Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care After Surgical Abortion (the FACTS Study Phase 3): Mixed Methods Prospective Pilot Study

BACKGROUND

In Canada, 1 in 3 women and people of gestational age undergo an abortion in their lifetime. Despite the liberal legal context, barriers continue to exist for women and people who can become pregnant to access this service.

OBJECTIVE

This study aims to (1) conduct a pilot study to demonstrate the feasibility and acceptability of myPostCare to support follow-up care after a procedural abortion; (2) use the findings to understand whether myPostCare has the potential to improve contraceptive behavior and knowledge, emotional well-being, and sexual health knowledge; and (3) develop a better understanding of how innovative mobile solutions can support integrative health programs in British Columbia with the goal of expanding to other sites across Canada.

METHODS

People of gestational age (aged 14-45 y) who underwent a procedural abortion were recruited from 2 urban abortion facilities in British Columbia. The participants completed a baseline quantitative survey and were provided access to myPostCare for up to 30 days. A follow-up quantitative survey was sent via email on day 30. Qualitative interviews were conducted to explore user satisfaction and usability of myPostCare. Responses to the survey questions were summarized using descriptive statistics, and the system usability scale (SUS) was scored according to the instructions. A secure analytics platform was implemented to obtain data on the overall use of the website by users. Qualitative analysis was conducted with NVivo using a thematic analysis approach. This study was approved by the Women's and Children's Research Ethics Board.

RESULTS

Overall, 62 participants were recruited (average age 30 y); 40% (25/62) of the participants completed the exit surveys, and 24% (6/25) consented to participate in the semistructured interviews; 40 participants had undergone an immediate postabortion intrauterine device (IUD) insertion, and 22 did not have an IUD inserted. Participants were satisfied with myPostCare. The SUS average score was 81.5 (SD 9.7; median 82.5, IQR 77.5-87.5), indicating high usability of the tool. Overall, 88% (22/25) of the participants changed their contraceptive method to an IUD. Web-based analytics demonstrated that there were 61 unique visitors to the site, and the top pages visited were Postprocedure Care, Emotional Well-Being, and Contraception Explorer. The longest time spent on the website was 56 minutes. The overall email open rate was 80%, with a click rate of 36%.

CONCLUSIONS

This study demonstrates that communities and individuals are important collaborators in developing a mobile innovation that facilitates access to high-quality patient-centered abortion care. Through the cocreation process, a digital platform such as myPostCare highlighted a gap in abortion care in Canada, particularly around follow-up support after a procedural abortion.

"I would love for there not to be so many hoops … ": recommendations to improve abortion service access and experiences made by Indigenous women and 2SLGTBQIA+ people in Canada

Acknowledging the barriers in accessing sexual and reproductive health services that disproportionately impact Indigenous women and 2SLGTBQIA+ people, coupled with the lack of knowledge surrounding Indigenous peoples' experiences with abortion, we present qualitative findings from a pilot study investigating Indigenous experiences of accessing abortion services in Canada. We focus on findings related to participant recommendations for improving safety and accessibility of abortion services made by and for Indigenous people in Canada. Informed by an Indigenous Advisory Committee consisting of front-line service providers working in the area of abortion service access and/ or support across Canada, the research team applied an Indigenous methodology to engage with 15 Indigenous people across Canada utilising a conversational interview method, between September and November 2021. With representation from nine provinces and territories across Canada, participants identified with Anishinaabe, Cree, Dene, Haudenosaunee, Inuit, Métis and/ or Mi'kmaq Nations. Five cross-cutting recommendations emerged, including: (1) location, comfort, and having autonomy to choose where the abortion takes place; (2) holistic post-abortion supports; (3) accessibility, availability, and awareness of non-biased and non-judgemental information; (4) companionship, advocacy, and logistical help before and during the abortion from a support person; and (5) cultural safety and the incorporation of local practices and knowledges. Recommendations demonstrate that Indigenous people who have experienced an abortion carry practical solutions for removing barriers and improving access to abortion services in the Canadian context.

"I just was really scared, because it's already such an uncertain time": Exploring women's abortion experiences during the COVID-19 pandemic in Canada

OBJECTIVE

Travel restrictions, physical distancing and quarantine requirements, lockdowns, and stay-at-home orders due to COVID-19 have impacted abortion services across Canada. We aimed to explore the decision-making and care experiences of those who obtained abortion services during the COVID-19 pandemic and understand recent abortion patients' perspectives on demedicalized models of medication abortion service delivery.

STUDY DESIGN

We conducted 23 semi-structured, in-depth interviews with women across Canada who obtained abortion care after March 15, 2020. We audio-recorded and transcribed the telephone/Skype/Zoom interviews and managed our data with ATLAS.ti. We analyzed the English-language interviews for content and themes using inductive and deductive techniques.

RESULTS

The COVID-19 pandemic, and the associated economic and social support uncertainties, factored into many of our participants' decisions to obtain an abortion. Participants expressed relief and gratitude for being able to secure abortion care during the pandemic. Although women in our study reflected positively on their abortion care experiences, many felt that service delivery changes initiated because of the public health emergency exacerbated pre-COVID-19 barriers to care and contributed to feelings of loneliness and isolation. Our participants expressed considerable enthusiasm for demedicalized models of medication abortion care, including telemedicine services and behind-the-counter availability of mifepristone/misoprostol.

CONCLUSIONS

For our participants, abortion care constituted an essential health service. Our findings demonstrate the importance of continuing to provide access to safe, effective, and timely abortion care during public health emergencies. Exploring additional models of demedicalized medication abortion service delivery to address persistent access barriers in Canada is warranted.

IMPLICATIONS

Policymakers and clinicians should consider patient experiences as well as clinical evidence when considering regulatory changes to facilitate access to abortion care during public health emergencies. Identifying a multitude of ways to offer a full range of abortion services, including demedicalized models of medication abortion care, has the potential to meet significant needs in the COVID-19 era and beyond. The COVID pandemic highlights the need for demedicalized models, not only for the sake of those seeking abortion care but also to ease the burden on medical professionals during public health emergencies.

Postabortion Medicaid Enrollment and the Affordable Care Act Medicaid Expansion in Oregon

Background: The Affordable Care Act Medicaid expansion had the potential to increase continuity of insurance coverage and remove barriers to accessing health services following an abortion in states where Medicaid pays for abortion. We examined the association of Medicaid expansion with postabortion Medicaid enrollment and described postabortion preventive reproductive services among Medicaid-enrolled women in Oregon. Methods: We used Medicaid claims and enrollment data to identify abortions to women ages 20-44 in 2009-2017 (N = 30,786), classified into a treatment group-those likely to be affected by Medicaid expansion-and a comparison group. Outcomes included Medicaid enrollment (number of months enrolled and any lapse in enrollment) in the 6 and 12 months postabortion. Difference-in-differences analyses were used to compare outcomes preexpansion (2009-2012) and postexpansion (2014-2017) for treatment and comparison groups. Linear regression models were adjusted for age, race/ethnicity, rurality, and month. We described receipt of preventive reproductive services in 0-2 months and in 3-12 months postabortion. Results: Medicaid expansion was associated with enrollment increases of 2.0 and 4.7 months and with declines in any enrollment lapse of 54 and 48 percentage-points over 6 and 12 months postabortion, respectively (p < 0.001). Many who remained enrolled through postabortion received preventive care including contraceptive services (41%) and screening for sexually transmitted infections (23%). Conclusions: Medicaid expansion may increase continuity of insurance coverage for those receiving abortions, and in turn promote access to preventive services that can improve subsequent reproductive health outcomes.

"I didn't doubt my choice, but I felt bad": A qualitative exploration of Canadian abortion patients' experiences with protesters

OBJECTIVES

Although a body of research has focused on violence, disruption, and harassment targeting abortion clinics and clinic staff, little research has explored Canadian abortion patients' experiences with protesters. Through this national qualitative study we aimed to address this gap.

METHODS

Between 2012 and 2016, we conducted in-depth interviews with 305 Canadian women who had an abortion in the previous five years. Thirty participants reported encountering protesters when seeking abortion care. We focused on this sub-set of interviews and analyzed these data for content and themes using inductive and deductive techniques.

RESULTS

Across the country, participants reported encountering protesters holding signs, chanting slogans, and shouting insults. These interactions were concentrated at clinics in New Brunswick, Newfoundland and Labrador, and Ontario. Although no participants reported that these encounters made them reconsider their decision, they did report that seeing and interacting with protesters was at times unsettling, stigmatizing, and frustrating. Participants who struggled with the decision to have an abortion and those who made the decision in the context of health issues or violence found these encounters especially upsetting. Participants discussed how their interactions with protesters and the additional security measures put in place by clinics contrasted with their experiences accessing other kinds of health care and they wished that the protesters had not been there.

CONCLUSIONS

For some Canadian abortion patients, encountering protesters is upsetting and stigmatizing. Exploring ways to minimize interactions between protesters and those seeking abortion care, such as enacting and enforcing safe access zone legislation, appears warranted.

IMPLICATIONS

Although several Canadian provinces have enacted safe access zone laws, these do not currently exist across all jurisdictions. In addition to protecting clinics and clinic staff, implementation of these buffer zones have the potential to improve some patients' experiences obtaining a medically necessary and essential service.

Feasibility and Acceptability of a Mobile Technology Intervention to Support Postabortion Care in British Columbia: Phase I

Background

Over 30% of women in Canada undergo an abortion. Despite the prevalence of the procedure, stigma surrounding abortion in Canada leads to barriers for women to access this service. The vast majority of care is concentrated in urban settings. There is evidence to support utilization of innovative mobile and other technology solutions to empower women to safely and effectively self-manage aspects of the abortion process. This study is part 1 of a 3-phase study that utilizes user-centered design methodology to develop a digital health solution to specifically support follow-up after an induced surgical abortion.

Objective

This study aimed to (1) understand how women at 3 surgical abortion clinics in an urban center of British Columbia utilize their mobile phones to access health care information and (2) understand women’s preferences of content and design of an intervention that will support follow-up care after an induced abortion, including contraceptive use.

Methods

The study design was based on development-evaluation-implementation process from Medical Research Council Framework for Complex Medical Interventions. This was a mixed-methods formative study. Women (aged 14-45 years) were recruited from 3 urban abortion facilities in British Columbia who underwent an induced abortion. Adaptation of validated surveys and using the technology acceptance model and theory of reasoned action, a cross-sectional survey was designed. Interview topics included demographic information; type of wireless device used; cell phone usage; acceptable information to include in a mobile intervention to support women’s abortion care; willingness to use a mobile phone to obtain reproductive health information; optimal strategies to use a mobile intervention to support women; understand preferences for health information resources; and design qualities in a mobile intervention important for ease of use, privacy, and security. Responses to questions in the survey were summarized using descriptive statistics. Qualitative analysis was conducted with NVivo using a thematic analysis approach. This study was approved by the local ethics board.

Results

A waiting-room survey was completed by 50 participants, and semistructured interviews were completed with 8 participants. The average age of participants was 26 years. Furthermore, 94% (47/50) owned a smartphone, 85% (41/48) used their personal phones to go online, and 85% would use their cell phone to assist in clinical care. Qualitative analysis demonstrated that women prefer a comprehensive website that included secure email or text notifications to provide tools and resources for emotional well-being, contraceptive decision making, general sexual health, and postprocedure care.

Conclusions

A community-based mixed-methods approach allowed us to understand how women use their cell phones and what women desire in a mobile intervention to support their postabortion care. The findings from this formative phase will assist in the development and testing of a mobile intervention to support follow-up care after an induced surgical abortion.