a delay in obtaining abortion care, compared with 18.2% (n = 4) of those who experienced a delay before the pandemic (p < 0.001). A significantly higher proportion of respondents who were pregnant during the pandemic considered abortion, compared with those who gave birth before the pandemic (39.1% vs. 7.6%; p < 0.001). Of the 39 respondents who miscarried during the pandemic, 35.9% (n = 14) delayed care, compared with 5.9% (n = 2) before the pandemic (p < 0.01). Some respondents also commented on the difficulty of accessing miscarriage services during COVID-19 in open-ended responses. Principal Conclusions Those who sought abortion or miscarriage care during the COVID-19 pandemic experienced significant delays in getting care. These are essential services that must be available during public health emergencies, and yet access to these services is now severely limited in many states due to the Dobbs vs. Jackson Women's Health Organization decision.
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Affiliation(s)
- Sarah Pickering
- Department of Community Health and Social Sciences, City University of New York (CUNY) Graduate School of Public Health and Health Policy, New York, New York, USA
| | - Meredith Manze
- Department of Community Health and Social Sciences, City University of New York (CUNY) Graduate School of Public Health and Health Policy, New York, New York, USA
| | - Jessie Losch
- Department of Community Health and Social Sciences, City University of New York (CUNY) Graduate School of Public Health and Health Policy, New York, New York, USA
| | - Diana Romero
- Department of Community Health and Social Sciences, City University of New York (CUNY) Graduate School of Public Health and Health Policy, New York, New York, USA
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Piay-Fernández N, Stenbacka E, Jaramillo MC, Guerrero G, Solano Rodríguez AA, Montenegro P, Moreno DC, Cleeve A. Implementing medical abortion through telemedicine in Colombia: a qualitative study. Sex Reprod Health Matters 2023; 31:2236780. [PMID: 37565788 PMCID: PMC10424593 DOI: 10.1080/26410397.2023.2236780] [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] [Indexed: 08/12/2023] Open
Abstract
The non-governmental organisation Profamilia developed and implemented medical abortion through telemedicine in response to the Covid-19 pandemic. This service is now integrated as an alternative to in-person care and available to abortion-seekers across Colombia. Previous research has emphasised bottlenecks in abortion provision, but less is known about implementation processes and experiences. We assessed the feasibility and acceptability of telemedicine for medical abortion from the perspectives of key informants involved in the implementation in Colombia. We conducted 15 in-depth interviews with healthcare professionals, coordinators and support staff implementing telemedicine for medical abortion in the early phase of implementation, between March and October 2021. We analysed the data using the framework method and applied the normalisation process theory in our analysis and interpretation of findings. Our findings show that strong leadership, organisational efforts on pre-implementation training, monitoring and evaluation, and collaboration between diversely skilled and experienced providers are essential for successful implementation. Participants were generally positive towards the use of telemedicine for medical abortion; concerns related to effectiveness, safety and safeguarding existed mainly among providers with less clinical experience. We identified contextual barriers, such as social opposition, regulatory barriers, providers' unavailability, and poor phone and internet connections in rural areas, which impacted the feasibility of the intervention negatively. In conclusion, to ensure stakeholders' buy-in and for the service to reach all abortion seekers in need, future implementation endeavours must address concerns about safety and effectiveness, and tackle identified contexual barriers.Plain Language SummaryIn telemedicine for medical abortion, all or some components of abortion care, such as initial consultations, home delivery of abortion medication, and post-abortion follow up are provided with the use of telecommunications. Telemedicine for medical abortion has been shown to be a safe and effective form of service delivery.In this study, we interviewed 15 healthcare providers and staff involved in the implementation of a telemedicine service for medical abortion in Colombia to determine whether they deemed the service to be acceptable and feasible. We found that collaboration between providers of different backgrounds and levels of experience, appropriate training and strong leadership were key factors for successfully implementing the service. However, some healthcare providers, especially those with less clinical experience, were concerned that telemedicine for medical abortion may not be safe and may risk the health and well-being of abortion-seekers. Further, social opposition to abortion, unclear regulation and limited access to technology were identified as barriers that need to be addressed to ensure the service reaches all abortion-seekers in need.In conclusion, despite contextual barriers and some provider's concerns about medical safety, telemedicine for medical abortion was viewed as a positive and feasible form of service delivery in Colombia.
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Affiliation(s)
- Nora Piay-Fernández
- Master’s Student, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Emma Stenbacka
- Resident Doctor in Obstetrics and Gynaecology, Danderyd Hospital, Danderyd, Sweden
| | | | - Giovanni Guerrero
- Director of Clinical Management and Quality, Profamilia, Bogotá, Colombia
| | | | | | | | - Amanda Cleeve
- Postdoctoral Researcher, Department of Global Public Health, and Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Midwife, South General Hospital, Stockholm, Sweden
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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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Verma N, Grossman D. Self-Managed Abortion in the United States. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2023; 12:70-75. [PMID: 37305376 PMCID: PMC9989574 DOI: 10.1007/s13669-023-00354-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
Purpose of Review This review aims to provide up-to-date information about self-managed abortion in the USA. Recent Findings Evidence indicates that there is growing demand for self-managed abortion in the USA as obstacles to facility-based care increase, especially since the Supreme Court overturned Roe v. Wade. Self-managed abortion with medications is safe and effective. Summary Based on a nationally representative survey, the lifetime prevalence of self-managed abortion in the USA in 2017 was estimated to be 7%. People experiencing barriers to abortion care, including people of color, people with lower incomes, people in states that have restrictive abortion laws, and those living farther from facilities providing abortion care are more likely to attempt self-managed abortion. While people may use a range of methods to self-manage abortion, there is growing use of safe and effective medications, including mifepristone used together with misoprostol and misoprostol used alone; use of traumatic and dangerous methods is rare. While many people attempt to self-manage their abortion because of barriers to facility-based care, others have a preference for self-care because it is convenient, accessible, and private. While the medical risks of self-managed abortion may be few, the legal risks may be significant. Sixty-one people have been criminally investigated or arrested between 2000 and 2020 for allegedly self-managing their abortion or helping someone else do so. Clinicians play an important role in providing evidence-based information and care to patients considering or attempting self-managed abortion, as well as minimizing legal risks.
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Affiliation(s)
- Nisha Verma
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco (UCSF), 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
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Rosenberg JD, Raymond E, Shochet T. An examination of loss to follow-up and potential bias in outcome ascertainment in a study of direct-to-patient telemedicine abortion in the United States. Contraception 2023; 122:109996. [PMID: 36841460 DOI: 10.1016/j.contraception.2023.109996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 02/26/2023]
Abstract
OBJECTIVES To examine associations between factors associated with loss to follow-up and effectiveness in the TelAbortion project, which provided medication abortion by direct-to-patient telemedicine and mail in the United States. STUDY DESIGN The study population for this descriptive analysis included abortions among participants enrolled in the TelAbortion study with data present in a web-based database tool from November 2018 to September 2021 who were mailed a medication package. The analysis included information on abortions across nine sites. In this analysis, we used generalized estimating equations to examine factors associated with loss to follow-up and effectiveness. RESULTS Of the 1831 abortions included in this analysis, 1553 (84.8%) were classified as having complete follow-up and 278 (15.2%) were classified as lost to follow-up. In a multivariable analysis, factors significantly associated with loss to follow-up included history of medical abortion, education, gestational age, study site, and whether the TelAbortion was performed pre- or post-COVID-19 onset (p < 0.05). The rate of treatment failure (i.e., abortions resulting in continuing pregnancy or uterine evacuation) reported in this study was 5.1%. The only covariate associated with both loss to follow-up and treatment failure was higher gestational age. However, using gestational age to impute missing abortion outcomes did not substantially change the estimated failure rate. CONCLUSIONS Abortions that were lost to follow-up differed substantially from those with complete follow-up, which could bias the effectiveness estimate. However, imputing outcomes based on available and appropriate pretreatment data did not substantially affect the estimate. This finding is encouraging, although it does not exclude the possibility of bias due to unmeasured factors. IMPLICATIONS Significant differences between abortion cases with complete follow-up and those lost to follow-up provide insights into abortion cases that may be at a higher risk for being lost. The low treatment failure rate indicates that the telemedicine provision of medication abortion is effective.
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Affiliation(s)
- Jessica D Rosenberg
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA; Guttmacher Institute, New York, NY, USA.
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No-Test Medication Abortion: A Systematic Review. Obstet Gynecol 2023; 141:23-34. [PMID: 36701607 DOI: 10.1097/aog.0000000000005016] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/22/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To summarize the effectiveness and safety outcomes of medication abortion performed without prior pelvic examination or ultrasonogram ("no-test medication abortion"). DATA SOURCES We searched the MEDLINE, Scopus, Web of Science, Cochrane (including ClinicalTrials.gov), CINAHL, Global Index Medicus, and CAB Direct databases to identify relevant studies published before April 2022 using a peer-reviewed search strategy including terms such as "medication abortion" and "ultrasonography." We contacted experts in the field for unpublished data and ongoing studies. METHODS OF STUDY SELECTION We reviewed 2,423 studies using Colandr. We included studies if they presented clinical outcomes of medication abortion performed with mifepristone and misoprostol and without prior pelvic examination or ultrasonogram. We excluded studies with duplicate data. We abstracted successful abortion rates overall, as well as rates by gestational age through 63 days, 70 days and past 84 days. We abstracted complication rates, including the need for surgical evacuation, additional medications, blood transfusion, and ectopic pregnancy. TABULATION, INTEGRATION AND RESULTS We included 21 studies with a total of 10,693 patients with outcome data reported. The overall efficacy of no-test medication abortion was 96.4%; 93.8% (95% CI 92.8-94.6%) through 63 days of gestation and 95.2% (95% CI 94.7-95.7%) through 70 days of gestation. The overall rate of surgical evacuation was 4.4% (95% CI 4.0-4.9), need for additional misoprostol 2.2% (95% CI 1.8-2.6), blood transfusion 0.5% (95% CI 0.3-0.6), and ectopic pregnancy 0.06% (95% CI 0.02-0.15). CONCLUSION Medication abortion performed without prior pelvic examination or ultrasonogram is a safe and effective option for pregnancy termination. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021240739.
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Fiastro AE, Sanan S, Jacob-Files E, Wells E, Coeytaux F, Ruben MR, Bennett IM, Godfrey EM. Remote Delivery in Reproductive Health Care: Operation of Direct-to-Patient Telehealth Medication Abortion Services in Diverse Settings. Ann Fam Med 2022; 20:336-342. [PMID: 35831175 PMCID: PMC9328706 DOI: 10.1370/afm.2821] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Established models of reproductive health service delivery were disrupted by the coronavirus disease 2019 (COVID-19) pandemic. This study examines rapid innovation of remote abortion service operations across health care settings and describes the use of telehealth consultations with medications delivered directly to patients. METHODS We conducted semi-structured interviews with 21 clinical staff from 4 practice settings: family planning clinics, online medical services, and primary care practices-independent or within multispecialty health systems. Clinicians and administrators described their telehealth abortion services. Interviews were recorded, transcribed, and analyzed. Staff roles, policies, and procedures were compared across practice settings. RESULTS Across all practice settings, telehealth abortion services consisted of 5 operational steps: patient engagement, care consultations, payment, medication dispensing, and follow-up communication. Online services and independent primary care practices used asynchronous methods to determine eligibility and complete consultations, resulting in more efficient services (2-5 minutes), while family planning and health system clinics used synchronous video encounters requiring 10-30 minutes of clinician time. Family planning and health system primary care clinics mailed medications from clinic stock or internal pharmacies, while independent primary care practices and online services often used mail-order pharmacies. Online services offered patients asynchronous follow-up; other practice settings scheduled synchronous appointments. CONCLUSIONS Rapid innovations implemented in response to disrupted in-person reproductive health care included remote medication abortion services with telehealth assessment/follow-up and mailed medications. Though consistent operational steps were identified across health care settings, variation allowed for adaptation of services to individual sites. Understanding remote abortion service operations may facilitate dissemination of a range of patient-centered reproductive health services.Annals "Online First" article.
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Affiliation(s)
- Anna E Fiastro
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - Sajal Sanan
- Department of Family Medicine, University of Washington, Seattle, Washington
| | | | | | | | - Molly R Ruben
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - Ian M Bennett
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - Emily M Godfrey
- Department of Family Medicine, University of Washington, Seattle, Washington
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Aiken AR, Romanova EP, Morber JR, Gomperts R. Safety and effectiveness of self-managed medication abortion provided using online telemedicine in the United States: A population based study. THE LANCET REGIONAL HEALTH - AMERICAS 2022; 10. [PMID: 35755080 PMCID: PMC9223776 DOI: 10.1016/j.lana.2022.100200] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background As access to clinical abortion care becomes increasingly restricted in the United States, the need for self-managed abortions (i.e. abortions taking place outside of the formal healthcare setting) may increase. We examine the safety, effectiveness, and acceptability of self-managed medication abortion provided using online telemedicine. Methods We retrospectively examined records of the outcomes of abortions provided by the sole online telemedicine service providing self-managed medication abortion in the U.S. We calculated the prevalence of successful medication abortion (the proportion who ended their pregnancy without surgical intervention); the prevalence of serious adverse events (the proportions who received intravenous antibiotics and blood transfusion); and assessed whether any deaths were reported to the service. We also examined the proportions who were satisfied and felt self-management was the right choice. Findings Between March 20th 2018 and March 20th 2019, abortion medications were mailed to 4,584 people and 3,186 (70%) provided follow-up information. Among these, 2,797 (88%) confirmed use of the medications and provided outcome information, while 389 (12%) confirmed non-use. Overall, 96.4% (95% CI 95.7% to 97.1%) of those who used the medications reported successfully ending their pregnancy without surgical intervention and 1.0% (CI 0.7%–1.5%) reported treatment for any serious adverse event. Among these, 0.6% (CI 0.4% to 1.0%) reported receiving a blood transfusion, and 0.5% (CI 0.3% to 0.9%) reported receiving intravenous antibiotics. No deaths were reported to the service by family, friends, the authorities, or the media. Among 2,268 who provided information about their experience, 98.4% were satisfied and 95.5% felt self-management was the right choice. Interpretation Self-managed medication abortion provided using online telemedicine can be highly effective with low rates of serious adverse events. In light of increasingly restricted access to in-clinic abortion in the U.S., it may offer a safe and effective option for those who cannot access clinical care. Funding The Society of Family Planning and The National Institutes of Health.
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Affiliation(s)
- Abigail R.A. Aiken
- LBJ School of Public Affairs, University of Texas at Austin, Austin, TX 78713, USA
- Corresponding author.
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Killinger K, Günther S, Gomperts R, Atay H, Endler M. Why women choose abortion through telemedicine outside the formal health sector in Germany: a mixed-methods study. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:e6-e12. [PMID: 33229399 DOI: 10.1136/bmjsrh-2020-200789] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/27/2020] [Accepted: 11/03/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Women on Web (WoW) is a global medical abortion telemedicine service operating outside the formal health sector. In April 2019 they opened their helpdesk to Germany. Our aim was to understand the motivations, and perceived barriers to access, for women who choose telemedicine abortion outside the formal health sector in Germany. METHODS We conducted a parallel convergent mixed-methods study among 1090 women consulting WoW from Germany between 1 January and 31 December 2019. We performed a cross-sectional study of data contained in online consultations and a content analysis of 108 email texts. Analysis was done until saturation; results were merged and triangulation used to validate results. RESULTS The quantitative analysis found that the need for secrecy (n=502, 48%) and the wish for privacy (n=500, 48%) were frequent reasons for choosing telemedicine abortion. Adolescents were more likely to report secrecy, cost, stigma and legal restrictions as reasons for using telemedicine abortion compared with older women. The content analysis developed two main themes and seven subsidiary categories, (1) internal motivations for seeking telemedicine abortion encompassing (i) autonomy, (ii) perception of external threat and (iii) shame and stigma, and (2) external barriers to formal abortion care encompassing (iv) financial stress, (v) logistic barriers to access, (vi) provider attitudes and (vii) vulnerability of foreigners. CONCLUSIONS Women in Germany who choose telemedicine abortion outside the formal health sector do so both from a place of empowerment and a place of disempowerment. Numerous barriers to abortion access exist in the formal sector which are of special relevance to vulnerable groups such as adolescents and undocumented immigrants.
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Affiliation(s)
- Kristina Killinger
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Hazal Atay
- Women on Web, Toronto, Ontario, Canada
- Centre of Political Research, Sciences Po (CEVIPOF), Paris, France
| | - Margit Endler
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Women's Health Research Unit, University of Cape Town, Cape Town, South Africa
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Kerestes C, Delafield R, Elia J, Chong E, Kaneshiro B, Soon R. “It was close enough, but it wasn't close enough”: A qualitative exploration of the impact of direct-to-patient telemedicine abortion on access to abortion care. Contraception 2021; 104:67-72. [DOI: 10.1016/j.contraception.2021.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
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Meurice ME, Whitehouse KC, Blaylock R, Chang JJ, Lohr PA. Client satisfaction and experience of telemedicine and home use of mifepristone and misoprostol for abortion up to 10 weeks’ gestation at British Pregnancy Advisory Service: A cross-sectional evaluation. Contraception 2021; 104:61-66. [DOI: 10.1016/j.contraception.2021.04.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 11/28/2022]
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Chong E, Shochet T, Raymond E, Platais I, Anger HA, Raidoo S, Soon R, Grant MS, Haskell S, Tocce K, Baldwin MK, Boraas CM, Bednarek PH, Banks J, Coplon L, Thompson F, Priegue E, Winikoff B. Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic. Contraception 2021; 104:43-48. [PMID: 33781762 PMCID: PMC9748604 DOI: 10.1016/j.contraception.2021.03.019] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/10/2021] [Accepted: 03/18/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To present updated evidence on the safety, efficacy and acceptability of a direct-to-patient telemedicine abortion service and describe how the service functioned during the COVID-19 pandemic. STUDY DESIGN We offered the study at 10 sites that provided the service in 13 states and Washington DC. Interested individuals obtained any needed preabortion tests locally and had a videoconference with a study clinician. Sites sent study packages containing mifepristone and misoprostol by mail and had remote follow-up consultations within one month by telephone (or by online survey, if the participant could not be reached) to evaluate abortion completeness. The analysis was descriptive. RESULTS We mailed 1390 packages between May 2016 and September 2020. Of the 83% (1157/1390) of abortions for which we obtained outcome information, 95% (1103/1157) were completed without a procedure. Participants made 70 unplanned visits to emergency rooms or urgent care centers for reasons related to the abortion (6%), and 10 serious adverse events occurred, including 5 transfusions (0.4%). Enrollment increased substantially with the onset of COVID-19. Although a screening ultrasound was required, sites determined in 52% (346/669) of abortions that occurred during COVID that those participants should not get the test to protect their health. Use of urine pregnancy test to confirm abortion completion increased from 67% (144/214) in the 6 months prior to COVID to 90% (602/669) in the 6 months during COVID. Nearly all satisfaction questionnaires (99%, 1013/1022) recorded that participants were satisfied with the service. CONCLUSIONS This direct-to-patient telemedicine service was safe, effective, and acceptable, and supports the claim that there is no medical reason for mifepristone to be dispensed in clinics as required by the Food and Drug Administration. In some cases, participants did not need to visit any facilities to obtain the service, which was critical to protecting patient safety during the COVID-19 pandemic. IMPLICATIONS Medical abortion using telemedicine and mail is effective and can be safely provided without a pretreatment ultrasound. This method of service delivery has the potential to greatly improve access to abortion care in the United States.
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Affiliation(s)
- Erica Chong
- Gynuity Health Projects, New York, NY, USA,Present address: Reproductive Health Education in Family Medicine, 3544 Jerome Avenue, Bronx, NY 10467.,Corresponding author
| | | | | | | | | | - Shandhini Raidoo
- Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
| | - Reni Soon
- Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii John A. Burns School of Medicine, Honolulu, HI, USA
| | | | - Susan Haskell
- carafem, 1001 Connecticut Avenue NW, Washington, DC, USA
| | - Kristina Tocce
- Planned Parenthood of the Rocky Mountains, Denver, CO, USA
| | | | | | | | - Joey Banks
- Planned Parenthood of Montana, Missoula, MT, USA
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Nortén H, Ilozumba O, Wilkinson J, Gemzell-Danielsson K, Gomperts R. 10-year evaluation of the use of medical abortion through telemedicine: a retrospective cohort study. BJOG 2021; 129:151-159. [PMID: 34018294 DOI: 10.1111/1471-0528.16765] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To provide a descriptive overview and evaluate changes in the use and outcome of abortions provided worldwide by telemedicine in the past 10 years. DESIGN Retrospective cohort study. SETTING Multi-country. POPULATION/SAMPLE 30 344 women who completed the follow-up survey of the telemedical abortion service Women on Web from January 2009 till January 2020. METHODS Analyses of follow-up surveys, binary logistic regressions to test the association between year and outcomes. MAIN OUTCOME MEASURES Rate of complete abortions, surgical interventions, ongoing pregnancies, blood transfusions per year, socio-economic situation, knowledge on medical abortion, acceptability of receiving service, appropriateness of method and the likelihood of recommending the service to a friend. RESULTS Medical abortions were provided to 81 683 women, of whom 30 344 (37.2%) completed the follow-up survey. In total, 26 076 women reported doing the medical abortion, of whom 1.5% reported an ongoing pregnancy, 10.2% a surgical intervention and 0.6% a blood transfusion. Acceptability of the service was 99%, and 59.2% of the users reported previous knowledge of medical abortion. We found a significant increase in complete abortions in 2019 (odds ratio 1.92; 95% CI 1.59-2.31) and decrease in surgical interventions (odds ratio 0.49; 95% CI 0.40-0.60) compared with 2009. CONCLUSION Low follow-up rates present a limitation in analysing trends in telemedical abortion usage. However, our findings suggest that it is a highly acceptable method around the world and that there has been an increase in complete abortions by telemedical abortions and a decrease in surgical interventions in the last 10 years. TWEETABLE ABSTRACT In the last 10 years, there has been an increase in complete abortions and decrease in surgical interventions of telemedical abortion.
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Affiliation(s)
- Hanna Nortén
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Women on Web, 1 Yonge Street, Toronto, Canada
| | - Onaedo Ilozumba
- Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - J Wilkinson
- Division of Population Health, Health Services Research and Primary Care, Centre for Biostatistics, University of Manchester, Manchester, UK
| | - K Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institutet & Karolinska University Hospital, Stockholm, Sweden
| | - R Gomperts
- Women on Web, 1 Yonge Street, Toronto, Canada
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15
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Schmidt-Hansen M, Pandey A, Lohr PA, Nevill M, Taylor P, Hasler E, Cameron S. Expulsion at home for early medical abortion: A systematic review with meta-analyses. Acta Obstet Gynecol Scand 2020; 100:727-735. [PMID: 33063314 DOI: 10.1111/aogs.14025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The safety and acceptability of medical abortion using mifepristone and misoprostol at home at ≤9+0 weeks' gestation is well established. However, the upper gestational limit at which the procedure remains safe and acceptable at home is not known. To inform a national guideline on abortion care we conducted a systematic review to determine what gestational limit for expulsion at home offers the best balance of benefits and harms for women who are having medical abortion. MATERIAL AND METHODS We searched Embase, MEDLINE, Cochrane Library, Cinahl Plus and Web-of-Science on 2 January 2020 for prospective and retrospective cohort studies with ≥50 women per gestational age group, published in English from 1995 onwards, that included women undergoing medical abortion and compared home expulsion of pregnancies of ≤9+0 weeks' gestational age with pregnancies of 9+1 -10+0 weeks or >10+1 weeks' gestational age, or compared the latter two gestational age groups. We assessed risk-of-bias using the Newcastle-Ottowa scale. All outcomes were meta-analyzed as risk ratios (RR) using the Mantel-Haenszel method. The certainty of the evidence was assessed using GRADE. RESULTS Six studies (n = 3381) were included. The "need for emergency care/admission to hospital" (RR = 0.79, 95% confidence interval [CI] 0.45-1.4), "hemorrhage requiring transfusion/≥500 mL blood loss" (RR = 0.62, 95% CI 0.11-3.55), patient satisfaction (RR = 0.99, 95% CI 0.95-1.03), pain (RR = 0.91, 95% CI 0.82-1.02), and "complete abortion without the need for surgical intervention" (RR = 1.03, 95% CI 1-1.05) did not differ statistically significantly between the ≤9+0 and >9+0 weeks' gestation groups. The rates of vomiting (RR = 0.8, 95% CI 0.69-0.93) and diarrhea (RR = 0.85, 95% CI 0.73-0.99) were statistically significantly lower in the ≤9+0 weeks group but these differences were not considered clinically important. We found no studies comparing pregnancies of 9+1 -10+0 weeks' gestation with pregnancies of >10+0 weeks' gestation. The certainty of this evidence was predominantly low and mainly compromised by low event rates and loss to follow up. CONCLUSIONS Women who are having a medical abortion and will be taking mifepristone up to and including 10+0 weeks' gestation should be offered the option of expulsion at home after they have taken the misoprostol. Further research needs to determine whether the gestational limit for home expulsion can be extended beyond 10+0 weeks.
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Affiliation(s)
- Mia Schmidt-Hansen
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Anuja Pandey
- Amaris Consulting, Work Life - Camden, London, UK
| | | | - Michael Nevill
- British Pregnancy Advisory Service, Stratford upon Avon, UK
| | | | - Elise Hasler
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Sharon Cameron
- Sexual and Reproductive Health Services, NHS Lothian, Edinburgh, Scotland
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Moseson H, Keefe-Oates B, Jayaweera RT, Filippa S, Motana R, Bercu C, Egwuatu I, Grosso B, Kristianingrum IA, Nmezi S, Zurbriggen R, Friedman E, Gerdts C. Studying Accompaniment model Feasibility and Effectiveness (SAFE) Study: study protocol for a prospective observational cohort study of the effectiveness of self-managed medication abortion. BMJ Open 2020; 10:e036800. [PMID: 33444174 PMCID: PMC7678383 DOI: 10.1136/bmjopen-2020-036800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION A range of barriers deter or prevent people from accessing facility-based abortion care. As a result, people are obtaining and using abortifacient medications to end their pregnancies outside of the formal healthcare system, without clinical supervision. One model of self-managed abortion has come to be known as the 'accompaniment' model, in which grassroots organisations provide pregnant people with evidence-based counselling and support through the medication abortion process. Data are needed to understand the safety and effectiveness of this increasingly common model of abortion care. METHODS AND ANALYSIS This is a large, prospective, observational study in Argentina and Nigeria. All people who contact one of two accompaniment groups seeking information for their own self-managed medication abortion, are ages 13 years and older, have no contraindications for medication abortion, are within the gestational range supported by the group (up to 12 weeks' gestation for the primary outcome) and are willing to be contacted for follow-up will be recruited. Participants will respond to an interviewer-administered baseline survey at enrolment, and 1-4 additional surveys over 6 weeks to ascertain whether they obtain medications for abortion, dosing and route of administration of medications, physical and emotional experience of medication abortion self-management, and effectiveness and safety outcomes. Analyses will include estimates of the primary outcome: the proportion of participants that report a complete abortion without surgical intervention at last recorded follow-up; as well as secondary outcomes including a pseudo-experimental test of non-inferiority of the effectiveness of self-managed medication abortion as compared with clinical medication abortion. ETHICS AND DISSEMINATION We describe the ethical considerations and protections for this study, as well the creation of a study-specific Data Monitoring and Oversight Committee. We describe dissemination plans to ensure that study results are shared widely with all relevant audiences, particularly researchers, advocates, policymakers and clinicians. TRIAL REGISTRATION NUMBER ISRCTN95769543.
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Affiliation(s)
| | | | | | - Sofia Filippa
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Chiara Bercu
- Ibis Reproductive Health, Oakland, California, USA
| | - Ijeoma Egwuatu
- Generation Initiative for Women and Youth Nigeria, Lagos, Nigeria
| | - Belen Grosso
- Colectiva Feminista La Revuelta, Neuquen, Argentina
| | | | - Sybil Nmezi
- Generation Initiative for Women and Youth Nigeria, Lagos, Nigeria
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17
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Endler M, Cleeve A, Lavelanet A, Gemzell-Danielsson K. The use of telemedicine services for medical abortion. Hippokratia 2020. [DOI: 10.1002/14651858.cd013764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Margit Endler
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
| | - Amanda Cleeve
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
| | - Antonella Lavelanet
- Department of Sexual and Reproductive Health and Research; World Health Organization; Geneva Switzerland
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
- Karolinska University Hospital; Stockholm Sweden
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18
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Moseson H, Jayaweera R, Raifman S, Keefe-Oates B, Filippa S, Motana R, Egwuatu I, Grosso B, Kristianingrum I, Nmezi S, Zurbriggen R, Gerdts C. Self-managed medication abortion outcomes: results from a prospective pilot study. Reprod Health 2020; 17:164. [PMID: 33109230 PMCID: PMC7588945 DOI: 10.1186/s12978-020-01016-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate the feasibility of conducting a prospective study to measure self-managed medication abortion outcomes, and to collect preliminary data on safety and effectiveness of self-managed medication abortion, we recruited callers to accompaniment groups (volunteer networks that provide counselling through the out-of-clinic medication abortion process by trained counselors over the phone or in-person). METHODS In 2019, we enrolled callers to three abortion accompaniment groups in three countries into a prospective study on the safety and effectiveness of self-managed medication abortion with accompaniment support. Participants completed up to five interview-administered questionnaires from baseline through 6-weeks after taking the pills. Primary outcomes included: (1) the number of participants enrolled in a 30-day period, (2) the proportion that had a complete abortion; and (3) the proportion who experienced any warning signs of potential or actual complications. RESULTS Over the 30-day recruitment period, we enrolled 227 participants (95% of those invited), and retained 204 participants (90%) for at least one study follow-up visit. At the 1-week follow-up, two participants (1%) reported a miscarriage prior to taking the pills, and 202 participants (89% of those enrolled and 99% of those who participated in the 1-week survey) had obtained and taken the medications. Three weeks after taking the medications, 192 (95%) participants reported feeling that their abortion was complete. Three (1.5%) received a surgical intervention, two (1%) received antibiotics, and five (3%) received other medications. Participants did not report any major adverse events. CONCLUSION These results establish the feasibility of conducting prospective studies of self-managed medication abortion in legally restrictive settings. Further, the high effectiveness of self-managed medication abortion with accompaniment support reported here is consistent with high levels of effectiveness reported in prior studies. Trial registration ISRCTN95769543.
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Affiliation(s)
- Heidi Moseson
- Ibis Reproductive Health, 1736 Franklin Street, Suite 600, Oakland, CA, 94612, USA.
| | - Ruvani Jayaweera
- Ibis Reproductive Health, 1736 Franklin Street, Suite 600, Oakland, CA, 94612, USA
| | - Sarah Raifman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | | | - Sofia Filippa
- Ibis Reproductive Health, 1736 Franklin Street, Suite 600, Oakland, CA, 94612, USA
| | | | - Ijeoma Egwuatu
- Generation Initiative for Women and Youth, Lagos, Nigeria
| | - Belen Grosso
- La Revuelta Colectiva Feminista, Neuquén, Argentina
| | | | - Sybil Nmezi
- Generation Initiative for Women and Youth, Lagos, Nigeria
| | | | - Caitlin Gerdts
- Ibis Reproductive Health, 1736 Franklin Street, Suite 600, Oakland, CA, 94612, USA
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19
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Moseson H, Bullard KA, Cisternas C, Grosso B, Vera V, Gerdts C. Effectiveness of self-managed medication abortion between 13 and 24 weeks gestation: A retrospective review of case records from accompaniment groups in Argentina, Chile, and Ecuador. Contraception 2020; 102:91-98. [DOI: 10.1016/j.contraception.2020.04.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
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20
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Thompson TA, Sonalkar S, Butler JL, Grossman D. Telemedicine for Family Planning: A Scoping Review. Obstet Gynecol Clin North Am 2020; 47:287-316. [PMID: 32451019 PMCID: PMC10093687 DOI: 10.1016/j.ogc.2020.02.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Telemedicine has the potential to increase access to family planning. The most common application involved the use of text message reminders and mobile apps. Text messaging increased knowledge in a variety of settings, but had no effect on contraceptive uptake and use. Two randomized studies found that text messaging improved continuation of oral contraceptives and injectables. Telemedicine provision of medication abortion included both clinic-to-clinic and direct-to-patient models of care. Telemedicine provision of medication abortion has been found to be equally safe and effective as in-person provision. Some measures of satisfaction are higher with telemedicine. Telemedicine may improve access to early abortion.
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Affiliation(s)
- Terri-Ann Thompson
- Ibis Reproductive Health, 2067 Massachusetts Avenue, Suite 320, Cambridge, MA 02140, USA.
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania, 1000 Courtyard, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Jessica L Butler
- The American College of Obstetricians and Gynecologists, 409 12th Street, Southwest, PO Box 96920, Washington, DC 20090-6920, USA
| | - Daniel Grossman
- Department of Obstetrics, Gynecology and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612, USA. https://twitter.com/DrDGrossman
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21
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Raymond EG, Grossman D, Mark A, Upadhyay UD, Dean G, Creinin MD, Coplon L, Perritt J, Atrio JM, Taylor D, Gold M. Commentary: No-test medication abortion: A sample protocol for increasing access during a pandemic and beyond. Contraception 2020; 101:361-366. [PMID: 32305289 PMCID: PMC7161512 DOI: 10.1016/j.contraception.2020.04.005] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 12/05/2022]
Affiliation(s)
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, Oakland, CA, United States.
| | - Alice Mark
- National Abortion Federation, Washington DC, United States.
| | - Ushma D Upadhyay
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, Oakland, CA, United States.
| | - Gillian Dean
- Planned Parenthood Federation of America, New York, NY, United States.
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States.
| | - Leah Coplon
- Maine Family Planning, Augusta, ME, United States.
| | - Jamila Perritt
- Reproductive Health and Family Planning Specialist, Washington DC, United States
| | - Jessica M Atrio
- Society of Family Planning, Clinical Affairs Subcommittee and Department of Obstetrics and Gynecology, Montefiore Hospital and Albert Einstein College of Medicine, Bronx, NY, United States.
| | - DeShawn Taylor
- Department of Obstetrics and Gynecology, University of Arizona College of Medicine Phoenix, AZ, United States.
| | - Marji Gold
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, United States.
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Alam B, Kaler A, Mumtaz Z. Women's voices and medical abortions: A review of the literature. Eur J Obstet Gynecol Reprod Biol 2020; 249:21-31. [PMID: 32348948 DOI: 10.1016/j.ejogrb.2020.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/27/2020] [Accepted: 04/01/2020] [Indexed: 10/24/2022]
Abstract
Globally, a growing proportion of induced abortions are medical abortions. The procedure has been hailed as a revolutionary technology, which, according to experts, has the potential to transform women's experiences of abortion and the way abortion services are accessed. Noticeably absent in the discourse, however, are women's voices. More specifically, there is a lack of understanding about what shapes women's preferences for medical abortion and the challenges they experience in accessing the drugs for the procedure. We conducted a systematic review of the literature to draw attention to these important issues which exist, but are often embedded within research highlighting other dominating aspects of medical abortions. A comprehensive search of four databases - supplemented by searching reference sections of selected articles, tracking their citations, and hand searching special editions on medical abortion - was conducted. A total of 45 peer-reviewed studies met our inclusion criteria. The studies were assessed for quality and analyzed using a critical interpretive synthesis approach. The findings revealed significant variations in women's preferences for surgical versus medical abortions. Country-specific abortion laws, implementing protocols, side-effects, rates of failures, and the need to verify the abortion shaped women's preference for abortion methods. Overall, women who preferred medical abortions did so because they perceived it as a 'natural' and safe procedure that can be self-conducted at home, thereby reducing their dependency on the health system. However, women face significant barriers to medical abortion care. These include legal requirements around type of provider, site of service, need for follow-up, providers' limited knowledge of the procedure, and preferences for surgical abortions. Borderless internet-based services have enabled some women to circumvent these barriers. Our review suggests that medical abortions are used by women either in countries where the health system is fully supportive or where the health system is completely disengaged, usually due to restricted abortion laws. In those countries where abortions are legal but often difficult to access due to health system barriers, women tend to prefer surgical abortions.
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Affiliation(s)
- Bushra Alam
- School of Public Health, University of Alberta, 3-330 Edmonton Clinic Health Academy, 11405 - 87 Ave, Edmonton, AB T6G 1C9, Canada.
| | - Amy Kaler
- Department of Sociology, University of Alberta, 6-14 Henry Marshall Tory Building, Edmonton, AB T6G 2H4.
| | - Zubia Mumtaz
- School of Public Health, University of Alberta, 3-330 Edmonton Clinic Health Academy, 11405 - 87 Ave, Edmonton, AB T6G 1C9, Canada.
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Raymond E, Chong E, Winikoff B, Platais I, Mary M, Lotarevich T, Castillo PW, Kaneshiro B, Tschann M, Fontanilla T, Baldwin M, Schnyer A, Coplon L, Mathieu N, Bednarek P, Keady M, Priegue E. TelAbortion: evaluation of a direct to patient telemedicine abortion service in the United States. Contraception 2019; 100:173-177. [DOI: 10.1016/j.contraception.2019.05.013] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/22/2019] [Accepted: 05/24/2019] [Indexed: 11/25/2022]
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Moseson H, Herold S, Filippa S, Barr-Walker J, Baum SE, Gerdts C. Self-managed abortion: A systematic scoping review. Best Pract Res Clin Obstet Gynaecol 2019; 63:87-110. [PMID: 31859163 DOI: 10.1016/j.bpobgyn.2019.08.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 08/06/2019] [Accepted: 08/07/2019] [Indexed: 12/20/2022]
Abstract
Self-managed abortion, when a person performs their own abortion without clinical supervision, is a model of abortion care used across a range of settings. To provide a comprehensive synthesis of the available literature on self-managed abortion, we conducted a systematic search for peer-reviewed research in April 2019 in PubMed, Embase, Web of Science, Popline, PsycINFO, Google Scholar, Scielo, and Redalyc. We included studies that had a research question focused on self-managed abortion; and were published in English or Spanish. The combined search returned 7167 studies; after screening, 99 studies were included in the analysis. Included studies reported on methods, procurement, characteristics of those who self-managed, effectiveness, safety, reasons for self-managed abortion, and emotional and physical experiences. Numerous abortion methods were reported, most frequently abortion with pills and herbs. Studies reporting on self-managed medication abortion reported high-levels of effectiveness. We identify gaps in the research, and make recommendations to address those gaps.
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Affiliation(s)
- Heidi Moseson
- Ibis Reproductive Health, 1736 Franklin Street, Oakland, CA, 94612, USA.
| | - Stephanie Herold
- Advancing New Standards in Reproductive Health, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA.
| | - Sofia Filippa
- Ibis Reproductive Health, 1736 Franklin Street, Oakland, CA, 94612, USA.
| | - Jill Barr-Walker
- Zuckerberg San Francisco General (ZSFG) Library, University of California, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
| | - Sarah E Baum
- Ibis Reproductive Health, 1736 Franklin Street, Oakland, CA, 94612, USA.
| | - Caitlin Gerdts
- Ibis Reproductive Health, 1736 Franklin Street, Oakland, CA, 94612, USA.
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25
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Telemedicine for medication abortion. Contraception 2019; 100:351-353. [PMID: 31356771 DOI: 10.1016/j.contraception.2019.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/13/2019] [Accepted: 07/15/2019] [Indexed: 11/21/2022]
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26
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Endler M, Cleeve A, Gemzell-Danielsson K. Online access to abortion medications: a review of utilization and clinical outcomes. Best Pract Res Clin Obstet Gynaecol 2019; 63:74-86. [PMID: 31383555 DOI: 10.1016/j.bpobgyn.2019.06.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 11/25/2022]
Abstract
We performed a search in PubMed and Web of Science on the self-use of abortion medication after online access. Studies published between January 1, 1995, and March 31, 2019, were considered. We included studies of online services that were (i) led by healthcare staff (n = 14), (ii) led by non-healthcare staff (n = 4), and (iii) providing noninteractive access (n = 17). Our outcomes were utilization (frequency and demand for services), acceptability for women, safety, and success rate. Key findings: Women are increasingly using the Internet to access abortion medication. Available services are of varying quality. Women accessing noninteractive services report feelings of distress related to the lack of medical guidance, and the demand for interactive guidance through the abortion process is high. Women using services led by healthcare staff report high rates of satisfaction and similar rates of clinical outcomes as those of in-person abortion care.
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Affiliation(s)
- Margit Endler
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Tomtebodavägen 18b, 171 77 Stockholm, Sweden; Department of Public Health, and Women's Health Research Unit, University of Cape Town, Falmouth Road, 7950 Cape Town, South Africa.
| | - Amanda Cleeve
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Tomtebodavägen 18b, 171 77 Stockholm, Sweden
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Tomtebodavägen 18b, 171 77 Stockholm, Sweden
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Larsson A, Ronnberg AM. Expanding a woman's options to include home use of misoprostol for medical abortion up until 76 days: an observational study of efficacy and safety. Acta Obstet Gynecol Scand 2019; 98:747-752. [DOI: 10.1111/aogs.13537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/10/2019] [Accepted: 01/11/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Amanda Larsson
- Department of Obstetrics and Gynecology University Hospital Örebro Örebro Sweden
| | - Ann‐Kristin M. Ronnberg
- Department of Obstetrics and Gynecology University Hospital Örebro Örebro Sweden
- School of Medical Sciences Faculty of Medicine and Health Örebro University Örebro Sweden
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