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Frisendahl C, Looft-Trägårdh E, Cleeve A, Atuhairwe S, Larsson EC, Kakaire O, Kayiga H, Aronsson A, Kihara A, Temmerman M, Klingberg Allvin M, Byamugisha J, Gemzell Danielsson K. Two decades of research capacity strengthening and reciprocal learning on sexual and reproductive health in East Africa - a point of (no) return. Glob Health Action 2024; 17:2353957. [PMID: 38826144 PMCID: PMC11149584 DOI: 10.1080/16549716.2024.2353957] [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: 11/14/2023] [Accepted: 05/07/2024] [Indexed: 06/04/2024] Open
Abstract
As the world is facing challenges such as pandemics, climate change, conflicts, and changing political landscapes, the need to secure access to safe and high-quality abortion care is more urgent than ever. On 27th of June 2023, the Swedish government decided to cut funding resources available for developmental research, which has played a fundamental role in the advancement of sexual and reproductive health and rights (SRHR) globally, including abortion care. Withdrawal of this funding not only threatens the fulfilment of the United Nations sustainable development goals (SDGS) - target 3.7 on ensuring universal access to SRHR and target 5 on gender equality - but also jeopardises two decades of research capacity strengthening. In this article, we describe how the partnerships that we have built over the course of two decades have amounted to numerous publications, doctoral graduates, and important advancements within the field of SRHR in East Africa and beyond.
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Affiliation(s)
- Caroline Frisendahl
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Emelie Looft-Trägårdh
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Amanda Cleeve
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Susan Atuhairwe
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Elin C. Larsson
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Othman Kakaire
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Herbert Kayiga
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Annette Aronsson
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Anne Kihara
- Department of Obstetrics and Gynecology, School of Medicine, University of Nairobi, Nairobi, Kenya
| | - Marleen Temmerman
- Department of Obstetrics and Gynecology, Aga Khan University, Nairobi, Kenya
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Marie Klingberg Allvin
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Kristina Gemzell Danielsson
- Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Cleeve A, Wallengren E, Brandell K, Lee S, Endler M, Reynolds-Wright J. No test medical abortion - a review of the evidence on selective use of preabortion testing. Curr Opin Obstet Gynecol 2024:00001703-990000000-00146. [PMID: 39109610 DOI: 10.1097/gco.0000000000000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
PURPOSE OF REVIEW The last decade has seen a cascade of different telemedicine models for medical abortion (MA) being tested and implemented. Among these service delivery models is the 'no-test' MA model, in which care is provided remotely and eligibility for the MA is based on history alone. The purpose of this review is to provide an overview of the existing evidence for no-test MA. RECENT FINDINGS The evidence base for no-test MA relies heavily on cohort and noncomparative studies predominantly from high resource settings. Recent findings indicate that no-test MA is safe, effective, and highly acceptable. Diagnoses of ectopic pregnancy and underestimation of gestational age were rare. Identified advantages included shortening time to access MA and mitigating access barriers such as cost, and geographical barriers. Abortion seekers valued omitting the ultrasound citing reasons such as privacy concerns, costs, more flexibility, and control. The impacts of no-test MA on unscheduled postabortion contacts and visits and on contraceptive use were unclear due to limited evidence. SUMMARY No-test MA can be provided to complement other care pathways including those with some or no in-person care. Further research is needed to allow for widespread adoption of no-test MA and scale-up in a variety of contexts, including low-resource settings.
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Affiliation(s)
- Amanda Cleeve
- Department of Women's and Children's Health, Karolinska Institutet, and the WHO Collaborating Centre for Human Reproduction, Karolinska University Hospital, Stockholm, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Emma Wallengren
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Karin Brandell
- Department of Women's and Children's Health, Karolinska Institutet, and the WHO Collaborating Centre for Human Reproduction, Karolinska University Hospital, Stockholm, Sweden
| | - Sabrina Lee
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Margit Endler
- Department of Women's and Children's Health, Karolinska Institutet, and the WHO Collaborating Centre for Human Reproduction, Karolinska University Hospital, Stockholm, Sweden
- University of Capetown, Department of Public Health, Capetown, South Africa
| | - John Reynolds-Wright
- Centre for Reproductive Health, Institute for Regeneration & Repair, University of Edinburgh, UK Chalmers Centre, NHS Lothian, Edinburgh, UK
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Simons HR, Diemert S, Passman R, Dean G. An assessment of clinical outcomes of medication abortion without pretreatment ultrasonography in Planned Parenthood, United States, 2020-2021. Contraception 2024; 136:110469. [PMID: 38641157 DOI: 10.1016/j.contraception.2024.110469] [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: 09/27/2023] [Revised: 04/08/2024] [Accepted: 04/15/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVES Routine ultrasound before medication abortion (MAB) may create an impediment to expanding abortion access. This study examines clinical outcomes of MAB without pretreatment ultrasound evaluation at Planned Parenthood health centers in multiple states. STUDY DESIGN We conducted a secondary analysis of data from 23 US-based Planned Parenthood affiliates that provided MAB without pretreatment ultrasound for eligible patients from March 2020 to December 2021. Affiliates aggregated electronic health record data from MABs at ≤77 days gestation (based on self-report of last menstrual period) without a pretreatment ultrasound (N = 18,041). Among MABs with known outcomes (N = 9821), we calculated the incidence rates and 95% confidence intervals (CI) for completed abortion, ongoing pregnancy, subsequent procedure, emergency department/hospital visits associated with MAB, ectopic pregnancies, and gestational duration greater than 77 days. RESULTS Among MABs with known outcomes, 96.3% had a complete abortion (95% CI = 95.9%-96.7%), and 2.0% had an ongoing pregnancy (95% CI = 1.7%-2.3%). Four percent had a subsequent procedure (95% CI = 3.6%-4.4%), and 2.3% had a documented emergency department/hospital visit (95% CI = 2.0%-2.6%). Less than 1% had a confirmed ectopic pregnancy (0.15%, 95% CI = 0.09%-0.25%) and had a gestational duration later identified to be greater than 77 days (0.13%, 95% CI = 0.05%-0.29%). CONCLUSIONS Our calculated incidence rates of clinical outcomes align with rates from the previous literature on MAB and from the emerging literature on MAB without pretreatment ultrasonography. Findings from this analysis suggest that MAB without pretreatment ultrasound is safe and effective for eligible patients. IMPLICATIONS This large US study found that medication abortion without pretreatment ultrasonography results in similar clinical outcomes to prepandemic models that include pretreatment ultrasonography. Medication abortion without a pretreatment ultrasound may be adopted by abortion providers seeking to expand options for their patients as access to abortion continues to erode.
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Affiliation(s)
- Hannah R Simons
- Research & Evaluation Department and Medical Services Department, Planned Parenthood Federation of America, New York, NY, United States.
| | - Sarah Diemert
- Research & Evaluation Department and Medical Services Department, Planned Parenthood Federation of America, New York, NY, United States
| | - Rebecca Passman
- Research & Evaluation Department and Medical Services Department, Planned Parenthood Federation of America, New York, NY, United States
| | - Gillian Dean
- Research & Evaluation Department and Medical Services Department, Planned Parenthood Federation of America, New York, NY, United States
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Kapp N, Bawah AA, Agula C, Menzel JL, Antobam SK, Asuming PO, Eckersberger E, Pearson EE. Medical abortion in Ghana: A non-randomized, non-inferiority study of access through pharmacies compared with clinics. Contraception 2024:110538. [PMID: 39002625 DOI: 10.1016/j.contraception.2024.110538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/03/2024] [Accepted: 07/09/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVES To compare self-reported clinical outcomes following medical abortion with mifepristone and misoprostol sourced from either a pharmacy or health clinic. STUDY DESIGN We conducted a prospective, non-randomized, non-inferiority cohort study across four regions in Ghana, from high-volume pharmacies and health clinics. Participants seeking medical abortion (less than nine weeks' gestation) who met usual medical abortion eligibility criteria were recruited. Data collection included baseline surveys, follow-up phone interviews, and self-reported assessments of medical abortion outcomes. The study aimed to enroll 2000 medical abortion users (1000 from each source). RESULTS Complete outcome data was available and analyzed from 1958 participants (of 2208 enrolled), with the adjusted risk difference of need for additional treatment to complete the abortion indicating non-inferiority of the pharmacy group compared to the clinic group [-2.3% (95% CI -5.3% to 0.7%)]. Both groups reported low rates of additional treatment (4.9%) and adhered similarly to the abortion regimen. Secondary outcomes showed no significant differences, with moderate acceptability in both groups (65.4% pharmacy, 52.3% facility). Adverse outcomes were rare: one ectopic pregnancy, one blood transfusion and no deaths or other major complications were reported. CONCLUSIONS Accessing medical abortion pills directly from pharmacies without prior consultation from a provider demonstrated non-inferior self-reported clinical outcomes compared to seeking care from health clinics. The findings align with the growing global evidence supporting the safety and effectiveness of medical abortion self-care. IMPLICATIONS This study contributes data which support future registration of over-the-counter use of medical abortion drugs up to nine weeks' gestation. Such measures could expand options for safe abortion care, especially in regions where unsafe abortion poses a substantial maternal health risk. TRIAL REGISTRATION ClinicalTrials.gov (NCT03727308).
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Affiliation(s)
| | - Ayaga A Bawah
- Regional Institute for Population Studies (RIPS), University of Ghana, Accra, Ghana
| | - Caesar Agula
- Regional Institute for Population Studies (RIPS), University of Ghana, Accra, Ghana
| | | | - Samuel K Antobam
- Regional Institute for Population Studies (RIPS), University of Ghana, Accra, Ghana
| | - Patrick O Asuming
- University of Ghana Business School (UGBS), University of Ghana, Accra, Ghana
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Raifman S, Gurazada T, Beaman J, Biggs MA, Schwarz EB, Gold M, Grossman D. Primary care and abortion provider perspectives on mail-order medication abortion: a qualitative study. BMC Womens Health 2024; 24:382. [PMID: 38956609 PMCID: PMC11221167 DOI: 10.1186/s12905-024-03202-z] [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: 12/15/2023] [Accepted: 06/11/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND This qualitative study aims to assess perspectives of clinicians and clinic staff on mail-order pharmacy dispensing for medication abortion. METHODS Participants included clinicians and staff involved in implementing a mail-order dispensing model for medication abortion at eleven clinics in seven states as part of a prospective cohort study, which began in January 2020 (before the FDA removed the in-person dispensing requirement for mifepristone). From June 2021 to July 2022, we invited participants at the participating clinics, including six primary care and five abortion clinics, to complete a semi-structured video interview about their experiences. We then conducted qualitative thematic analysis of interview data, summarizing themes related to perceived benefits and concerns about the mail-order model, perceived patient interest, and potential barriers to larger-scale implementation. RESULTS We conducted 24 interviews in total with clinicians (13 physicians and one nurse practitioner) and clinic staff (n = 10). Participants highlighted perceived benefits of the mail-order model, including its potential to expand abortion services into primary care, increase patient autonomy and privacy, and to normalize abortion services. They also highlighted key logistical, clinical, and feasibility concerns about the mail-order model, and specific challenges related to integrating abortion into primary care. CONCLUSION Clinicians and clinic staff working in primary care and abortion clinics were optimistic that mail-order dispensing of medication abortion can improve the ability of some providers to provide abortion and enable more patients to access services. The feasibility of mail-order pharmacy dispensing of medication abortion following the Supreme Court Dobbs decision is to be determined. TRIAL REGISTRATION Registry: Clinicaltrials.gov. TRIAL REGISTRATION NUMBER NCT03913104. Date of registration: first submitted on April 3, 2019 and first posted on April 12, 2019.
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Affiliation(s)
- Sarah Raifman
- Advancing New Standards in Reproductive Health, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA.
| | - Tanvi Gurazada
- Nell Hodgson Woodruff School of Nursing at Emory University, 1520 Clifton Rd, Atlanta, GA, 30322, USA
| | - Jessica Beaman
- San Francisco Division of General Internal Medicine, University of California, 1001 Potrero Ave, San Francisco, CA, USA
| | - M Antonia Biggs
- Advancing New Standards in Reproductive Health, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
| | - Eleanor Bimla Schwarz
- San Francisco Division of General Internal Medicine, University of California, 1001 Potrero Ave, San Francisco, CA, USA
| | - Marji Gold
- Montefiore Medical Center, Albert Einstein College of Medicine, 3544 Jerome Ave, Bronx, NY, 10467, USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
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Hoggart L, Purcell C, Bloomer F, Newton V, Oluseye A. Social connectedness and supported self-management of early medication abortion in the UK: experiences from the COVID-19 pandemic and learning for the future. CULTURE, HEALTH & SEXUALITY 2024; 26:855-870. [PMID: 37830180 DOI: 10.1080/13691058.2023.2258189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 09/08/2023] [Indexed: 10/14/2023]
Abstract
Medication abortion has been established globally as safe and effective. This modality has increased accessibility and the opportunity to centre individual autonomy at the heart of abortion care, by facilitating self-managed abortion. Previous research has shown how self-managed abortion is beneficial in myriad settings ranging from problematic to (relatively) unproblematic contexts of access. In this paper we explore the relationship between self-management and sources of support (including health professionals, family, and friends); as well as considering issues of reproductive control and autonomy. Drawing on qualitative, experience-centred interviews, we utilise the concept of social connectedness to examine how supported self-managed abortion was experienced in the United Kingdom during the COVID-19 pandemic. Overall, self-management was welcomed, with participants speaking positively about managing their own abortion at home. However, a sense of connectedness was crucial in helping participants deal with difficult experiences; and functioned to support individual autonomy in self-care. This paper is the first to examine factors of connection, support, and isolation, as experienced by those undergoing self-managed abortion in the UK in detail. Our research suggests a continued need to advocate for high quality support for self-managed abortion, as well as for choice of abortion method, to support patient-centered care.
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Affiliation(s)
- Lesley Hoggart
- Faculty of Wellbeing, Education & Language Studies, Open University, Milton Keynes, UK
| | - Carrie Purcell
- Faculty of Wellbeing, Education & Language Studies, Open University, Milton Keynes, UK
| | - Fiona Bloomer
- School of Applied Social and Policy Sciences, Ulster University, Belfast, UK
| | - Victoria Newton
- Faculty of Wellbeing, Education & Language Studies, Open University, Milton Keynes, UK
| | - Ayomide Oluseye
- Faculty of Wellbeing, Education & Language Studies, Open University, Milton Keynes, UK
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Li F, Han M, Zhang J, Ji J, Wu Y, Wei J. Effects of medical abortion assisted by traditional Chinese medicine: A network meta-analysis of randomized controlled trials. Int J Gynaecol Obstet 2024; 166:152-162. [PMID: 38037875 DOI: 10.1002/ijgo.15272] [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: 07/07/2023] [Revised: 11/04/2023] [Accepted: 11/11/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND To what extent traditional Chinese medicine (TCM) combined with mifepristone and misoprostol is beneficial for improving the complete abortion rate and duration of vaginal bleeding has been a subject of debate in the field of medical abortion. OBJECTIVE To assess the evidence regarding the complete abortion rate and duration of vaginal bleeding of medical abortion assisted by different kinds of TCM. SEARCH STRATEGY We searched electronic databases such as PubMed, Web of Science and Cochrane Library database, China National Knowledge Internet, Wan fang Database, VIP Database, and China Biology Medicine disc from 2000 to February 15, 2023. SELECTION CRITERIA The control group was medical abortion with mifepristone and misoprostol, and the experimental group was medical abortion assisted by TCM. DATA COLLECTION AND ANALYSIS Major data extraction included sample size, age, medicine used for abortion, outcome measures. RevMan 5.3 and Stata 15.1 software were used to assess the literature quality and perform network meta-analysis, respectively. MAIN RESULTS A total of 73 randomized controlled trials (RCTs) with 11 683 patients and nine kinds of TCM were included in this study. Compared with mifepristone and misoprostol, eight kinds of TCM had statistical significance in improving the complete abortion rate. The effect value of Sancao decoction was 5.86 (95% confidence interval [CI] 2.53-13.58). Seven kinds of TCM shortened the duration of vaginal bleeding. The effect value of comfrey and trichosanthin decoction was -8.75 (95% CI -10.86 to -6.64). CONCLUSIONS This network meta-analysis showed that Lenge Zhumo decoction and Sancao decoction could have a large beneficial effect on complete abortion rate in medical abortion during early pregnancy, and comfrey and trichosanthin decoction could be the best TCM for shortening the duration of vaginal bleeding.
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Affiliation(s)
- Fuxing Li
- Department of Epidemiology, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Mei Han
- Department of Epidemiology, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jiayu Zhang
- Department of Epidemiology, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jingru Ji
- Department of Obstetrics, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yanfei Wu
- Department of Chinese Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Junni Wei
- Department of Epidemiology, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
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Farooqi S, Lackie E, Pham A, Zolis L, Sharma K, Devarajan K, Smith K, Nevin-Lam A, Lee S, Tempest H, Mei-Dan E, Tunde-Byass M. The Success of Mifepristone and Misoprostol in the Management of Early Pregnancy Loss at a Community Hospital: A Prospective Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102604. [PMID: 38950878 DOI: 10.1016/j.jogc.2024.102604] [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: 02/03/2024] [Revised: 04/04/2024] [Accepted: 04/11/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVES This prospective single-arm study was conducted to understand the expulsion rate of the gestational sac in the management of early pregnancy loss (EPL). METHODS We recruited 441 participants; 188 met the eligibility criteria. Participants were 18 years of age and older who experienced a confirmed EPL (<12 weeks gestational age) defined by an intrauterine pregnancy with a non-viable embryonic or anembryonic gestational sac with no fetal heart activity. Participants were given 200 mg of mifepristone pre-treatment orally followed by 2 doses of misoprostol 800 μg vaginally after 24 and 48 hours. Participants were seen in follow-up on day 14 to confirm the absence of a gestational sac, classified as treatment success. For failed treatment (defined by retained gestational sac), we offered expectant management or a third dose of misoprostol and/or dilatation and curettage. We followed all participants for 30 days. We collected data on overtreatment for retained products of conception and hospital admissions for adverse events. RESULTS Overall, 181 participants followed the protocol and 169 (93.3%) participants had a complete expulsion of the gestational sac by the second visit (day 14). Twelve (6.6%) failed the treatment and 1 had an adverse event of heavy vaginal bleeding requiring dilatation and curettage. Despite the expulsion of the gestational sac, 29 cases (17.1%) at subsequent follow-up were diagnosed as retained products of conception based on ultrasound assessment of thickened endometrium. CONCLUSIONS Pretreatment with mifepristone followed by 2 doses of misoprostol with a 14-day follow-up resulted in a high expulsion rate and is a safe management option for EPL.
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Affiliation(s)
- Salwa Farooqi
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON.
| | - Elyse Lackie
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON
| | - Alice Pham
- Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON
| | - Lynne Zolis
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON
| | - Kalpana Sharma
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON
| | - Karthika Devarajan
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON
| | - Kirsten Smith
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON
| | - Alexandra Nevin-Lam
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON
| | - Sabrina Lee
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON
| | - Heather Tempest
- Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON
| | - Elad Mei-Dan
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON
| | - Modupe Tunde-Byass
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON
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Cely-Andrade L, Cárdenas-Garzón K, Enríquez-Santander LC, Saavedra-Avendano B, Ortiz-Avendano GA, Betancourt-Rojas LA, Guerrero-Conde JG. Effectiveness and safety of medication abortion via telemedicine versus in-person: A cohort of pregnant people in Colombia. Contraception 2024:110514. [PMID: 38879070 DOI: 10.1016/j.contraception.2024.110514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 06/05/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE To compare the effectiveness and safety of medication abortion (MAB) via telemedicine versus in-person in pregnant people with less than 12 gestational weeks in Colombia. STUDY DESIGN A retrospective cohort study was conducted with 23,362 pregnant people who requested MAB service from Profamilia (a Colombian non-governmental organization) in 2021-2022. The outcomes were success and safety of MAB. We performed a descriptive and a multivariate statistical analysis using the binary regression model to obtain an adjusted Odds Ratio (aOR) to identify factors associated with abortion success. RESULTS In comparison to in-person care (n = 20,289), individuals in telemedicine (n = 3073) were predominantly from urban areas, belonged to a lower socioeconomic stratum, single and did not identify with any ethnic group. In-person users tended to have higher levels of education and accessed the service through private insurance (p < 0,05). There were no differences in the odd of a successful abortion based on the modality of care (aOR 1.18; 95% CI=0.87-1.59). The results were also the same with sensitivity analysis stratified: pregnant people who were nine weeks gestation or less (aOR 0.86; 95% CI=0.63-1.17) or more (aOR 0.87; 95% CI=0.28-2.65). CONCLUSION Telemedicine is an effective and safe option for MAB, as in-person care. Telemedicine has the potential to increase abortion access by extending the availability of providers and offering people a new option for obtaining care conveniently and privately, especially for women with disadvantaged socioeconomic and educational background. IMPLICATIONS This study demonstrates that medication abortion (MAB) administered via telemedicine produces outcomes akin to those of in-person care, providing a compelling rationale for its adoption, particularly in underserved regions. This approach can be replicated in other countries in Latin America and the Caribbean.
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Tsereteli T, Platais I, Maru M, Maystruk G, Kurbanbekova D, Rzayeva G, Winikoff B. Evaluation of telemedicine medical abortion using a no-test protocol in the Eastern Europe and Central Asian region: Evidence from Ukraine, Uzbekistan, and Azerbaijan. Int J Gynaecol Obstet 2024. [PMID: 38803127 DOI: 10.1002/ijgo.15708] [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: 10/02/2023] [Revised: 04/10/2024] [Accepted: 05/11/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE To evaluate safety, feasibility, and acceptability of a telemedicine medical abortion service without pre-treatment in-person tests in Ukraine, Uzbekistan, and Azerbaijan. METHODS We conducted an open-label, prospective, observational clinical study at five clinics in the three countries. Interested and eligible participants scheduled a telemedicine consultation with a study provider by phone or video. Medical abortion pills could be obtained by mail or courier or picked up at the study clinic or a pharmacy. Study providers contacted participants 1 week after mifepristone ingestion to assess abortion outcomes based on symptoms, and 3 weeks later to review the result of an at-home, high-sensitivity, urine pregnancy test. Participants were referred to in-person visit based on symptoms, urine pregnancy test results, or initiative by the participant. RESULTS In all, 300 women participated in the study. Almost all participants received medical abortion medications the same day as their first contact with the study clinic, and the majority (n = 297, 99.0%) did not experience any problems receiving them. All except two women (0.67%) followed provider instructions on administration of medications. The majority of participants had a complete abortion without a procedure (Ukraine: n = 115, 95.8%; Uzbekistan: n = 127, 97.7%; Azerbaijan: n = 49, 98.0%), few had in-person visits (Ukraine: n = 30, 25.0%; Uzbekistan: n = 3, 2.3%; Azerbaijan: n = 4, 8.0%), and most were very satisfied or satisfied with the service (Ukraine: n = 116, 96%; Uzbekistan: n = 128, 98%; Azerbaijan: n = 45, 90%). No serious adverse events occurred. CONCLUSION Telemedicine medical abortion using the no-test protocol is safe, feasible and acceptable for women in Ukraine, Uzbekistan, and Azerbaijan.
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Affiliation(s)
| | - Ingrida Platais
- Gynuity Health Projects, New York, New York, USA
- New York University Grossman School of Medicine, New York, New York, USA
| | - Mahlet Maru
- Gynuity Health Projects, New York, New York, USA
| | - Galyna Maystruk
- Charitable Foundation Women Health and Family Planning, Kyiv, Ukraine
| | | | - Gulnara Rzayeva
- Scientific-Research Institute of Obstetrics and Gynecology, Baku, Azerbaijan
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11
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Rousseau A, Baumann S, Constant J, Deplace S, Multon O, Lenoir-Delpierre L, Gaucher L. Defining practices suitable for care via teleconsultation in gynaecological and obstetrical care: a French Delphi survey. BMJ Open 2024; 14:e085621. [PMID: 38719331 PMCID: PMC11086368 DOI: 10.1136/bmjopen-2024-085621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 04/11/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE Delineate the scope of teleconsultation services that can be effectively performed to provide women with comprehensive gynaecological and obstetrical care. DESIGN Based on the literature and experts' insights, we identified a list of gynaecological and obstetrical care practices suitable for teleconsultation. A three-round Delphi consensus survey was then conducted online among a panel of French experts. Experts using a 9-point Likert scale assessed the relevance of each teleconsultation practice in four key domains: prevention, gynaecology and antenatal and postnatal care. Consensus was determined by applying a dual-criteria approach: the median score on a 9-point Likert scale and the percentage of votes either below 5 or 5 and higher. SETTING The study was conducted at a national level in France and involved multiple healthcare centres and professionals from various geographical locations. PARTICIPANTS The panel comprised 22 French experts with 19 healthcare professionals, including 12 midwives, 3 obstetricians-gynaecologists, 4 general practitioners and 3 healthcare system users. Participants were selected to include diverse practice settings encompassing hospital and private practices in both rural and urban areas. PRIMARY AND SECONDARY OUTCOME MEASURES The study's primary outcome was the identification of gynaecological and obstetrical care practices suitable for teleconsultation. Secondary outcomes included the level of professional consensus on these practices. RESULTS In total, 71 practices were included in the Delphi survey. The practices approved for teleconsultation were distributed as follows: 92% in prevention (n=12/13), 55% in gynaecology (n=18/33), 31% in prenatal care (n=5/16) and 12% in postnatal care (n=1/9). Lastly, 10 practices remained under discussion: 7 in gynaecology, 2 in prenatal care and 1 in postnatal care. CONCLUSIONS Our consensus survey highlights both the advantages and limitations of teleconsultations for women's gynaecological and obstetrical care, emphasising the need for careful consideration and tailored implementation.
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Affiliation(s)
- Anne Rousseau
- CESP, Villejuif, France
- Department of Obstetrics and Gynecology, Poissy-Saint Germain Hospital, Poissy, France
| | | | | | | | - Olivier Multon
- Department of Obstetrics and Gynecology, Saint Herblain, France
| | | | - Laurent Gaucher
- Midwifery, Geneva School of Health Sciences, Genève, Switzerland
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12
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Parsons JA, Romanis EC. "All hands on deck": a qualitative study of safeguarding and the transition to telemedical abortion care in England and Wales. Soc Sci Med 2024; 348:116835. [PMID: 38626482 DOI: 10.1016/j.socscimed.2024.116835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 03/12/2024] [Accepted: 03/25/2024] [Indexed: 04/18/2024]
Abstract
The COVID-19 pandemic raised significant challenges for in-person healthcare provision, leading healthcare providers to embrace digital health like never before. Whilst changes were made as part of a public health response, many have now become permanent fixtures of the healthcare landscape, significantly altering the way care is provided not only for patients, but also for the healthcare professionals that provide care. In abortion care in England and Wales, previously stringent regulations on in-person care provision were relaxed to permit the use of telemedicine and self-administration of medications at home. These changes have since been made permanent. However, there remains opposition to remote abortion care pathways on the basis of safeguarding. Opponents argue that it is not feasible to effectively safeguard patients accessing abortion care remotely. We conducted a qualitative study using semi-structured interviews with abortion care providers in England and Wales. Participants were asked about their views and experiences of the transition to remote care provision, with a particular focus on how they adapted their safeguarding practice. In this article, we present three themes that highlight the changing roles of healthcare professionals in abortion care: (1) a challenging backdrop and resulting apprehension, (2) adaptive practices, and (3) the continued importance of professional curiosity. Across all three themes, participants reflected significantly on how changes were made and what they experienced in the period of transition to telemedicine. In particular, they discussed the changing nature of their professional roles amidst digitalisation. Our findings provide a basis for reflection on the increasing introduction of digital approaches to healthcare provision, highlighting points for caution and emphasising the need to involve professionals in the transition process to ensure vital buy-in. Through this, we articulate two novel understandings of digitalisation: (1) the impact of speed-associated pressures on professional adaptation during digitalisation, and (2) off-proforma safeguarding through telemedicine as a form of invisible non-routine work.
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Affiliation(s)
- Jordan A Parsons
- Birmingham Medical School, University of Birmingham, Birmingham, B15 2TT, UK; Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK.
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13
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Purcell C, Newton VL, Bloomer F, Hoggart L. Foregrounding pain in self-managed early medication abortion: a qualitative study. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024:bmjsrh-2023-202198. [PMID: 38429082 DOI: 10.1136/bmjsrh-2023-202198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/13/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE To explore experiences of pain in the context of early medical abortion (EMA) in the UK and to guide best practice around anticipatory guidance on pain. METHODS From late 2020 to early 2021, we recruited individuals from across the UK who had undergone abortion during the COVID-19 pandemic to participate in in-depth, semi-structured telephone interviews. A storytelling approach was used and data were analysed thematically using NVivo 12 software. RESULTS Focused coding and thematic analysis addressed accounts of pain, which were prominent in many interviews. We constructed the following subthemes: expected pain is manageable for some; the problem with unexpected pain; pain (co)produces fear; and problematising 'period-like pain'. The key issue which our analysis draws out is that while EMA pain experience might vary, for some it may be much worse than anticipated. Moreover, the common trope of likening it to 'period pain' can be misleading and a source of additional uncertainty at a potentially already challenging time. CONCLUSIONS For some individuals, pain experienced in EMA will be severe and/or worse than expected. Insufficient preparation for pain can result in extremely negative experiences of EMA. Alongside development of improved analgesia, improvements should be made to anticipatory guidance on pain, particularly for those self-manging EMA at home. Framings of 'period-like pain' do not clarify expectations and should be avoided.
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Affiliation(s)
- Carrie Purcell
- Faculty of Wellbeing, Education and Language Studies, The Open University in Scotland, Edinburgh, UK
| | - Victoria Louise Newton
- Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK
| | - Fiona Bloomer
- School of Applied Social and Policy Sciences, Ulster University, Belfast, UK
| | - Lesley Hoggart
- Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK
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14
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Peng K, Tu K, Li Z, Hallinan CM, Laughlin A, Manski-Nankervis JA, Apajee J, Lapadula MC, Ortigoza A, Da Roza CC, Baste V, Flottorp S, Wensaas KA, Goh LH, Ling ZJ, Kristiansson R, Gaona G, Pace WD, Westfall JM, Ng APP, Wong WCW. Global impacts of COVID-19 pandemic on sexual and reproductive health services: An international comparative study on primary care from the INTRePID Consortium. BJOG 2024; 131:508-517. [PMID: 37935645 DOI: 10.1111/1471-0528.17704] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVE To understand how the COVID-19 pandemic has impacted sexual and reproductive health (SRH) visits. DESIGN An ecological study comparing SRH services volume in different countries before and after the onset of the COVID-19 pandemic. SETTING Seven countries from the INTernational ConsoRtium of Primary Care BIg Data Researchers (INTRePID) across four continents. POPULATION Over 3.8 million SRH visits to primary care physicians in Australia, China, Canada, Norway, Singapore, Sweden and the USA. METHODS Difference in average SRH monthly visits before and during the pandemic, with negative binomial regression modelling to compare predicted and observed number of visits during the pandemic for SRH visits. MAIN OUTCOME MEASURES Monthly number of visits to primary care physicians from 2018 to 2021. RESULTS During the pandemic, the average volume of monthly SRH visits increased in Canada (15.6%, 99% CI 8.1-23.0%) where virtual care was pronounced. China, Singapore, Sweden and the USA experienced a decline (-56.5%, 99% CI -74.5 to -38.5%; -22.7%, 99% CI -38.8 to -6.5%; -19.4%, 99% CI -28.3 to -10.6%; and -22.7%, 99% CI -38.8 to -6.5%, respectively); while Australia and Norway showed insignificant changes (6.5%, 99% CI -0.7 to -13.8% and 1.7%, 99% CI -6.4 to -9.8%). The countries that maintained (Australia, Norway) or surpassed (Canada) pre-pandemic visit rates had the greatest use of virtual care. CONCLUSIONS In-person SRH visits to primary care decreased during the pandemic. Virtual care seemed to counterbalance that decline. Although cervical cancer screening appeared insensitive to virtual care, strategies such as incorporating self-collected samples for HPV testing may provide a solution in a future pandemic.
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Affiliation(s)
- Kangning Peng
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Karen Tu
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Departments of Research and Innovation and Family Medicine-North York General Hospital, Toronto Western Family Health Team-University Health Network, Toronto, Ontario, Canada
| | - Zhuo Li
- Department of Family Medicine and Primary Care, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Christine Mary Hallinan
- Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Adrian Laughlin
- Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jo-Anne Manski-Nankervis
- Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jemisha Apajee
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - María Carla Lapadula
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Angela Ortigoza
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Cecilia Clara Da Roza
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Valborg Baste
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen, Norway
| | - Signe Flottorp
- Norwegian Institute of Public Health, Oslo, Norway
- Department of General Practice, University of Oslo, Oslo, Norway
| | - Knut-Arne Wensaas
- Research Unit for General Practice, NORCE Norwegian Research Centre AS, Bergen, Norway
| | - Lay Hoon Goh
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Zheng Jye Ling
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Robert Kristiansson
- Department of Public Health and Caring Sciences, Health Services Research, Uppsala University, Uppsala, Sweden
| | | | | | | | - Amy Pui Pui Ng
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Department of Family Medicine and Primary Care, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - William Chi-Wai Wong
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- Department of Family Medicine and Primary Care, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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15
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Lerma K, Arey W, Strelitz-Block E, Nathan S, White K. Abortion Clients' Perceptions of Alternative Medication Abortion Service Delivery Options in Mississippi. Womens Health Issues 2024; 34:156-163. [PMID: 38151449 DOI: 10.1016/j.whi.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVES We assessed Mississippi abortion clients' perceptions of alternative medication abortion service delivery options that were restricted under state law but available elsewhere. METHODS We conducted in-depth interviews with medication abortion clients between November 2020 and March 2021 at Mississippi's only abortion facility. We described alternative service delivery models: telemedicine, medications by mail, and follow-up care in their community versus returning to the facility. We asked if participants would be interested in using any of these models, if available, and how use of each model would have changed their abortion experience. We used thematic analysis, organizing codes into common themes based on participants' preferences and concerns for each option. RESULTS Of the 25 participants interviewed, nearly all (n = 22) expressed interest in at least one option and reported that, had they been available, these would have alleviated cost, travel, and childcare barriers. Many believed these options would further ensure privacy, but a minority thought abortion was too sensitive for telemedicine or were concerned about mailing errors. Participants not interested in the alternative options also feared missing valued aspects of face-to-face care. Most did not return to the facility for follow-up (n = 19), citing financial and logistical barriers. Largely, participants were not interested in obtaining follow-up care in their community, citing concerns about provider judgment, stigma, and privacy. CONCLUSIONS Mississippi abortion clients were interested in models that would make abortion care more convenient while ensuring their privacy and allowing for meaningful client-provider interaction. These features of care should guide the development of strategies aimed at helping those in restricted settings, such as Mississippi, to overcome barriers to abortion care following the implementation of abortion bans in many states following the overturn of Roe v. Wade.
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Affiliation(s)
- Klaira Lerma
- Population Research Center, The University of Texas at Austin, Austin, Texas.
| | - Whitney Arey
- Population Research Center, The University of Texas at Austin, Austin, Texas; Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Eva Strelitz-Block
- Population Research Center, The University of Texas at Austin, Austin, Texas
| | - Sacheen Nathan
- Jackson Women's Health Organization, Jackson, Mississippi
| | - Kari White
- Population Research Center, The University of Texas at Austin, Austin, Texas; Department of Sociology, The University of Texas at Austin, Austin, Texas; Steve Hicks School of Social Work, The University of Texas at Austin, Austin, Texas
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16
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Kerns JL, Brown K, Nippita S, Steinauer J. Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion. Contraception 2024; 129:110292. [PMID: 37739302 DOI: 10.1016/j.contraception.2023.110292] [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: 12/01/2022] [Revised: 09/07/2023] [Accepted: 09/15/2023] [Indexed: 09/24/2023]
Abstract
Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Although medication abortion is associated with more bleeding than procedural abortion, overall bleeding for the two methods is minimal and not clinically different. Hemorrhage can be caused by atony, coagulopathy, and abnormal placentation, as well as by such procedure complications as perforation, cervical laceration, and retained tissue. Evidence for practices around postabortion hemorrhage is extremely limited. The Society of Family Planning recommends preoperative identification of individuals at high risk of hemorrhage as well as development of an organized approach to treatment. Specifically, individuals with a uterine scar and complete placenta previa seeking abortion at gestations after the first trimester should be evaluated for placenta accreta spectrum. For those at high risk of hemorrhage, referral to a higher-acuity center should be considered. We propose an algorithm for treating postabortion hemorrhage as follows: (1) assessment and examination, (2) uterine massage and medical therapy, (3) resuscitative measures with laboratory evaluation and possible reaspiration or balloon tamponade, and (4) interventions such as embolization and surgery. Evidence supports the use of oxytocin as prophylaxis for bleeding with dilation and evacuation; methylergonovine prophylaxis, however, is associated with more bleeding at the time of dilation and evacuation. Future research is needed on tranexamic acid as prophylaxis and treatment and misoprostol as prophylaxis. Structural inequities contribute to bleeding risk. Acknowledging how our policies hinder or remedy health inequities is essential when developing new guidelines and approaches to clinical services.
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Affiliation(s)
- Jennifer L Kerns
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, USA.
| | - Katherine Brown
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, USA
| | - Siripanth Nippita
- New York University, Department of Obstetrics and Gynecology, New York, NY, USA
| | - Jody Steinauer
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, USA
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17
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Dunlop H, Sinay AM, Kerestes C. Telemedicine Abortion. Clin Obstet Gynecol 2023; 66:725-738. [PMID: 37910115 DOI: 10.1097/grf.0000000000000818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Telemedicine has become a substantial part of abortion care in recent years. In this review, we discuss the history and regulatory landscape of telemedicine for medication abortion in the United States, different models of care for telemedicine, and the safety and effectiveness of medication abortion via telemedicine, including using history-based screening protocols for medication abortion without ultrasound. We also explore the acceptability of telemedicine for patients and their perspectives on its benefits, as well as the use of telemedicine for other parts of abortion care. Telemedicine has expanded access to abortion for many, although there remain limitations to its implementation.
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Affiliation(s)
| | - Anne-Marie Sinay
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Courtney Kerestes
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
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18
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Adu J, Roemer M, Page G, Dekonor E, Akanlu G, Fofie C, Teye MD, Afriyie PO, Affram AA, Ohemeng F, Tabong PTN, Dwomoh D. Expanding access to early medical abortion services in Ghana with telemedicine: findings from a pilot evaluation. Sex Reprod Health Matters 2023; 31:2250621. [PMID: 37728548 PMCID: PMC10512762 DOI: 10.1080/26410397.2023.2250621] [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] [Indexed: 09/21/2023] Open
Abstract
Abortion in Ghana is legally permissible under certain conditions. Updated in June 2021, the National Comprehensive Abortion Care Services Standards and Protocols included telemedicine as a recognised option for early medical abortion (EMA). Subsequently, Marie Stopes Ghana launched this pilot project to understand the feasibility and acceptability of providing EMA services through telemedicine. The pilot evaluation drew on two research protocols - a process evaluation and a qualitative study. The process evaluation focused on existing routine data sources and additional pilot-specific monitoring, while the qualitative protocol included in-depth interviews with a range of key stakeholders, including telemedicine and in-person patients, healthcare managers, and service providers. Telemedicine for EMA is feasible, acceptable, and has likely expanded access to safe abortion in Ghana. The MSIG telemedicine service package enabled 97% of patients to have a successful EMA at home. Thirty-six per cent of the total 878 patients during the pilot reported that they had no other option for accessing an abortion. Patients described telemedicine EMA services as a highly acceptable and appealing service option. Eighty-four per cent reported they would opt for the telemedicine service again and 83% reported they were very likely to recommend the service. There is potential for telemedicine to expand and improve access to critical SRH services. EMA via telemedicine can be delivered effectively in a low-resource setting. This pilot also showed how telemedicine provides access to patients who feel they do not have other safe service options, meeting specific patient needs in terms of discretion, convenience, and timing.
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Affiliation(s)
- Joseph Adu
- Director of Medical Services, MSI Reproductive Choices, Ghana
| | - Matthea Roemer
- Innovation, Evidence and Research Manager, MSI Reproductive Choices, Accra, Ghana
| | - Georgina Page
- Head of SBC and Inclusion, MSI Reproductive Choices, Accra, Ghana
| | - Elymas Dekonor
- Head of Marketing, MSI Reproductive Choices, Accra, Ghana
| | - George Akanlu
- Country Director, MSI Reproductive Choices, Accra, Ghana
| | - Chris Fofie
- Deputy Director, Reproductive and Child Health, Ghana Health Services, Accra, Ghana
| | | | - Patricia Opoku Afriyie
- Monitoring, Evaluation, Research and Learning (MERL) Manager, MSI Reproductive Choices, Ghana
| | - Adjeiwa Akosua Affram
- PhD Candidate, Department of Health Policy, Planning and Management, School of Public Health, University of Ghana, Accra, Ghana
| | - Fidelia Ohemeng
- Senior Lecturer, Department of Sociology, University of Ghana, Accra, Ghana
| | - Philip Teg-Nefaah Tabong
- Lecturer, Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, Accra, Ghana
| | - Duah Dwomoh
- Director, D&D Statistical Consulting Services Limited, Accra, Ghana
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19
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Footman K. Revolution in abortion care? Perspectives of key informants on the importance of abortion method choice in the era of telemedicine. Sex Reprod Health Matters 2023; 31:2149379. [PMID: 36876426 PMCID: PMC10013513 DOI: 10.1080/26410397.2022.2149379] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
Patient choice of medical or surgical abortion is a standard of quality abortion care, but the choice of surgical abortion is constrained in England and Wales, particularly since the COVID-19 pandemic and introduction of telemedicine. This qualitative study explored the perspectives of abortion service providers, managers, and funders on the need to offer a choice of methods within early gestation abortion services in England and Wales. Twenty-seven key informant interviews were conducted between August and November 2021, and framework analysis methods were used. Participants presented arguments both for and against offering method choice. Most participants felt that it was important to maintain choice, although they recognised that medical abortion suits most patients, that both methods are very safe and acceptable, and that the priority for abortion services is to maintain timely access to respectful care. Their arguments related to practicalities around patient needs, the risk of reinforcing inequalities in access to patient-centred care, potential impacts on patients and providers, comparisons to other services, costs, and moral issues. Participants argued that constraining choice has a greater impact on those who are less able to advocate for themselves and there were concerns that patients may feel stigmatised or isolated when unable to choose their preferred method. In conclusion, although medical abortion suits most patients, this study highlights arguments for maintaining the option of surgical abortion in the era of telemedicine. More nuanced discussion of the potential benefits and impacts of self-management of medical abortion is needed.
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Affiliation(s)
- Katy Footman
- PhD Candidate, London School of Economics, London, UK. Correspondence:
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20
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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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21
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Lerma K, Coplon L, Goyal V. Travel for abortion care: implications for clinical practice. Curr Opin Obstet Gynecol 2023; 35:476-483. [PMID: 37916900 DOI: 10.1097/gco.0000000000000915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
PURPOSE OF REVIEW Traveling long distances to obtain abortion care due to restrictions and scarce availability is associated with significant obstacles. We review clinical strategies that can facilitate abortion access and outline considerations to ensure person-centered and equitable care. RECENT FINDINGS Establishing a patient's gestational duration prior to travel may be beneficial to ensure they are eligible for their desired abortion method at the preferred facility or to determine if a multiday procedure is required. If a local ultrasound cannot be obtained prior to travel, evidence demonstrates people can generally estimate their gestational duration accurately. If unable to provide care, clinicians should make timely referrals for abortion. Integration of telemedicine into abortion care is safe and well regarded by patients and should be implemented into service delivery where possible to reduce obstacles to care. Routine in-person follow-up care is not necessary. However, for those who want reassurance, formalized pathways to care should be established to ensure people have access to care in their community. To further minimize travel-related burdens, facilities should routinely offer information about funding and practical support, emotional support, and legal resources. SUMMARY There are many opportunities to optimize clinical practice to support those traveling for abortion care.
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Affiliation(s)
- Klaira Lerma
- Population Research Center, The University of Texas at Austin, Austin, Texas
| | - Leah Coplon
- Abortion On Demand, Seattle, Washington, USA
| | - Vinita Goyal
- Population Research Center, The University of Texas at Austin, Austin, Texas
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22
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Kapp N, Mao B, Menzel J, Eckersberger E, Saphonn V, Rathavy T, Pearson E. A prospective, comparative study of clinical outcomes following clinic-based versus self-use of medical abortion. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:300-307. [PMID: 36894309 PMCID: PMC10579469 DOI: 10.1136/bmjsrh-2022-201722] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/12/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND To determine whether clinical outcomes differ among women accessing a combined medical abortion regimen from a health clinic when compared with those accessing it from a pharmacy. METHODS We conducted a multicentre, prospective, comparative, non-inferiority study of participants aged ≥15 years seeking medical abortion from five clinics and five adjacent pharmacy clusters in three provinces of Cambodia. Participants were recruited in-person at the point of purchase (clinic or pharmacy). Follow-up for self-reported pill use, acceptability, and clinical outcomes occurred by telephone at days 10 and 30 after mifepristone administration. RESULTS Over 10 months, we enrolled 2083 women with 1847 providing outcome data: 937 from clinics and 910 from pharmacies. Most were early in their pregnancy (mean gestational age of 6.3 and 6.1 weeks, respectively) and almost all took the pills correctly (98% and 96%,). Additional treatment needed to complete the abortion was non-inferior for the pharmacy group (9.3%) compared with the clinic group (12.7%). More from the clinic group received additional care from a provider, such as antibiotics or diagnostics tests, than those from the pharmacy group (11.5% and 3.2%,), and one ectopic pregnancy (pharmacy group) was successfully treated. Most said they felt prepared for what happened after taking the pills (90.9% and 81.3%, respectively, p=0.273). CONCLUSIONS Self-use of a combined medical abortion product resulted in comparable clinical outcomes as use following a clinical visit, consistent with existing literature on its safety and efficacy. Registration and availability of medical abortion as an over-the-counter product would likely increase women's access to safe abortion.
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Affiliation(s)
| | - Bunsoth Mao
- University of Health Sciences, Phnom Penh, Cambodia
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23
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Podolskyi V, Gemzell-Danielsson K, Marions L, Gomperts R. Preabortion ultrasound - a patient perspective. EUR J CONTRACEP REPR 2023; 28:268-273. [PMID: 37698511 DOI: 10.1080/13625187.2023.2249158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/14/2023] [Accepted: 08/11/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE To explore women's perception of the need for an ultrasound scan before medical abortion provided by telemedicine services. METHODS We have analysed women's requests for medical abortion through the website www.womenonweb.org from the 1st of January 2019 to the 5th of October 2020. Before receiving abortion drugs for self-managed medical abortion, women received online counselling and were asked to complete an online survey on pre-abortion ultrasound scan and the reasons for having or not having one. The initial dataset included 62641 entries from 207 countries. Each entry corresponded to a person's request for medical abortion. Women reported only one or multiple reasons for not having a pre-abortion ultrasound scan. RESULTS Among 59648 women requesting a medical abortion, 45653 (76,54%) did not have any pre-abortion ultrasound scan and specified a reason for that. The countries with the highest rates of women not having a pre-abortion ultrasound scan were Thailand, Poland, Northern Ireland, Mexico, South Korea, Japan, Chile, Indonesia, Germany, and Brazil. The main reasons for not having a pre-abortion ultrasound scan were being confident regarding pregnancy length; and thus, no need for a scan stated by 10910/34390 women (31.7%), lack of resources stated by 10589/34390 women (30.8%), and privacy issues stated by 6472/34390 women (18.8%). CONCLUSION Most women opting for medical abortion through telemedicine did not undergo a pre-abortion ultrasound scan. The main reason stated was that women did not find it necessary, lack of resources and privacy issues.
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Affiliation(s)
- Volodymyr Podolskyi
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- WHO-Centre, Karolinska University Hospital Solna, QB:84, Stockholm, Sweden
- Lukyanova Institute of Pediatrics, Obstetrics and Gynecology of NAMS of Ukraine, Kyiv, Ukraine
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- WHO-Centre, Karolinska University Hospital Solna, QB:84, Stockholm, Sweden
| | - Lena Marions
- Department Obstetrics and Gynecology, Södersjukhuset, Stockholm, Sweden
- Department Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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24
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Hull SC, Chou JC, Yee LM, Yee D, Esserman L. A Truly Pro-Life Position Requires Access to Reproductive Health Care. J Womens Health (Larchmt) 2023; 32:1023-1026. [PMID: 37379465 DOI: 10.1089/jwh.2023.0305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023] Open
Affiliation(s)
- Sarah C Hull
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Program for Biomedical Ethics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Josephine C Chou
- Division of Cardiovascular Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Douglas Yee
- Division of Hematology, Oncology, and Transplantation, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Laura Esserman
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
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25
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Cirucci CA. Self-Managed Medication Abortion: Implications for Clinical Practice. LINACRE QUARTERLY 2023; 90:273-289. [PMID: 37841380 PMCID: PMC10566489 DOI: 10.1177/00243639221128389] [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: 10/17/2023]
Abstract
Medication abortion represents more than 50 percent of abortions in the United States (US). Since its approval in the US in 2000, the Food and Drug Administration (FDA) has progressively relaxed the prescribing requirements such that currently, no office visit, in-person dispensing, or ultrasound is required. Obtaining medication for abortion online without medical supervision or evaluation is also possible. This article reviews the complications of medication abortion by examining major studies and delineates the risks specific to self-managed abortion to inform clinicians in caring for women. Summary Medication abortion has become the most common abortion method in the United States. This document provides a detailed history of the relaxation requirements on medication abortion and reviews the major studies on medication abortion complications including a discussion of their limitations. Finally, the paper delineates the ease of access to medication abortion without a health care provider and the risks associated with self-managed abortion. This paper is intended to provide information for clinicians who likely will be encountering increasing number of patients with such complications.
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26
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Kumsa FA, Prasad R, Shaban-Nejad A. Medication abortion via digital health in the United States: a systematic scoping review. NPJ Digit Med 2023; 6:128. [PMID: 37438435 PMCID: PMC10338479 DOI: 10.1038/s41746-023-00871-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/26/2023] [Indexed: 07/14/2023] Open
Abstract
Digital health, including telemedicine, has increased access to abortion care. The convenience, flexibility of appointment times, and ensured privacy to abortion users may make abortion services via telemedicine preferable. This scoping review systematically mapped studies conducted on abortion services via telemedicine, including their effectiveness and acceptability for abortion users and providers. All published papers included abortion services via telemedicine in the United States were considered. Articles were searched in PubMed, CINAHL, and Google Scholar databases in September 2022. The findings were synthesized narratively, and the PRISMA-ScR guidelines were used to report this study. Out of 757 retrieved articles, 33 articles were selected based on the inclusion criteria. These studies were published between 2011 and 2022, with 24 published in the last 3 years. The study found that telemedicine increased access to abortion care in the United States, especially for people in remote areas or those worried about stigma from in-person visits. The effectiveness of abortion services via telemedicine was comparable to in-clinic visits, with 6% or fewer abortions requiring surgical intervention. Both care providers and abortion seekers expressed positive perceptions of telemedicine-based abortion services. However, abortion users reported mixed emotions, with some preferring in-person visits. The most common reasons for choosing telemedicine included the distance to the abortion clinic, convenience, privacy, cost, flexibility of appointment times, and state laws imposing waiting periods or restrictive policies. Telemedicine offered a preferable option for abortion seekers and providers. The feasibility of accessing abortion services via telemedicine in low-resource settings needs further investigation.
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Affiliation(s)
- Fekede Asefa Kumsa
- The University of Tennessee Health Science Center (UTHSC) - Oak Ridge National Laboratory (ORNL) Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, Memphis, TN, 38103, USA.
| | - Rameshwari Prasad
- The University of Tennessee Health Science Center (UTHSC) - Oak Ridge National Laboratory (ORNL) Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, Memphis, TN, 38103, USA
| | - Arash Shaban-Nejad
- The University of Tennessee Health Science Center (UTHSC) - Oak Ridge National Laboratory (ORNL) Center for Biomedical Informatics, Department of Pediatrics, College of Medicine, Memphis, TN, 38103, USA.
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Slavin MN, West BS, Levin FR, El-Bassel N. Women with substance use disorders are highly impacted by the overturning of Roe v. Wade: Advocacy steps are urgently needed. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 150:209052. [PMID: 37105267 PMCID: PMC10433178 DOI: 10.1016/j.josat.2023.209052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/22/2022] [Accepted: 04/15/2023] [Indexed: 04/29/2023]
Abstract
The Supreme Court's ruling to overturn the 1973 Roe v. Wade verdict represents a major setback for women's reproductive freedoms in the United States. This ruling revokes constitutional protection for abortion rights and returns the decision to the states. Since this ruling in June 2022, numerous states have adopted total or near total abortion bans, with many of these bans offering no exception for rape, incest, or nonfatal maternal health risks. Legal experts also warn that this ruling can open the door to restrict contraceptive rights previously protected under the same implied constitutional right to privacy as abortion. Already, this decision has increased momentum for states to place restrictions on specific forms of contraception. Certain groups of women will be disproportionately harmed by these bans, such as women with substance use disorders (SUDs). Women with SUDs face unique barriers to sexual and reproductive health services that exist at the structural level (e.g., criminalization; costs and accessibility), interpersonal level (e.g., higher rates of intimate partner violence) and individual level (e.g., reduced reproductive autonomy). These synergistic barriers interact to produce lower contraceptive use, increased unintended pregnancy rates, and subsequently a greater need for abortion services among this population. This ruling will exacerbate the effects of these barriers on women with SUDs, resulting in even greater difficulties accessing contraceptive and abortion services, and ultimately increasing rates of criminalization among pregnant and parenting women with SUDs. This commentary describes these barriers and highlights potential advocacy steps that are urgently needed to assist reproductive-aged women with SUDs during these challenging times when essential health services are increasingly inaccessible.
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Affiliation(s)
| | - Brooke S West
- School of Social Work, Columbia University, New York, NY, USA
| | - Frances R Levin
- Columbia University, Vagelos College of Physicians and Surgeons, USA; New York State Psychiatric Institute, USA
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28
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Jain D, Davies M, Perritt J, Blasdell J. The Provision of Medication Abortion Care via Telehealth. Womens Health Issues 2023:S1049-3867(23)00099-3. [PMID: 37301724 DOI: 10.1016/j.whi.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 04/13/2023] [Accepted: 04/28/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Divya Jain
- Harvard Kennedy School of Government, Cambridge, Massachusetts; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
| | - MiQuel Davies
- Physicians for Reproductive Health, Washington, District of Columbia
| | - Jamila Perritt
- Physicians for Reproductive Health, Washington, District of Columbia
| | - Jennifer Blasdell
- Physicians for Reproductive Health, Washington, District of Columbia
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29
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Pearlman Shapiro M, Myo M, Chen T, Nathan A, Raidoo S. Remote Provision of Medication Abortion and Contraception Through Telemedicine. Obstet Gynecol 2023:00006250-990000000-00746. [PMID: 37054393 DOI: 10.1097/aog.0000000000005205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/23/2023] [Indexed: 04/15/2023]
Abstract
This Narrative Review describes the remote provision of family planning services, including medication abortion and contraception, through telemedicine. The coronavirus disease 2019 (COVID-19) pandemic was a catalyst to shift toward telemedicine to maintain and expand access to crucial reproductive health services when public health measures necessitated social distancing. There are legal and political considerations when providing medication abortion through telemedicine, along with unique challenges, even more so after the Dobbs decision starkly limited options for much of the country. This review includes the literature describing the logistics of telemedicine and modes of delivery for medication abortion and details special considerations for contraceptive counseling. Health care professionals should feel empowered to adopt telemedicine practices to provide family planning services to their patients.
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Affiliation(s)
- Marit Pearlman Shapiro
- University of Southern California, Los Angeles, and the University of California, San Diego, La Jolla, California; and the University of Hawaii, Honolulu, Hawaii
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30
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Jung C, Oviedo J, Nippita S. Abortion Care in the United States - Current Evidence and Future Directions. NEJM EVIDENCE 2023; 2:EVIDra2200300. [PMID: 38320010 DOI: 10.1056/evidra2200300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Abortion Care in the United StatesAbortion services are a vital component of reproductive health care. Jung and colleagues review medication abortion and procedural abortion as well as implications of increasing restrictions on access in the United States.
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Affiliation(s)
- Christina Jung
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine
| | - Johana Oviedo
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine
| | - Siripanth Nippita
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine
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31
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Atay H, Kim S, Kim J, Gomperts R. Self-managed medication abortion in South Korea: A retrospective records review of the uptake of medication abortion through online telemedicine prior to decriminalization. Contraception 2023; 120:109923. [PMID: 36535413 DOI: 10.1016/j.contraception.2022.109923] [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: 07/21/2022] [Revised: 12/04/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To examine the uptake of medication abortion through online telemedicine in South Korea prior to decriminalization of abortion beginning in 2019. STUDY DESIGN We conducted a descriptive cross-sectional analysis of medication abortion consultations submitted to Women on Web, an online telemedicine service, from South Korea between 2013 and 2019. RESULTS The uptake of medication abortion through Women on Web increased every year between 2013 and 2019, adding up to 12,115 consultations across 7 years. The median age was 25 and the median gestational age was 37 days. Individuals reported financial constraints (66.2%) as the most common reason for wanting an abortion. This was followed by not wanting a child at this point (64.7%) and wanting to finish school (34.6%). CONCLUSIONS This study illustrates the uptake of medication abortions via Women on Web between 2013 and 2019, prior to decriminalization of abortion in South Korea. IMPLICATIONS This study attests to the use of online telemedicine for medication abortion, despite the legal restrictions prior to decriminalization of abortion in South Korea.
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Affiliation(s)
- Hazal Atay
- CEVIPOF, Sciences Po - 1 Place Saint Thomas d'Aquin, Paris, France; Women on Web International Foundation, Toronto, Ontario, Canada.
| | - Sunhye Kim
- Ewha Womans University, Seodaemun-gu, Seoul, Republic of Korea
| | - Jiyoung Kim
- Women on Web International Foundation, Toronto, Ontario, Canada
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Rivlin K, Brenner-Levoy J, Odum T, Muzyczka Z, Norris A, Norris Turner A, Bessett D. Provider Mistrust and Telemedicine Abortion Care Preferences Among Patients in Ohio, West Virginia, and Kentucky. Telemed J E Health 2023; 29:414-424. [PMID: 35856859 PMCID: PMC10081726 DOI: 10.1089/tmj.2022.0101] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/29/2022] [Accepted: 05/07/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: The convenience and privacy provided by telemedicine medication abortion may make this service preferable to patients who mistrust their abortion provider. We assessed associations between mistrust in the abortion provider and preferences for telemedicine abortion. Study Design: From April 2020 to April 2021, we surveyed patients seeking abortion in Ohio, West Virginia, and Kentucky. Using unconditional logistic regression models, we examined unadjusted and adjusted associations between mistrust in the abortion provider and preferences for telemedicine abortion among all participants, and among only participants undergoing medication abortion. Results: Of 1,218 patients who met inclusion criteria, 546 used medication abortion services. Just more than half (56%) of all participants and many (64%) of medication abortion participants preferred telemedicine services. Only 6% of medication abortion participants received telemedicine medication dispensing services. Only 1.4% of all participants and 1% of medication abortion participants mistrusted the abortion provider. Participants who mistrusted the abortion provider were somewhat more likely to prefer telemedicine abortion (unadjusted odds ratio [OR]: 2.5, 95% CI: 0.8-7.9; adjusted OR: 2.9, 95% CI: 0.9-9), and medication abortion participants who mistrusted the abortion provider were also somewhat more likely to prefer telemedicine abortion (unadjusted OR: 3.5, 95% CI: 0.4-28.9; adjusted OR: 5.0, 95% CI: 0.6-43), although these associations were not statistically significant. Conclusions: In three abortion-restrictive states, most patients expressed preferences for telemedicine abortion, but few accessed them. Provider mistrust was rare, but those experiencing mistrust trended toward preferring telemedicine services. Telemedicine may improve access to abortion services for patients experiencing medical mistrust.
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Affiliation(s)
- Katherine Rivlin
- Department of Obstetrics and Gynecology, The College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | | | - Tamika Odum
- Behavioral Science Department, Blue Ash College, University of Cincinnati, Cincinnati, Ohio, USA
| | - Zoe Muzyczka
- Department of Sociology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alison Norris
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Abigail Norris Turner
- Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Danielle Bessett
- Department of Sociology, University of Cincinnati, Cincinnati, Ohio, USA
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Healy A, Davidson C, Allbert J, Bauer S, Toner L, Combs CA. Society for Maternal-Fetal Medicine Special Statement: Telemedicine in obstetrics-quality and safety considerations. Am J Obstet Gynecol 2023; 228:B8-B17. [PMID: 36481188 DOI: 10.1016/j.ajog.2022.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The frequency of telemedicine encounters has increased dramatically in recent years. This review summarizes the literature regarding the safety and quality of telemedicine for pregnancy-related services, including prenatal care, postpartum care, diabetes mellitus management, medication abortion, lactation support, hypertension management, genetic counseling, ultrasound examination, contraception, and mental health services. For many of these, telemedicine has several potential or proven benefits, including expanded patient access, improved patient satisfaction, decreased disparities in care delivery, and health outcomes at least comparable to those of traditional in-person encounters. Considering these benefits, it is suggested that payers should reimburse providers at least as much for telemedicine as for in-person services. Areas for future research are considered.
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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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35
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Shochet T, Berro Pizzarossa L, Larrea S, Blum J, Jelinska K, Comendant R, Sagaidac I. Self-managed abortion via the internet: Analysis of one year of service delivery data from Women Help Women. Gates Open Res 2023; 7:41. [PMID: 37123048 PMCID: PMC10130357 DOI: 10.12688/gatesopenres.14369.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 02/15/2023] Open
Abstract
Background: To better comprehend the demand for online medication abortion and to inform service delivery practice, we conducted an analysis of Women Help Women (WHW) service delivery statistics. The primary goals were to understand their user profile, evaluate self-reported outcomes and use of other medical services, and assess the overall experience both with the abortion itself and with the counseling and care provided by WHW. Methods: We retrospectively evaluated user characteristics, abortion outcomes, and acceptability of both the medication abortion and WHW’s services, using consultation data and corresponding evaluation data from a one-year period. For users who did not complete the evaluation form, WHW staff reviewed email correspondences to identify key outcomes. Results: From August 2016-July 2017, 3,307 individuals received abortion pills from WHW. Users were geographically located in thirty countries and correspondence was conducted in seven languages. Most reported their gestational age to be less than eight weeks. Of the 2,295 who took the pills and provided outcome information, almost all (99.1%, n=2275) reported that they were no longer pregnant. The majority (84.1%, n=1576/1875) used symptoms to confirm outcome; one fourth (22.8%, n=428) sought an ultrasound and one sixth (18.0%, n=338) used urine and/or serum testing. One in eight users (12.6%, n=292/2317) reported seeking additional medical care after taking the abortion pills. Most (87.5%, n=1551/1773) reported being satisfied or very satisfied with the abortion. Conclusions: Our study confirms that self-managed abortion is a process that people can do safely and effectively with community support and without medical supervision. In the context of a global backlash against abortion rights, self-managed abortion is an integral part of a spectrum of options for abortion care that must be made available to all.
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Affiliation(s)
| | | | - Sara Larrea
- Women Help Women, Amsterdam, The Netherlands
- Independent Researcher, Amstersdam, The Netherlands
| | | | | | - Rodica Comendant
- Women Help Women, Amsterdam, The Netherlands
- Reproductive Health Training Center, Chisinau, Moldova
| | - Irina Sagaidac
- Women Help Women, Amsterdam, The Netherlands
- Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Moldova
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36
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Hogue CJ. The War on Reproductive Health Care in the United States. Ann Intern Med 2023; 176:276-277. [PMID: 36592460 DOI: 10.7326/m22-3634] [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: 01/03/2023] Open
Affiliation(s)
- Carol J Hogue
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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37
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García-Vigara A, Martín-González V, Carbonell JA, Bauset-Castelló C, Martínez-Aspas A, Monllor-Tormos A, García-Pérez MÁ, Tarín JJ, Cano A. The covid-19 pandemic and the usability of telehealth in a midlife women's health integrated care program. Maturitas 2023; 168:7-12. [PMID: 36370490 PMCID: PMC9633107 DOI: 10.1016/j.maturitas.2022.10.011] [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: 05/18/2022] [Revised: 09/05/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Telehealth has emerged as an alternative to conventional, face-to-face visits, and the COVID pandemic has hastened its introduction. Telephone appointments make use of an easy-to-use and accessible technology. AIM To investigate the usability of telephone-based telehealth in a women's health outpatient clinic and whether this may be affected by the severity of the COVID pandemic. METHOD A telephone survey was prepared to explore two usability domains: interaction quality (4 items) and satisfaction, preference and future use (6 items). Women were selected from two periods during the COVID pandemic when the infection rates were high and low. RESULTS The survey was completed by 106 women (60 when the prevalence of COVID was high, mean age 53.58 years, and 46 when it was low, mean age 48.59 years) out of the 153 women who had a telephone appointment. The severity of the COVID pandemic showed an effect on responses. Women were less enthusiastic about using the telephone during the period of low COVID prevalence, as shown by lower scores on 3 of the 4 items of the first domain [I had enough time; I would have understood better in person; I would have expressed myself better in person (p < 0.001 for comparison between groups on each of the 3 items)], and on 4 of the 6 items in the second domain [satisfied with quality of care (p < 0.001), or with the information received (p = 0.018); use of telephone in future (p < 0.001); preference to try other technologies in future (p < 0.001)]. Overall, women expressed a preference for in-person visits regardless of COVID prevalence rates. CONCLUSION Telephone calls were a feasible alternative to face-to-face visits in a women's health outpatient clinic, but the pandemic pressure modified usability parameters. Respondents preferred in-person visits at any pandemic stage.
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Affiliation(s)
- Alicia García-Vigara
- Service of Obstetrics and Gynecology, Hospital Clínico Universitario – INCLIVA, Av. Blasco Ibáñez 17, 46010, Valencia, Spain
| | - Víctor Martín-González
- Service of Obstetrics and Gynecology, Hospital Clínico Universitario – INCLIVA, Av. Blasco Ibáñez 17, 46010, Valencia, Spain
| | - Juan-Antonio Carbonell
- Bioinformatics and Biostatistics Unit, Biomedical Research Institute (INCLIVA). Valencia, Spain
| | - Celia Bauset-Castelló
- Service of Obstetrics and Gynecology, Hospital Clínico Universitario – INCLIVA, Av. Blasco Ibáñez 17, 46010, Valencia, Spain
| | - Ana Martínez-Aspas
- Service of Obstetrics and Gynecology, Hospital Clínico Universitario – INCLIVA, Av. Blasco Ibáñez 17, 46010, Valencia, Spain
| | - Aitana Monllor-Tormos
- Service of Obstetrics and Gynecology, Hospital Clínico Universitario – INCLIVA, Av. Blasco Ibáñez 17, 46010, Valencia, Spain
| | - Miguel-Ángel García-Pérez
- Department of Genetics, Faculty of Biological Sciences, University of Valencia, Burjassot, and INCLIVA, Burjassot 46100, Valencia, Spain
| | - Juan J. Tarín
- Department of Cellular Biology, Functional Biology and Physical Anthropology, Faculty of Biological Sciences, University of Valencia, Burjassot, 46100, Valencia, Spain
| | - Antonio Cano
- Service of Obstetrics and Gynecology, Hospital Clínico Universitario – INCLIVA, Av. Blasco Ibáñez 17, 46010, Valencia, Spain,Department of Pediatrics, Obstetrics and Gynecology, University of Valencia and INCLIVA, Av Blasco Ibáñez 15, 46010, Valencia, Spain,Corresponding author at: Department of Pediatrics, Obstetrics and Gynecology, Facultad de Medicina, Av Blasco Ibáñez 15, 46010, Valencia, Spain
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Clure C, Sheeder J, Teal S, Cohen R. Telemedicine to improve reproductive health care for rural Coloradans: Perceptions of interest and access. J Rural Health 2023; 39:172-178. [PMID: 35829619 DOI: 10.1111/jrh.12697] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE To evaluate rural Colorado women's access to and preferences for receiving reproductive health care services. METHODS We conducted an online survey of women ages 18-45 years old. We mailed recruitment postcards to a random sample of female, registered voters in rural Colorado zip codes. Survey questions assessed experiences, beliefs, and preferences regarding reproductive health care. We performed bivariate statistics and logistic regression for predictors of interest in telemedicine. FINDINGS Respondents (n = 478) had a median age of 34 years (range 18-45). Most women identified as White (90.2%) and were insured (67.1% private; 20.5% public). Most (74.1%) noted barriers to obtaining reproductive care in their communities. Those who reported barriers cited a median of 3 barriers (range 1-8), most commonly too few community-based providers (81.4%) and long distance to care (69.5%). Among respondents, 51.0% had used telemedicine before and 52.5% were interested in using telemedicine for reproductive health services. Interest in telemedicine significantly differed by perceived difficulty accessing care, previous telemedicine use, traveling over 100 miles for medical care in the last year, and belief in the safety of abortion. Those interested in telemedicine were less likely to value having an established relationship with providers and face-to-face visits. CONCLUSIONS Most reproductive-aged, rural Colorado women endorsed barriers to obtaining reproductive health care in their communities. Over half of rural women are interested in using telemedicine for reproductive health care; however, many are not. Both optimizing telemedicine and developing additional innovative solutions are needed to improve access to reproductive care in rural communities.
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Affiliation(s)
- Cara Clure
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jeanelle Sheeder
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Stephanie Teal
- Departments of Obstetrics and Gynecology and Reproductive Biology, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Rebecca Cohen
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado, 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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Hunter J, Houchens N, Gupta A. Quality and safety in the literature: January 2023. BMJ Qual Saf 2023; 32:56-60. [PMID: 36549698 DOI: 10.1136/bmjqs-2022-015682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 12/24/2022]
Affiliation(s)
- John Hunter
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nathan Houchens
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Ashwin Gupta
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Bosó Pérez R, Reid D, Maxwell KJ, Gibbs J, Dema E, Bonell C, Mercer CH, Sonnenberg P, Field N, Mitchell KR. Access to and quality of sexual and reproductive health services in Britain during the early stages of the COVID-19 pandemic: a qualitative interview study of patient experiences. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:12-20. [PMID: 35444001 PMCID: PMC9062459 DOI: 10.1136/bmjsrh-2021-201413] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/05/2022] [Indexed: 05/17/2023]
Abstract
INTRODUCTION Access to quality sexual and reproductive health (SRH) services remains imperative even during a pandemic. Our objective was to understand experiences of delayed or unsuccessful access to SRH services in Britain during the early stages of the COVID-19 pandemic. METHODS In October and November 2020 we conducted semi-structured telephone interviews with 14 women and six men reporting an unmet need for SRH services in the Natsal-COVID survey, a large-scale quasi-representative web-panel survey of sexual health and behaviour during COVID-19 (n=6654). We purposively sampled eligible participants using sociodemographic quotas. Inductive thematic analysis was used to explore service access and quality and to identify lessons for future SRH service delivery. RESULTS Twenty participants discussed experiences spanning 10 SRH services including contraception and antenatal/maternity care. Participants reported hesitancy and self-censorship of need. Accessing telemedicine and 'socially-distanced' services required tenacity. Challenges included navigating changing information and procedures; perceptions of gatekeepers as obstructing access; and inflexible appointment systems. Concerns about reconfigured services included reduced privacy; decreased quality of interactions with professionals; reduced informal support; and fewer preventive SRH practices. However, some participants also described more streamlined services and staff efforts to compensate for disruptions. Many viewed positively the ongoing blending of telemedicine with in-person care. CONCLUSION The COVID-19 pandemic impacted access and quality of SRH services. Participants' accounts revealed self-censorship of need, difficulty navigating shifting service configurations and perceived quality reductions. Telemedicine offers potential if intelligently combined with in-person care. We offer initial evidence-based recommendations for promoting an equitable restoration and future adaption of services.
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Affiliation(s)
- Raquel Bosó Pérez
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - David Reid
- The National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections in partnership with Public Health England, University College London, London, UK
| | - Karen J Maxwell
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Jo Gibbs
- Institute for Global Health, University College London, London, UK
| | - Emily Dema
- Institute for Global Health, University College London, London, UK
| | - Christopher Bonell
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Pam Sonnenberg
- Institute for Global Health, University College London, London, UK
| | - Nigel Field
- Institute for Global Health, University College London, London, UK
| | - Kirstin R Mitchell
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
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Improvidence, Precaution, and the Logical-Empirical Disconnect in UK Health Policy. HEALTH CARE ANALYSIS 2022; 31:114-133. [PMID: 36571710 PMCID: PMC9791148 DOI: 10.1007/s10728-022-00450-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 12/27/2022]
Abstract
The last decade has seen significant developments in UK health policy, with are largely claimed to be evidence based. However, such a characterisation ought, in many cases, to be questioned. Policies can be broadly understood as based primarily on either a logical or empirical case. In the absence of relevant empirical evidence, policymakers understandably appeal to logical cases. Once such evidence is available, however, it can inform policy and enable the logical case to be set aside. Such a linear policy process is not always the reality, and logical cases often continue to guide policy decisions in direct opposition to empirical evidence. In this paper, I discuss two recent examples of this disconnect between logical and empirical cases in UK health policy. The first-organ donation-illustrates an example of a significant policy change being made in opposition to the evidence. I refer to this as the improvidence approach. The second-abortion-provides an example of policymakers not making a change that has extensive supporting data. I refer to this using the more recognisable language of the precautionary approach. Ultimately, I argue that both the improvidence and precautionary approaches are examples of problematic public policy where policymakers provide no explicit justification for going against the evidence.
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Larrea-Schiavon S, Vázquez-Quesada LM, Bartlett LR, Lam-Cervantes N, Sripad P, Vieitez I, Coutiño-Escamilla L. Interventions to Improve the Reproductive Health of Undocumented Female Migrants and Refugees in Protracted Situations: A Systematic Review. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2100418. [PMID: 36562449 PMCID: PMC9771456 DOI: 10.9745/ghsp-d-21-00418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 11/08/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Limited evidence exists on interventions aimed at enabling reproductive health (RH) services access for undocumented female migrants and refugee women. We aimed to identify intervention characteristics and impacts on RH outcomes among migrants and refugee women in protracted situations. METHODS We conducted a systematic literature review of RH intervention studies that reported on migrants and refugee women in protracted situations. We applied 2 search strategies across 6 databases to identify peer-reviewed articles in English, Spanish, and Portuguese. Eligible studies were assessed for content and quality. RESULTS Of the 21,453 screened studies, we included 10 (all observational) for final data extraction. Interventions implemented among migrant and refugee women included financial support (n=2), health service delivery structure strengthening (n=4), and educational interventions (n=4). Financial support intervention studies showed that enabling women to obtain RH services for free or at a low cost promoted utilization (e.g., increased use of contraception). Interventions that established or strengthened health service delivery structures and linkage demonstrated increased prenatal visits, decreased maternal mortality, and facilitated access to safe abortion through referral services or access to medical abortion. Educational interventions indicated positive effects on RH knowledge and the importance of involving peers and meeting the unique needs of a mobile population. All intervention studies emphasized the need to accommodate migrant security concerns and cultural and linguistic needs. CONCLUSION Interventions in protracted situations reported positive outcomes when they were migrant or refugee-centered and complementary, culturally acceptable, geographically proximate, and cost-sensitive, as well as recognized the concerns around legality and involved opportunities for peer learning. Free or low-cost RH services and greater availability of basic and emergency maternal and neonatal care showed the most promise but required further community outreach, education, and stronger referral mechanisms. We recommend further participatory implementation research linked to policy and programming.
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Jacobs MG, Boing AC. Travel as a barrier to abortion provided by law access. Brazil, 2010-2019. REVISTA BRASILEIRA DE SAÚDE MATERNO INFANTIL 2022. [DOI: 10.1590/1806-9304202200040007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Abstract Objectives: to analyze abortions provided by law (APL) carried out in Brazil between 2010 and 2019 regarding the need for travel of users, as well as the expenditure of time and money on these trips. Methods: descriptive study of records of outpatient care and hospitalizations for APL between 2010 and 2019. The municipal provision and the inter-municipal flows for the realization of the APL, the availability of public transportation for this travel, as well as its cost and time, were identified. Results: 2.6% of Brazilian municipalities had a sustained provision of APL between 2010 and 2019. Of the 15,889 APL performed, 14.8% occurred in municipalities other than those where the user lived. The smaller the population size of the municipality of residence, the higher the percentage of the need for travel. Of these inter-municipal trips, 16.0% had regular round-trip links by public transport. The total travel time ranged from 26 minutes to 4 and a half days, and the cost from R$2.70 to R$1,218.06; the highest medians were among residents of the Midwest region. Conclusions: the concentration of services, the deficiency of inter-municipal public transport, and the expenditure on travel to access the APL are barriers to users that need the health service, demanding public policies to overcome them.
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Kerestes C, Delafield R, Elia J, Shochet T, Kaneshiro B, Soon R. Person-centered, high-quality care from a distance: A qualitative study of patient experiences of TelAbortion, a model for direct-to-patient medication abortion by mail in the United States. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2022; 54:177-187. [PMID: 36229416 DOI: 10.1363/psrh.12210] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
CONTEXT Direct-to-patient telemedicine abortion allows people to receive mifepristone and misoprostol for medication abortion in their home without requiring an in-person visit with a healthcare provider. This method has high efficacy and safety, but less is known about the person-centered quality of care provided with telemedicine. METHODS We interviewed 45 participants from the TelAbortion study of direct-to-patient telemedicine abortion in the United States from January to July 2020. Semi-structured qualitative interviews queried their choices, barriers to care, expectations for care, actual abortion experience, and suggestions for improvement. We developed a codebook through an iterative, inductive process and performed content and thematic analyses. RESULTS The experience of direct-to-patient telemedicine abortion met the person-centered domains of dignity, autonomy, privacy, communication, social support, supportive care, trust, and environment. Four themes relate to the person-centered framework for reproductive health equity: (1) Participants felt well-supported and safe with TelAbortion; (2) Participants had autonomy in their care which led to feelings of empowerment; (3) TelAbortion exceeded expectations; and (4) Challenges arose when interfacing with the healthcare system outside of TelAbortion. Participants perceived abortion stigma which often led them to avoid traditional care and experienced enacted stigma during encounters with non-study healthcare workers. CONCLUSION TelAbortion is a high quality, person-centered care model that can empower patients seeking care in an increasingly challenging abortion context.
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Affiliation(s)
- Courtney Kerestes
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawai'i, USA
| | - Rebecca Delafield
- Department of Native Hawaiian Health, University of Hawai'i at Mānoa, Honolulu, Hawai'i, USA
| | - Jennifer Elia
- Maternal and Infant Health, Early Childhood Action Strategy, Honolulu, Hawai'i, USA
| | - Tara Shochet
- Gynuity Health Projects, New York, New York, USA
| | - Bliss Kaneshiro
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawai'i, USA
| | - Reni Soon
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawai'i, USA
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Ni H, Lou W, Fang Y. Epidemiological characteristics of induced abortion and clinical value of PAC in Keqiao District of Shaoxing City, China. Panminerva Med 2022; 64:585-586. [PMID: 32875780 DOI: 10.23736/s0031-0808.20.04070-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Huijuan Ni
- Department of Gynecology, Shaoxing Central Hospital, Shaoxing, China -
| | - Wuying Lou
- Department of Gynecology, Shaoxing Central Hospital, Shaoxing, China
| | - Yaqin Fang
- Department of Gynecology, Shaoxing Central Hospital, Shaoxing, China
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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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Brandell K, Reynolds-Wright JJ, Boerma C, Gibson G, Hognert H, Tuladhar H, Heikinheimo O, Cameron S, Gemzell-Danielsson K. Medical Abortion before Confirmed Intrauterine Pregnancy: A Systematic Review. Semin Reprod Med 2022; 40:258-263. [PMID: 36626915 DOI: 10.1055/s-0042-1760117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
"Very early medical abortion" (VEMA) refers to medical abortion (with mifepristone and misoprostol) before intrauterine pregnancy is visualized on ultrasound. Our aim is to present the current evidence on efficacy, safety (focused on ectopic pregnancies), and how to assess treatment success of VEMA. We conducted a systematic review of studies reporting outcomes of VEMA. The field is small and so our objective was to map all relevant literature, without conducting meta-analysis. We searched PubMed, Medline, and Embase on April 19, 2022. We conducted a narrative synthesis of the evidence. A total of 373 articles were identified. Six articles (representing four observational and one pilot trial) were included in the final review. Across all included studies, treatment efficacy ranged between 91 and 100%. Prevalence of ectopic pregnancy was low and very few cases (n = 2) of ruptures were reported. Most studies used serial serum human chorionic gonadotrophin (s-hCG) levels to determine success of abortion; one study used low sensitivity urine hCG. From the available evidence, VEMA appears to be efficacious and does not appear to cause harm to ectopic pregnancies. Treatment can be assessed with pre- and postabortion s-hCG. Good quality, randomized controlled trial evidence is needed to best inform practice.
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Affiliation(s)
- Karin Brandell
- Department of Women's and Children's Health, Karolinska Institutet, Solna, Sweden.,Södertalje Hospital, Södertalje, Sweden
| | | | | | - Gillian Gibson
- Womens Health, Auckland City Hospital, Auckland, New Zealand
| | - Helena Hognert
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Institution of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
| | | | - Oskari Heikinheimo
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Sharon Cameron
- NHS Lothian and University of Edinburgh, Edinburgh, United Kingdom
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institutet, Solna, Sweden.,Karolinska University Hospital, Stockholm, Sweden
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Brandell K, Vanbenschoten H, Parachini M, Gomperts R, Gemzell-Danielsson K. Telemedicine as an alternative way to access abortion in Italy and characteristics of requests during the COVID-19 pandemic. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:252-258. [PMID: 34697044 PMCID: PMC8550869 DOI: 10.1136/bmjsrh-2021-201281] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/06/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Induced abortion is legal in Italy but with restrictions. The online abortion provider Women on Web (WoW) serves as an alternative way to access abortion. The COVID-19 pandemic has affected sexual and reproductive health worldwide. Italy was one of the first countries hit by the pandemic and imposed strict lockdown measures. We aimed to understand why women requested WoW abortion in Italy and how this was affected by the pandemic. METHODS We conducted an observational study analysing requests made to WoW before and during the pandemic. We analysed 778 requests for medical abortion from Italy between 1 March 2019 to 30 November 2020 and compared the characteristics of requests submitted before and during the pandemic. We also performed subgroup analysis on teenagers and COVID-19-specific requests. RESULTS There was an increase in requests during the COVID-19 pandemic compared with the previous year (12% in the first 9 months). The most common reasons for requesting a telemedicine abortion through WoW were privacy-related (40.9%); however, this shifted to COVID-19-specific (50.3%) reasons during the pandemic. Requests from teenagers (n=61) were more frequently made at later gestational stages (p=0.003), had a higher prevalence of rape (p=0.003) as the cause of unwanted pregnancies, and exhibited less access to healthcare services compared with adult women. CONCLUSIONS There was an increase in total demand for self-managed abortion during the pandemic and reasons for requesting an abortion changed, shifting from privacy-related to COVID-19-specific reasons. This study also highlighted the uniquely vulnerable situation of teenagers with unwanted pregnancies seeking self-managed abortion.
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Affiliation(s)
- Karin Brandell
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Sodertalje Hospital, Sodertalje, Sweden
| | - Hannah Vanbenschoten
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Bioengineering, University of Washington, Seattle, Washington, USA
| | - Mirella Parachini
- AMICA (Associazione Medici Italiani Contraccezione e Aborto), Rome, Italy
- International Federation of Abortion and Contraception Professionals, Vienna, Austria
| | | | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Gynecology and Reproductive Medicine, Karolinska Universitetssjukhuset, Stockholm, Sweden
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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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