Primary care providers' knowledge, attitudes and practices of medical abortion: a systematic review

What do Australian primary care clinicians need to provide long-acting reversible contraception and early medical abortion? A content analysis of a virtual community of practice

BACKGROUND

Uptake of long-acting reversible contraception (LARC) is lower in Australia compared with other high-income countries, and access to early medical abortion (EMA) is variable with only 11% of general practitioners (GPs) providing EMA. The AusCAPPS (Australian Contraception and Abortion Primary Care Practitioner Support) Network is a virtual community of practice established to support GPs, nurses and pharmacists to provide LARC and EMA in primary care. Evaluating participant engagement with AusCAPPS presents an opportunity to understand clinician needs in relation to LARC and EMA care.

METHODS

Data were collected from July 2021 until July 2023. Numbers of online resource views on AusCAPPS were analysed descriptively and text from participant posts underwent qualitative content analysis.

RESULTS

In mid-2023 AusCAPPS had 1911 members: 1133 (59%) GPs, 439 (23%) pharmacists and 272 (14%) nurses. Concise point-of-care documents were the most frequently viewed resource type. Of the 655 posts, most were created by GPs (532, 81.2%), followed by nurses (88, 13.4%) then pharmacists (16, 2.4%). GPs most commonly posted about clinical issues (263, 49% of GP posts). Nurses posted most frequently about service implementation (24, 27% of nurse posts). Pharmacists posted most about health system and regulatory issues (7, 44% of pharmacist posts).

CONCLUSIONS

GPs, nurses and pharmacists each have professional needs for peer support and resources to initiate or continue LARC and EMA care, with GPs in particular seeking further clinical education and upskilling. Development of resources, training and implementation support may improve LARC and EMA provision in Australian primary care.

Knowledge, attitude, and intended practice of abortion among pharmacy students in Thailand after the amendment of the Thai Abortion Law

BACKGROUND

The recently amended Thai abortion law allows pregnant women to undergo abortions up to the gestational age of 12 weeks. Medical abortion is significant because it has revolutionized access to safe abortion care-abortion medicine can now be safely and effectively administered outside of a healthcare facility to women in early pregnancy. This contribution supports the pharmacists' role in interprofessional safe abortion teamwork. Adequate knowledge of the current laws regarding safe abortion services will increase pharmacists' competence in providing services. However, safe abortions as a subject have not been formally incorporated into the curriculum for Thai pharmacy students. Therefore, this study aimed to evaluate the knowledge, attitude, and intended practice of fifth-year pharmacy students at Chulalongkorn University.

METHODS

A cross-sectional study was conducted using an electronic self-administered questionnaire adapted from previously published studies to evaluate participants' knowledge of the recently amended Thai abortion law, attitude toward abortion, and intended practices. The invitations were sent to all fifth-year pharmacy students at Chulalongkorn University.

RESULTS

Among all invitations sent, 104/150 (69.3%) participants responded to the survey. Only a third of the participants (31.7%) had good knowledge scores. Based on five questions regarding the gestational age limit for legal abortion, most participants (52.7%) answered questions incorrectly. Although more than half of the participants (52.5%) disagreed with two pro-choice statements, an overwhelming majority (87.5%) agreed that abortion was a woman's right. Safe abortion services were mostly agreed upon with serious fetal defects (91.9%), non-HIV maternal health conditions (82.2%), and sexual assaults (77.4%). A positive attitude toward abortion affects the intention to perform an abortion under socioeconomic conditions.

CONCLUSION

Most participants lacked knowledge on the amended abortion law, especially on the gestational limits of abortion. Participants with favorable attitudes toward abortion tended to be more liberal regarding safe abortion services.

Utilising HealthPathways to understand the availability of public abortion in Australia

BACKGROUND

Access to publiclyfunded abortion in Australia is limited, with a considerable proportion carried out by private providers. There are no nationally reported data on public abortion services, and referral pathways are poorly coordinated between hospital and primary care sectors. HealthPathways is an online system for use in primary care that provides information on referral pathways to local services. The aim of this study was to describe abortion referral pathways for each HealthPathways portal in Australia.

METHODS

A review of Australian HealthPathways content on abortion was undertaken between January and June 2022. For each HealthPathways portal, data were extracted on referral options to abortion services.

RESULTS

Overall, 17 out of 34 Australian HealthPathways consented to be included. Nearly half (47%) had no public services listed for surgical abortion, and 35% had no public services for medical abortion. The majority (64% for surgical abortion, 67% for medical abortion) emphasised that public services should be considered only as a last resort. There was variation in information regarding gestation-specific options, the time-critical nature of referrals, and the importance of women's own preference when deciding between medical or surgical abortion.

CONCLUSION

Despite few remaining legal restrictions to abortion, many regions across Australia either do not have public abortion services or do not provide information about them. There is an urgent need for transparency around public abortion service availability, clear guidelines to support referral pathways, and commitment from State and Federal governments to expand the availability of accessible, no-cost abortion in Australia.

Improving rural and regional access to long-acting reversible contraception and medical abortion through nurse-led models of care, task-sharing and telehealth (ORIENT): a protocol for a stepped-wedge pragmatic cluster-randomised controlled trial in Australian general practice

INTRODUCTION

Women living in rural and regional Australia often experience difficulties in accessing long-acting reversible contraception (LARC) and medical abortion services. Nurse-led models of care can improve access to these services but have not been evaluated in Australian general practice. The primary aim of the ORIENT trial (ImprOving Rural and regIonal accEss to long acting reversible contraceptioN and medical abortion through nurse-led models of care, Tasksharing and telehealth) is to assess the effectiveness of a nurse-led model of care in general practice at increasing uptake of LARC and improving access to medical abortion in rural and regional areas.

METHODS AND ANALYSIS

ORIENT is a stepped-wedge pragmatic cluster-randomised controlled trial. We will enrol 32 general practices (clusters) in rural or regional Australia, that have at least two general practitioners, one practice nurse and one practice manager. The nurse-led model of care (the intervention) will be codesigned with key women's health stakeholders. Clusters will be randomised to implement the model sequentially, with the comparator being usual care. Clusters will receive implementation support through clinical upskilling, educational outreach and engagement in an online community of practice. The primary outcome is the change in the rate of LARC prescribing comparing control and intervention phases; secondary outcomes include change in the rate of medical abortion prescribing and provision of related telehealth services. A within-trial economic analysis will determine the relative costs and benefits of the model on the prescribing rates of LARC and medical abortion compared with usual care. A realist evaluation will provide contextual information regarding model implementation informing considerations for scale-up. Supporting nurses to work to their full scope of practice has the potential to increase LARC and medical abortion access in rural and regional Australia.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Monash University Human Research Ethics Committee (Project ID: 29476). Findings will be disseminated via multiple avenues including a knowledge exchange workshop, policy briefs, conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622000086763).

Co-design of a nurse-led model of care to increase access to medical abortion and contraception in rural and regional general practice: A protocol

PROBLEM

Women in rural and regional Australia experience a number of barriers to accessing sexual and reproductive health care including lack of local services, high costs and misinformation.

SETTING

Nurse-led task-sharing models of care for provision of long-acting reversible contraception (LARC) and early medical abortion (EMA) are one strategy to reduce barriers and improve access to services but have yet to be developed in general practice.

KEY MEASURES FOR IMPROVEMENT

Through a co-design process, we will develop a nurse-led model of care for LARC and EMA provision that can be delivered through face-to-face consultations or via telehealth in rural general practice in Australia.

STRATEGIES FOR CHANGE

A co-design workshop, involving consumers, health professionals (particularly General Practitioners (GPs) and Practice Nurses (PNs)), GP managers and key stakeholders will be conducted to design nurse-led models of care for LARC and EMA including implant insertion by nurses. The workshop will be informed by the 'Experience-Based Co-Design' toolkit and involves participants mapping the patient journey for service provision to inform a new model of care.

EFFECTS OF CHANGE

Recommendations from the workshop will inform a nurse-led model of care for LARC and EMA provision in rural general practice. The model will provide practical guidance for the set-up and delivery of services.

LESSONS LEARNT

Nurses will work to their full scope of practice to increase accessibility of EMA and LARC in rural Australia.

Dutch GPs' views on prescribing mifepristone and misoprostol: a mixed-methods study

BACKGROUND

The World Health Organization has indicated that GPs can safely and effectively provide mifepristone and misoprostol for medical termination of pregnancy (TOP). Dutch GPs are allowed to treat miscarriages with mifepristone and misoprostol, but few do so. Current Dutch abortion law prohibits GPs from prescribing these medications for medical TOP. Medical TOP is limited to the specialised settings of abortion clinics and hospitals. Recently, the House of Representatives debated shifting abortion to the domain of primary care, following the example of France and the Republic of Ireland. This would improve access to sexual and reproductive health care, and increase choices for women. Nevertheless, little is known about GPs' willingness to provide medical TOP and miscarriage management.

AIM

To gain insight into Dutch GPs' willingness to prescribe mifepristone and misoprostol for medical TOP and miscarriages, as well as the anticipated barriers.

DESIGN AND SETTING

Mixed-methods study among Dutch GPs.

METHOD

A questionnaire provided quantitative data that were analysed using descriptive methods. Thematic analyses were performed on qualitative data collected through in-depth interviews.

RESULTS

The questionnaire was sent to 575 GPs; the response rate was 22.1% (n = 127). Of the responders, 84.3% (n = 107) were willing to prescribe mifepristone and misoprostol, with 58.3% (n = 74) willing to provide this medication for both medical TOP and miscarriage management. A total of 57.5% (n = 73) of participants indicated a need for training. The main barriers influencing participants' willingness to provide medical TOP and miscarriage management were lack of experience, lack of knowledge, time constraints, and a restrictive abortion law.

CONCLUSION

Over 80.0% of responders were willing to prescribe mifepristone and misoprostol for medical TOP or miscarriages. Training, (online) education, and a revision of the abortion law are recommended.

Early medical abortion services provided in Australian primary care

OBJECTIVES

To examine primary care provision of early medical abortion services in Australia.

DESIGN

Cross-sectional study; analysis of Pharmaceutical Benefits Scheme (PBS) dispensing data.

SETTING, PARTICIPANTS

Women of child-bearing age (15-54 years), Australia, 2015-2019.

MAIN OUTCOME MEASURES

Age-standardised rates of MS-2 Step prescriptions dispensed by year for 2015-2019, and age-standardised rates by state, remoteness area, and level 3 statistical areas (SA3s) for 2019. Numbers and proportions of SA3s in which MS-2 Step was not prescribed by a GP or dispensed by a community pharmacy during 2019 (unweighted and weighted by number of women of reproductive age), by state and remoteness area.

RESULTS

During 2015-2019, 91 643 PBS prescriptions for MS-2 Step were dispensed; the national age-standardised rate increased from 1.63 in 2015 to 3.79 prescriptions per 1000 women aged 15-54 years in 2019. In 2019, rates were higher in outer regional Australia (6.53 prescriptions per 1000 women aged 15-54 years) and remote Australia (6.02 per 1000) than in major cities (3.30 per 1000). However, about 30% of women in Australia lived in SA3s in which MS-2 Step had not been prescribed by a GP during 2019, including about 50% of those in remote Australia.

CONCLUSIONS

The rate of early medical abortion is greater among women in remote, outer regional, and inner regional Australia than in major cities, but a considerable proportion of women live in areas in which MS-2 Step was not locally prescribed or dispensed during 2019. Supporting GPs in the delivery of early medical abortion services locally should be a focus of health policy.

Pharmacists' knowledge, perspectives, and experiences with mifepristone dispensing for medication abortion

BACKGROUND

The U.S. Food and Drug Administration (FDA) restricts dispensing of mifepristone for medication abortion to certified health care providers at clinical facilities, thus prohibiting pharmacist dispensing. Allowing mifepristone dispensing by pharmacists could improve access to medication abortion.

OBJECTIVE

To assess the feasibility of pharmacists dispensing mifepristone to patients who have undergone evaluation for eligibility and counseling for medication abortion by a clinician.

METHODS

Before providing a study training on medication abortion, we administered baseline surveys to pharmacists who participated in a multisite mifepristone-dispensing intervention. The survey assessed medication abortion knowledge-using a 15-item score-and perceptions about the benefits and challenges of the model. We administered follow-up surveys in the study's final month that also assessed the pharmacists' satisfaction and experiences with mifepristone dispensing. To investigate the association of the study intervention with the pharmacists' knowledge, perceptions, and experiences dispensing mifepristone, we conducted multivariable linear regression analyses using generalized estimating equation models, accounting for clustering by individual.

RESULTS

Among the 72 pharmacists invited from 6 pharmacies, 47 (65%) completed the baseline surveys, and 56 (78%) received training. At the study's end (mean 18 months later), 43 of the 56 pharmacists who received training (77%) completed the follow-up surveys. At follow-up, 36 (83%) respondents were very or somewhat satisfied with mifepristone dispensing, and 24 (56%) reported experiencing no challenges dispensing mifepristone. Four (6%) of the 72 pharmacists invited objected to participating in mifepristone dispensing. In regression analyses, average knowledge scores, perceived ease of implementation, and level of support for the pharmacist-dispensing model were higher at follow-up (P < 0.001).

CONCLUSION

Most pharmacists were willing to be trained, dispensed mifepristone with few challenges when given the opportunity, were satisfied with the model, and had higher knowledge levels at follow-up. Our findings support removal of FDA's restriction on pharmacist dispensing of mifepristone.

Termination of pregnancy in Tasmania: access and service provision from the perspective of GPs

Termination of pregnancy (TOP) is considered an important component of sexual and reproductive health internationally, but there are known barriers in Australia and countries worldwide. This study investigated the issues for GPs regarding aiding access to TOP and providing early medical abortion (EMA) services for Tasmanian women. Specifically, the aims of the study were to identify the knowledge and attitudes of Tasmanian GPs regarding TOP services and to determine which known barriers to providing EMA are most significant for GPs in Tasmania, Australia. A survey was developed and piloted based on previous qualitative research that identified known barriers to accessing TOP. Surveys were posted to all identified GPs in Tasmania with a reply-paid envelope. In all, 211 (27.4%) responses were returned. GPs identified difficulty accessing TOP services, particularly for rural women and those on a low income. Almost half the GPs, excluding conscientious objectors, indicated they would be interested in providing EMA services, but perceived barriers were significant. The most significant barriers related to accessing appropriate training and support. There was uncertainty around financial reward, support services, medical indemnity and access to the medical abortifacient medications mifepristone and misoprostol. In conclusion, accessing TOP remains an issue for Tasmanian women. Many Tasmanian GPs are interested in providing EMA services if barriers are addressed, but there is a lack of knowledge about the practicalities of implementing EMA. Providing practical support to GPs and increasing knowledge pertaining to EMA provision in general practice could improve access in primary care.

Attitudes and Opinions of Young Gynecologists on Pregnancy Termination: Results of a Cross-Sectional Survey in Poland

Background: This paper aims to explore the attitudes and opinions of a group of Polish young gynecologists toward pregnancy termination. Method: An anonymous questionnaire was completed by physicians who participated in obligatory trainee courses held in 2019 in Warsaw. Results: The study group included 71 physicians with an average age of 29 years (SD 3.05). A considerable number of the physicians accepted terminations for medical reasons up to the end of pregnancy, especially in cases of lethal defects (46%) and a serious disease in the mother (34%). Only 6% of the group of gynecologists not performing terminations claimed that the procedure was contrary to their conscience, and 62% of them stated that such procedures were not performed at their hospital. Terminations would be performed by 90% of the respondents in cases of lethal defects of the fetus and by 80% if severe irreversible fetal defects were diagnosed. Conclusions: The main problem associated with the inaccessibility of pregnancy termination in Poland is not linked to individuals, meaning medical personnel and the possibility of invoking the conscience clause, but probably to the lack of approval for terminations granted by hospital supervisors. Adequate knowledge on pregnancy termination procedures, fetal defects, and diseases in the mother translated into the changes of opinions on pregnancy terminations.