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Godfrey EM, Zhang Y, Stulberg DB. Primary Care's Role in Prescribing Mail-Order Mifepristone. JAMA Intern Med 2024; 184:859-860. [PMID: 38739400 DOI: 10.1001/jamainternmed.2024.1448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
This Viewpoint discusses the controversy over mail-order mifepristone prescribed by primary care clinicians for first-trimester abortion as it relates to the history of initial approval, the Supreme Court case Alliance for Hippocratic Medicine v US Food and Drug Administration, and available clinical research.
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Affiliation(s)
- Emily M Godfrey
- Department of Family Medicine, University of Washington School of Medicine, Seattle
| | - Ying Zhang
- Department of Family Medicine, University of Washington School of Medicine, Seattle
| | - Debra B Stulberg
- Department of Family Medicine, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
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2
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Corbin CE, Sliwowska A, Levine JP, Stimmel S, Amico JR. Contraception Initiation after Early Abortion in a Family Medicine Setting: A Retrospective Chart Review. South Med J 2024; 117:498-503. [PMID: 39094801 DOI: 10.14423/smj.0000000000001718] [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: 08/04/2024]
Abstract
OBJECTIVES Early abortion increasingly is provided in the primary care setting, allowing improved access, continuity of care, and contraception, if desired. We aimed in this retrospective chart review to describe postabortion contraception provision in a family medicine office. METHODS Participants were those patients who obtained an induced abortion during an 11-year period at a family medicine office. We documented contraception provision within 30 days of abortion and used simple proportions, Fisher exact tests, and χ2 tests to describe differences in contraceptive provision by type of abortion and continuity status. RESULTS Most of the patients who underwent abortions (254/353, 72%) had documentation of a contraceptive method within 30 days of abortion, which was similar for patients who had either a medication (124/166, 75%) or an aspiration abortion (130/187, 70%, P = 0.71). The most common contraceptives were contraceptive pills (104/353, 29%) or intrauterine devices (68/353, 19%). Patients who chose a tier 1 method were more likely to have a procedure abortion (50/87, 57%), whereas patients who chose a tier 2 method were likely to have a medication abortion (83/160, 52%). Fewer than half (45%, 158/353, P = 0.0002) were continuity patients and established patients in the primary care office. Most tier 1 contraceptive users were continuity patients (49/87, 60%), whereas most patients without a contraceptive method were noncontinuity patients (72/99, 73%). CONCLUSIONS The primary care setting is uniquely equipped for providing early abortion and postabortion contraception. Although the providers offered all contraceptive options to eligible patients, continuity patients were more likely to receive more effective contraception in their primary care office.
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Affiliation(s)
- Cresandra E Corbin
- From the Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Anna Sliwowska
- From the Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jeffrey P Levine
- From the Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Samantha Stimmel
- From the Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jennifer R Amico
- From the Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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3
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Tressan A, Nyandak D, Srinivasulu S, Fiastro AE, MacNaughton H, Godfrey EM. Telemedicine Abortion in Primary Care: An Exploration of Patient Experiences. Ann Fam Med 2024; 22:19-25. [PMID: 38253506 PMCID: PMC11233084 DOI: 10.1370/afm.3058] [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: 04/09/2023] [Revised: 09/25/2023] [Accepted: 09/29/2023] [Indexed: 01/24/2024] Open
Abstract
PURPOSE The purpose of the study was to explore patients' experiences and perspectives obtaining telemedicine medication abortion (TeleMAB) through their primary care health system. METHODS We conducted in-depth telephone interviews with 14 English-, Spanish-, and/or Portuguese-speaking patients who received a TeleMAB between July 2020 and December 2021, within a large primary care safety-net community health system in Massachusetts. We created and piloted a semistructured interview guide informed by patient-clinician communication frameworks and prior studies on patient experiences with TeleMAB. We analyzed data using reflexive thematic analysis and summarized main themes. RESULTS Overall, participants found TeleMAB services in their primary care health system acceptable, positive, and easy. Participants discussed how TeleMAB supported their ability to exercise control, autonomy, and flexibility, and decreased barriers experienced with in-clinic care. Many participants perceived their primary care health system as the place to go for any pregnancy-related health care need, including abortion. They valued receiving abortion care from their established health care team within the context of ongoing social and medical concerns. CONCLUSIONS Patients find TeleMAB from their primary care health system acceptable and beneficial. Primary care settings can integrate TeleMAB services to decrease care silos, normalize abortion as a part of comprehensive primary care, and improve access through remote care offerings. TeleMAB supports patients' access and autonomy, with the potential to benefit many people of reproductive age.
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Affiliation(s)
- Amy Tressan
- Department of Family Medicine, Planned Parenthood of Orange and San Bernadino counties, Anaheim, California
| | - Deyang Nyandak
- Department of Family Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
| | | | - Anna E Fiastro
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - Honor MacNaughton
- Department of Family Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Emily M Godfrey
- Departments of Family Medicine and Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington
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4
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Wulf S, Vinekar K, Dehlendorf C, Srinivasulu S, Steinauer J, Carvajal DN. Implications of Overturning Roe v Wade on Abortion Training in US Family Medicine Residency Programs. Ann Fam Med 2023; 21:545-548. [PMID: 38012041 PMCID: PMC10681702 DOI: 10.1370/afm.3042] [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] [Received: 04/13/2022] [Revised: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 11/29/2023] Open
Abstract
In June 2022, the US Supreme Court overturned Roe v Wade, opening the door to state-level abortion bans. By August 2023, 17 states banned abortion or instituted early gestational age bans. We performed an analysis to assess the proportion of accredited US family medicine residency programs and trainees in states with abortion restrictions. Twenty-nine percent of family medicine residency programs (n = 201) and residents (n = 3,930) are in states with bans or very restrictive policies. Family medicine residency programs must optimize training and exposure to abortion within their contexts, so graduates are able to care for patients seeking abortions or needing follow-up care.
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Affiliation(s)
- Sarah Wulf
- Person-Centered Reproductive Health Program, Department of Family and Community Medicine, University of California, San Francisco, California
| | - Kavita Vinekar
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christine Dehlendorf
- Person-Centered Reproductive Health Program, Department of Family and Community Medicine, University of California, San Francisco, California
| | | | - Jody Steinauer
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, California
| | - Diana N Carvajal
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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5
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Fiastro AE, Young E, Jacob-Files E, Ruben MR, Coeytaux FM, Bennett IM, Godfrey EM. Advance provision of medication for induced abortion: A qualitative study of patient perspectives. Contraception 2023; 123:110050. [PMID: 37085094 DOI: 10.1016/j.contraception.2023.110050] [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: 12/09/2022] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVES To examine potential users' perspectives regarding the provision of abortion medications for future use or "advance provision." STUDY DESIGN In this qualitative study, we partnered with an independent reproductive health care clinic in Washington State to conduct semistructured, in-depth interviews with 22 individuals who obtained a medication abortion between August 2021 and January 2022. We asked participants their views on advance provision of abortion medications. Interviews were transcribed and deidentified. Inductive content analysis was used to identify major themes. RESULTS Participants in our sample generally reacted positively to the idea of abortion medications for future use. Having pills in advance could improve timeliness and convenience of care and decrease the stigma associated with their use. Participants stressed the importance of adequate information regarding medication use, what to expect, and potential side effects. Most concerns about advance provision related to the safety and efficacy of medication abortion. CONCLUSIONS This study found that individuals who recently obtained a medication abortion supported the provision of abortion medications for future use. IMPLICATIONS Patient-centered educational materials, with adequate information for self-managing pregnancy termination, can be shared at time of prescription. Clinicians have an opportunity to offer these safe and effective medications in advance of need and increase timely access to this essential health care service. User concerns regarding abortion medications for future use should inform clinical innovation and evaluative research of service options.
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Affiliation(s)
| | | | | | - Molly R Ruben
- University of Washington, Seattle, WA, United States
| | | | - Ian M Bennett
- University of Washington, Seattle, WA, United States
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6
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Bridwell R, Long B, Montrief T, Gottlieb M. Post-abortion Complications: A Narrative Review for Emergency Clinicians. West J Emerg Med 2022; 23:919-925. [DOI: 10.5811/westjem.2022.8.57929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/23/2022] [Indexed: 11/15/2022] Open
Abstract
An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally “safe” (performed in a safe, clean environment with experienced providers and no legal restrictions) or “unsafe” (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.
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Affiliation(s)
- Rachel Bridwell
- Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
| | - Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Tim Montrief
- Jackson Memorial Health System, Department of Emergency Medicine, Miami, Florida
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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7
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Patel D, Liu G, Roberts SCM, Leslie DL, Weisman CS, Horvath S, Chuang CH. Association of Provider Specialty With Abortion-Related Morbidity and Adverse Events Among Patients Having Procedural and Medication Abortions. Womens Health Issues 2022; 32:327-333. [PMID: 35437157 DOI: 10.1016/j.whi.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 02/20/2022] [Accepted: 03/11/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Since abortion was legalized throughout the United States in 1973, states have passed restrictive abortion policies, including permitting only obstetrician-gynecologist physicians (OBGYNs) to provide abortions. We are unaware of any research that directly compares patient safety-related outcomes by physician specialty. In this study, we compared major and any abortion-related morbidity and adverse events in abortion care provided by physicians of other specialties versus OBGYNs. STUDY DESIGN Using the IBM Watson Health MarketScan claims database, we identified privately insured individuals who had an induced abortion between January 1, 2011, and December 31, 2014. The primary outcome was major abortion-related morbidity or adverse events, and the secondary outcome was any abortion-related morbidity or adverse events occurring within 6 weeks of the abortion. RESULTS The study cohort included 34,764 patients who had 35,407 abortions-4,843 (13.7%) abortions provided by physicians of other specialties and 30,564 (86.3%) abortions provided by OBGYNs. Major and any abortion-related morbidity or adverse event occurred in 115 (0.3%) and 1,271 (3.6%) of 35,407 of abortions, respectively. In adjusted analyses, there was no statistically significant difference in major abortion-related morbidity or adverse events comparing physicians of other specialties versus OBGYNs (adjusted odds ratio, 1.02; 95% confidence interval, 0.59-1.75), and no statistically significant difference in any abortion-related morbidity or adverse events comparing physicians of other specialties versus OBGYNs (adjusted odds ratio, 0.91; 95% confidence interval, 0.77-1.09). CONCLUSIONS There were no differences in abortion-related morbidity or adverse events by physician specialty. Our findings do not support state laws limiting abortion care to OBGYN physicians.
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Affiliation(s)
- Dolly Patel
- Pennsylvania State University College of Medicine, Hershey, Pennsylvania.
| | - Guodong Liu
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Sarah C M Roberts
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco School of Medicine, San Francisco, California
| | - Douglas L Leslie
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Carol S Weisman
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Department of Obstetrics and Gynecology, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Sarah Horvath
- Department of Obstetrics and Gynecology, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Cynthia H Chuang
- Division of General Internal Medicine, Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Department of Obstetrics and Gynecology, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
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Razon N, Wulf S, Perez C, McNeil S, Maldonado L, Fields AB, Carvajal D, Logan R, Dehlendorf C. Exploring the impact of mifepristone's Risk Evaluation and Mitigation Strategy (REMS) on the integration of medication abortion into US family medicine primary care clinics. Contraception 2022; 109:19-24. [PMID: 35131289 PMCID: PMC9018589 DOI: 10.1016/j.contraception.2022.01.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 01/22/2023]
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Family medicine provision of online medication abortion in three US states during COVID-19. Contraception 2021; 104:54-60. [PMID: 33939985 PMCID: PMC8086374 DOI: 10.1016/j.contraception.2021.04.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To examine provision of direct-to-patient medication abortion during COVID-19 by United States family physicians through a clinician-supported, asynchronous online service, Aid Access. STUDY DESIGN We analyzed data from United States residents in New Jersey, New York, and Washington who requested medication abortion from 3 family physicians using the online service from Aid Access between April and November 2020. This study seeks to examine individual characteristics, motivations, and geographic locations of patients receiving abortion care through the Aid Access platform. RESULTS Over 7 months, three family physicians using the Aid Access platform provided medication abortion care to 534 residents of New Jersey, New York, and Washington. There were no demographic differences between patients seeking care in these states. A high percentage (85%) were less than 7 weeks gestation at the time of their request for care. The reasons patients chose Aid Access for abortion services were similar regardless of state residence. The majority (71%) of Aid Access users lived in urban areas. Each family physician provided care to most counties in their respective states. Among those who received services in the three states, almost one-quarter (24%) lived in high Social Vulnerability Index (SVI) counties, with roughly one-third living in medium-high SVI counties (33%), followed by another quarter (26%) living in medium-low SVI counties. CONCLUSIONS Family physicians successfully provided medication abortion in three states using asynchronous online consultations and medications mailed directly to patients. IMPLICATIONS Primary care patients are requesting direct-to-patient first trimester abortion services online. By providing abortion care online, a single provider can serve the entire state, thus greatly increasing geographic access to medication abortion.
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10
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Levi A, Goodman S, Weitz T, AbiSamra R, Nobel K, Desai S, Battistelli M, Taylor D. Training in aspiration abortion care: An observational cohort study of achieving procedural competence. Int J Nurs Stud 2018; 88:53-59. [DOI: 10.1016/j.ijnurstu.2018.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 08/05/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022]
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Abstract
Patients commonly present with unintended pregnancy in the primary care setting, and 1 in 4 women has an abortion in her lifetime. Early abortion services can be safely provided in the primary care setting. Abortion options provided in primary care settings include both medication abortion and early uterine aspiration abortion. Medication abortion, provided up to 10 weeks' gestational age, includes mifepristone (a progestin antagonist) and misoprostol (a prostaglandin). Uterine aspiration can be provided via manual or electronic vacuum in the first trimester.
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Affiliation(s)
- Jennifer R Amico
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 125 Paterson Street, MEB 262, New Brunswick, NJ 08901, USA.
| | - Terri L Cheng
- Department of Family Medicine and Public Health, University of California San Diego, 200 West Arbor Drive #8201A, San Diego, CA 92103, USA
| | - Emily M Godfrey
- Family Medicine, University of Washington, 4311 11th Avenue Northeast, Suite 210, Box 354982, Seattle, WA 98105, USA; Obstetrics and Gynecology, University of Washington, 4311 11th Avenue Northeast, Suite 210, Box 354982, Seattle, WA 98105, USA
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12
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Upadhyay UD, Johns NE, Barron R, Cartwright AF, Tapé C, Mierjeski A, McGregor AJ. Abortion-related emergency department visits in the United States: An analysis of a national emergency department sample. BMC Med 2018; 16:88. [PMID: 29898742 PMCID: PMC6000974 DOI: 10.1186/s12916-018-1072-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/10/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Media depictions and laws passed in state legislatures regulating abortion suggest abortion-related medical emergencies are common. An accurate understanding of abortion-related emergencies is important for informing policy and practice. We assessed the incidence of abortion-related emergency department (ED) visits in the United States (U.S.). METHODS We used a retrospective observational study design using 2009-2013 data from the Nationwide Emergency Department Sample, a nationally representative sample of U.S. ED visits from 947 to 964 hospitals across the U.S. per year. All ED visits among women of reproductive age (15-49) were included. We categorized ED visits by abortion relatedness and treatments received, and assessed whether the visit was for a major incident (defined as requiring blood transfusion, surgery, or overnight inpatient stay). We estimated the proportion of visits that were abortion-related and described the characteristics of patients making these visits, the diagnoses and subsequent treatments received by these patients, the sociodemographic and hospital characteristics associated with the incidents and observation care only (defined as receiving no treatments), and the rate of major incidents for all abortion patients in the U.S. RESULTS Among all ED visits by women aged 15-49 (189,480,685), 0.01% (n = 27,941) were abortion-related. Of these visits, 51% (95% confidence interval, 95% CI 49.3-51.9%) of the women received observation care only. A total of 20% (95% CI 19.3-21.3%) of abortion-related ED visits were for major incidents. One-fifth (22%, 95% CI 20.9-23.0%) of abortion-related visits resulted in admission to the same hospital for abortion-related reasons. Of the visits, 1.4% (n = 390, 95% CI 1.1-1.7%) were potentially due to attempts at self-induced abortion. In multivariable models, women using Medicaid (adjusted odds ratio, AOR 1.28, 95% CI 1.08-1.52) and women with a comorbid condition (AORs 2.47-4.63) had higher odds of having a major incident than women using private insurance and those without comorbid conditions. During the study period, 0.11% of all abortions in the U.S. resulted in major incidents as seen in EDs. CONCLUSIONS Abortion-related ED visits comprise a small proportion of women's ED visits. Many abortion-related ED visits may not be indicated or could have been managed at a less costly level of care. Given the low rate of major incidents, perceptions that abortion is unsafe are not based on evidence.
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Affiliation(s)
- Ushma D Upadhyay
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, California, 94612, USA.
| | - Nicole E Johns
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, California, 94612, USA
| | - Rebecca Barron
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Alice F Cartwright
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, California, 94612, USA
| | - Chantal Tapé
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Alyssa Mierjeski
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Alyson J McGregor
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
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13
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Taylor D, Upadhyay UD, Fjerstad M, Battistelli MF, Weitz TA, Paul ME. Standardizing the classification of abortion incidents: the Procedural Abortion Incident Reporting and Surveillance (PAIRS) Framework. Contraception 2017; 96:1-13. [PMID: 28578150 DOI: 10.1016/j.contraception.2017.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 04/30/2017] [Accepted: 05/14/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To develop and validate standardized criteria for assessing abortion-related incidents (adverse events, morbidities, near misses) for first-trimester aspiration abortion procedures and to demonstrate the utility of a standardized framework [the Procedural Abortion Incident Reporting & Surveillance (PAIRS) Framework] for estimating serious abortion-related adverse events. STUDY DESIGN As part of a California-based study of early aspiration abortion provision conducted between 2007 and 2013, we developed and validated a standardized framework for defining and monitoring first-trimester (≤14weeks) aspiration abortion morbidity and adverse events using multiple methods: a literature review, framework criteria testing with empirical data, repeated expert reviews and data-based revisions to the framework. RESULTS The final framework distinguishes incidents resulting from procedural abortion care (adverse events) from morbidity related to pregnancy, the abortion process and other nonabortion related conditions. It further classifies incidents by diagnosis (confirmatory data, etiology, risk factors), management (treatment type and location), timing (immediate or delayed), seriousness (minor or major) and outcome. Empirical validation of the framework using data from 19,673 women receiving aspiration abortions revealed almost an equal proportion of total adverse events (n=205, 1.04%) and total abortion- or pregnancy-related morbidity (n=194, 0.99%). The majority of adverse events were due to retained products of conception (0.37%), failed attempted abortion (0.15%) and postabortion infection (0.17%). Serious or major adverse events were rare (n=11, 0.06%). CONCLUSIONS Distinguishing morbidity diagnoses from adverse events using a standardized, empirically tested framework confirms the very low frequency of serious adverse events related to clinic-based abortion care. IMPLICATIONS The PAIRS Framework provides a useful set of tools to systematically classify and monitor abortion-related incidents for first-trimester aspiration abortion procedures. Standardization will assist healthcare providers, researchers and policymakers to anticipate morbidity and prevent abortion adverse events, improve care metrics and enhance abortion quality.
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Affiliation(s)
- Diana Taylor
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, and School of Nursing, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612.
| | - Ushma D Upadhyay
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612
| | - Mary Fjerstad
- National Abortion Federation, 1090 Vermont Avenue NW #1000, Washington, DC 20005
| | - Molly F Battistelli
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612
| | - Tracy A Weitz
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612
| | - Maureen E Paul
- Beth Israel Deaconess Medical Center, Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215
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14
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Li CL, Song LP, Tang SY, Zhou LJGYK, He H, Mo XT, Liao YM. Efficacy, Safety, and Acceptability of Low-Dose Mifepristone and Self-Administered Misoprostol for Ultra-Early Medical Abortion: A Randomized Controlled Trial. Reprod Sci 2016; 24:731-737. [PMID: 27678099 DOI: 10.1177/1933719116669055] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study was to investigate the efficacy, safety, and acceptability of low-dose mifepristone combined with self-administered misoprostol for ultra-early medical abortion. A total of 744 women with ultra-early pregnancy (amenorrhea ≤35 days) who fulfilled the inclusion criteria were enrolled in the study. Equal numbers of participants were allocated randomly to the hospital administration and self-administration groups. All participants took 75 mg mifepristone at the initial visit and 400 µg oral misoprostol 24 hours later in the hospital or by self-administration. The primary end point was complete abortion. Secondary end points were rates of unscheduled reattendance, time required for and cost of hospital observation and follow-up, vaginal bleeding, adverse effects, menstrual disturbance in the posttreatment period, and satisfaction rating. No differences in the rates of complete abortion, unscheduled reattendance, vaginal bleeding, adverse effects, or return of posttreatment menstruation were observed. The time required for (and costs of) hospital observation and follow-up per participant was 557.82 minutes (and US$40.12) in the hospital administration group and 18.46 minutes (and US$1.96) in the self-administration group (both P < .001). Satisfaction rates were similar in both groups, but the rates of "very satisfied" responses (87.60% vs 25.41%) and follow-up compliance (loss to follow-up, 0.45% vs 7.70%) were higher in the self-administration group (both P < .001). Low-dose mifepristone combined with self-administered misoprostol for ultra-early pregnancy termination was as effective and safe as hospital administration, with greater acceptability and lower cost to the women.
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Affiliation(s)
- Cui-Lan Li
- 1 Key Laboratory for Reproduction and Genetics of Guangdong Higher-Education Institutes and Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital, Guangzhou Institute of Obstetrics and Gynecology, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Li-Ping Song
- 1 Key Laboratory for Reproduction and Genetics of Guangdong Higher-Education Institutes and Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital, Guangzhou Institute of Obstetrics and Gynecology, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Shi-Yan Tang
- 1 Key Laboratory for Reproduction and Genetics of Guangdong Higher-Education Institutes and Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital, Guangzhou Institute of Obstetrics and Gynecology, Guangzhou Medical University, Guangzhou, People's Republic of China
| | | | - Hong He
- 1 Key Laboratory for Reproduction and Genetics of Guangdong Higher-Education Institutes and Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital, Guangzhou Institute of Obstetrics and Gynecology, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Xue-Tang Mo
- 1 Key Laboratory for Reproduction and Genetics of Guangdong Higher-Education Institutes and Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital, Guangzhou Institute of Obstetrics and Gynecology, Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Yi-Ming Liao
- 1 Key Laboratory for Reproduction and Genetics of Guangdong Higher-Education Institutes and Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital, Guangzhou Institute of Obstetrics and Gynecology, Guangzhou Medical University, Guangzhou, People's Republic of China
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Abstract
OBJECTIVE This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care. INTENDED USERS Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services. TARGET POPULATION Women with an unintended first trimester pregnancy. EVIDENCE Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required. VALUES The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1). BENEFITS, HARMS AND/OR COSTS Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability. SUMMARY STATEMENTS Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care RECOMMENDATIONS Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.
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17
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Complications from first-trimester aspiration abortion: a systematic review of the literature. Contraception 2015; 92:422-38. [DOI: 10.1016/j.contraception.2015.07.013] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 06/03/2015] [Accepted: 07/26/2015] [Indexed: 01/09/2023]
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18
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Medical Compared With Surgical Abortion for Effective Pregnancy Termination in the First Trimester. Obstet Gynecol 2015; 126:22-8. [DOI: 10.1097/aog.0000000000000910] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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20
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Ingvoldstad C, Georgsson Öhman S, Lindgren P. Implementation of combined ultrasound and biochemistry for risk evaluation of chromosomal abnormalities during the first trimester in Sweden. Acta Obstet Gynecol Scand 2014; 93:868-73. [DOI: 10.1111/aogs.12445] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 06/18/2014] [Indexed: 11/27/2022]
Affiliation(s)
| | - Susanne Georgsson Öhman
- Department of Women's and Children's Health; Karolinska Institute, and Sophiahemmet University; Stockholm Sweden
| | - Peter Lindgren
- Department of Public Health and Caring Science; Uppsala University; Uppsala Sweden
- Department of Clinical Science, Intervention and Technology; Division of Obstetrics and Gynecology; Karolinska University Hospital; Stockholm Sweden
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21
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A review of evidence for safe abortion care. Contraception 2013; 88:350-63. [DOI: 10.1016/j.contraception.2012.10.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 09/04/2012] [Accepted: 10/22/2012] [Indexed: 11/19/2022]
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22
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Tzeng CR, Hwang JL, Au HK, Chien LW. Sonographic patterns of the endometrium in assessment of medical abortion outcomes. Contraception 2013; 88:153-9. [DOI: 10.1016/j.contraception.2012.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 09/02/2012] [Accepted: 09/24/2012] [Indexed: 10/27/2022]
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23
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Weitz TA, Taylor D, Desai S, Upadhyay UD, Waldman J, Battistelli MF, Drey EA. Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver. Am J Public Health 2013; 103:454-61. [PMID: 23327244 DOI: 10.2105/ajph.2012.301159] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the impact on patient safety if nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs) were permitted to provide aspiration abortions in California. METHODS In a prospective, observational study, we evaluated the outcomes of 11 487 early aspiration abortions completed by physicians (n = 5812) and newly trained NPs, CNMs, and PAs (n = 5675) from 4 Planned Parenthood affiliates and Kaiser Permanente of Northern California, by using a noninferiority design with a predetermined acceptable risk difference of 2%. All complications up to 4 weeks after the abortion were included. RESULTS Of the 11 487 aspiration abortions analyzed, 1.3% (n = 152) resulted in a complication: 1.8% for NP-, CNM-, and PA-performed aspirations and 0.9% for physician-performed aspirations. The unadjusted risk difference for total complications between NP-CNM-PA and physician groups was 0.87 (95% confidence interval [CI] = 0.45, 1.29) and 0.83 (95% CI = 0.33, 1.33) in a propensity score-matched sample. CONCLUSIONS Abortion complications were clinically equivalent between newly trained NPs, CNMs, and PAs and physicians, supporting the adoption of policies to allow these providers to perform early aspirations to expand access to abortion care.
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Affiliation(s)
- Tracy A Weitz
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California, San Francisco, CA 94612, USA.
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Low N, Mueller M, Van Vliet HAAM, Kapp N. Perioperative antibiotics to prevent infection after first-trimester abortion. Cochrane Database Syst Rev 2012; 2012:CD005217. [PMID: 22419307 PMCID: PMC6823200 DOI: 10.1002/14651858.cd005217.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND There are two main strategies for the prevention of post-abortal upper genital tract infection: antibiotics given around the time of surgery for all women; and 'screen-and-treat', in which all women presenting for abortion are screened for genital infections and those with positive results are treated. OBJECTIVES To determine:1. the effectiveness of antibiotic prophylaxis in preventing post-abortal upper genital tract infection; 2. the most effective antibiotic regimen; 3. the most effective strategy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, POPLINE and LILACS. The search was last updated in May 2011. SELECTION CRITERIA Randomised controlled trials (RCTs) in any language including women undergoing induced first trimester surgical or medical abortion, comparing: 1) any antibiotic regimen to placebo, nothing, or another antibiotic; 2) screen-and-treat versus antibiotics. The primary outcome was the proportion of women diagnosed with post-abortal upper genital tract infection. DATA COLLECTION AND ANALYSIS Two reviewers independently selected references and extracted data. We calculated risk ratios (RR) with 95% confidence intervals (CI). We used meta-analysis where appropriate and examined between trial heterogeneity using the I(2) statistic. In the presence of between trial heterogeneity we also estimated the 95% prediction interval (PI). MAIN RESULTS A total of 703 unique items was identified. We included 19 RCTs. There was evidence of small study biases (Egger test, P = 0.002). In 15 placebo-controlled RCTs there was an effect of antibiotic prophylaxis (pooled RR 0.59, 95% CI 0.46 to 0.75, 95% PI 0.30 to 1.14, I(2) = 39%). There were insufficient data (three trials) to determine whether one regimen was superior to another. In one trial, the incidence of post-abortal upper genital tract infection was higher in women allocated to the screen-and-treat strategy (RR 1.53, 95% CI 0.99 to 2.36). AUTHORS' CONCLUSIONS Antibiotic prophylaxis at the time of first trimester surgical abortion is effective in preventing post-abortal upper genital tract infection. Evidence of between trial heterogeneity suggests that the effect might not apply to all settings, population groups or interventions.This review did not determine the most effective antibiotic prophylaxis regimen. Antibiotic choice should take into account the local epidemiology of genital tract infections, including sexually transmitted infections.Further RCTs comparing different antibiotics or combinations of antibiotics with each other would be useful. Such trials could be done in low and middle income countries and where the prevalence of genital tract infections in women presenting for abortion is high.
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Affiliation(s)
- Nicola Low
- Division of Clinical Epidemiology and Biostatistics, Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
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25
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Godfrey EM, Bordoloi A, Moorthie M, Pela E. Medication abortion within a student health care clinic: a review of the first 46 consecutive cases. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2012; 60:178-183. [PMID: 22316416 DOI: 10.1080/07448481.2011.585479] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Medication abortion with mifepristone and misoprostol has been available in the United States since 2000. The authors reviewed the first 46 medication abortion cases conducted at a university-based student health care clinic to determine the safety and feasibility of medication abortion in this type of clinical setting. PARTICIPANTS Female patients presenting for medication abortion at a student health care clinic between October 1, 2006, and April 1, 2009. METHODS Retrospective consecutive case review. RESULTS Successful completion not requiring uterine aspiration occurred in 85% of the cases that were not lost to follow-up. Six cases (15%) required uterine aspiration for completion: 3 underwent uterine aspiration only; 3 had aspiration after failing an additional dose of misoprostol. Only 1 patient visited the emergency room. There were no hospitalizations. CONCLUSIONS Medication abortion services in a student health care clinic are safe and feasible. However, additional treatment may be required with some patients.
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Affiliation(s)
- Emily M Godfrey
- Department of Family Medicine, University of Illinois at Chicago, Chicago, Illinois 60612, USA.
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Wu JP, Porch E, Womack JP. Successful retrieval of an intrauterine device with "missing strings" using a manual vacuum aspirator in a desired early pregnancy: case report. J Minim Invasive Gynecol 2011; 18:254-6. [PMID: 21354074 DOI: 10.1016/j.jmig.2010.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 11/19/2010] [Accepted: 11/26/2010] [Indexed: 10/18/2022]
Abstract
Intrauterine pregnancy in the presence of an intrauterine device (IUD) is a rare event. If the pregnancy is desired, IUD removal must be negotiated so that the risk of pregnancy disruption is minimized. Cases in which the IUD strings are "missing" present further challenges. We report successful removal of a copper T380A IUD with missing strings using a hand-held manual vacuum aspirator in the setting of a desired pregnancy. Under real-time abdominal ultrasound guidance, the IUD was removed from the lower cervical canal using a 6-mm cannula attached to a manual vacuum aspirator. Fetal cardiac activity was undisturbed throughout the procedure. The patient subsequently delivered a healthy full-term infant via spontaneous vaginal delivery. Manual vacuum aspiration, a simple office-based procedure, may be a useful approach to removal of an IUD with missing strings.
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Affiliation(s)
- Justine P Wu
- Department of Family Medicine and Community Health, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
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