My Health in My Hands: Improving Medication Abortion Knowledge and Closing Disparities with a Community-Led Media Intervention

Purpose

Inaccurate beliefs about medication abortion (MA) are common. This study evaluated pilot data from a community-led media intervention designed to increase MA knowledge among Black and Latinx women in Georgia.

Methods

Participants (N=855) viewed the intervention video and completed pre-post surveys. Data were analyzed using linear and logistic regression.

Results

Knowledge scores significantly increased from 3.88/5.00 to 4.47/5.00. Participants who were Native American, Asian and Pacific Islander, multiracial, Black, <20 years old, and living in Georgia scored below the sample mean at baseline; however, nearly all disparities disappeared after intervention exposure.

Conclusions

This intervention effectively increased MA knowledge and narrowed racial/ethnic, age-based, and geographic disparities.

Abortion-related crowdfunding post-Dobbs

Previous research on abortion-related crowdfunding campaigns found that they are impacted by stigma around abortion and rarely successful. This paper analyzes crowdfunding activity in the US following a leak of the Supreme Court decision in Dobbs. V. Jackson Women's Health Organization, a time period that saw increased financial support of abortion access funds. Crowdfunding campaigns that included "abort" or "abortion" and were created between May 2 and November 8, 2022 were recorded from the GoFundMe and GiveSendGo crowdfunding platforms. These campaigns were reviewed for whether they were US based and sought funding where abortion was used as a justification for support. Included campaigns were assigned a campaign recipient type: (1) Organizations providing abortion access; (2) Organizations seeking legal protection for abortion; (3) Individuals seeking abortion access; (4) Organizations seeking to reduce abortion access; and (5) Individuals with needs resulting from choosing not to access abortion. The authors also identified four types of rationale for supporting these campaigns. Following a leak of the Dobbs decision, 398 abortion-related crowdfunding campaigns in the US raised over $3.8 million from over 50,000 donations. Campaigns supporting abortion access organizations raised higher median amounts than organizations seeking to reduce abortion access. Individuals seeking abortion access raised higher median amounts than individuals who chose not to terminate a pregnancy. In a reversal from pre-Dobbs crowdfunding, abortion access campaigns tended to outperform other abortion-related campaigns. It is not clear how long-lived this change in support will be and campaigners remain vulnerable to changes in platforms' content moderation policies.

Assessing the Accuracy of Information on Medication Abortion: A Comparative Analysis of ChatGPT and Google Bard AI

Background and objective ChatGPT and Google Bard AI are widely used conversational chatbots, even in healthcare. While they have several strengths, they can generate seemingly correct but erroneous responses, warranting caution in medical contexts. In an era where access to abortion care is diminishing, patients may increasingly rely on online resources and AI-driven language models for information on medication abortions. In light of this, this study aimed to compare the accuracy and comprehensiveness of responses generated by ChatGPT 3.5 and Google Bard AI to medical queries about medication abortions. Methods Fourteen open-ended questions about medication abortion were formulated based on the Frequently Asked Questions (FAQs) from the National Abortion Federation (NAF) and the Reproductive Health Access Project (RHAP) websites. These questions were answered using ChatGPT version 3.5 and Google Bard AI on October 7, 2023. The accuracy of the responses was analyzed by cross-referencing the generated answers against the information provided by NAF and RHAP. Any discrepancies were further verified against the guidelines from the American Congress of Obstetricians and Gynecologists (ACOG). A rating scale used by Johnson et al. was employed for assessment, utilizing a 6-point Likert scale [ranging from 1 (completely incorrect) to 6 (correct)] to evaluate accuracy and a 3-point scale [ranging from 1 (incomplete) to 3 (comprehensive)] to assess completeness. Questions that did not yield answers were assigned a score of 0 and omitted from the correlation analysis. Data analysis and visualization were done using R Software version 4.3.1. Statistical significance was determined by employing Spearman's R and Mann-Whitney U tests. Results All questions were entered sequentially into both chatbots by the same author. On the initial attempt, ChatGPT successfully generated relevant responses for all questions, while Google Bard AI failed to provide answers for five questions. Repeating the same question in Google Bard AI yielded an answer for one; two were answered with different phrasing; and two remained unanswered despite rephrasing. ChatGPT showed a median accuracy score of 5 (mean: 5.26, SD: 0.73) and a median completeness score of 3 (mean: 2.57, SD: 0.51). It showed the highest accuracy score in six responses and the highest completeness score in eight responses. In contrast, Google Bard AI had a median accuracy score of 5 (mean: 4.5, SD: 2.03) and a median completeness score of 2 (mean: 2.14, SD: 1.03). It achieved the highest accuracy score in five responses and the highest completeness score in six responses. Spearman's correlation coefficient revealed no correlation between accuracy and completeness for ChatGPT (rs = -0.46771, p = 0.09171). However, Google Bard AI showed a marginally significant correlation (rs = 0.5738, p = 0.05108). Mann-Whitney U test indicated no statistically significant differences between ChatGPT and Google Bard AI concerning accuracy (U = 82, p>0.05) or completeness (U = 78, p>0.05). Conclusion While both chatbots showed similar levels of accuracy, minor errors were noted, pertaining to finer aspects that demand specialized knowledge of abortion care. This could explain the lack of a significant correlation between accuracy and completeness. Ultimately, AI-driven language models have the potential to provide information on medication abortions, but there is a need for continual refinement and oversight.

Medication Abortion Follow-Up Rates in a Rural Population Before and After Introduction of a Remote Follow-Up Option

Background: Medication abortion (MAB) follow-up historically involves visiting a health care facility for ultrasonography or laboratory testing. In rural states such as New Mexico, many patients travel hours for MAB, making two visits burdensome. Studies demonstrate feasibility, safety, and patient preference for remote follow-up. Materials and Methods: We evaluated whether MAB follow-up by telephone had noninferior loss-to-follow-up (LTFU) rates compared with ultrasonography or laboratory follow-up in a rural population. This was a retrospective chart review of University of New Mexico MAB LTFU rates after changing to telephone follow-up (home group, n = 136). Patients were propensity-matched in a 1:2 ratio to a historical cohort (health care group, n = 272) to eliminate significant differences. We defined LTFU as no contact within 50 days. We evaluated complications requiring intervention, possible ongoing pregnancy, completion of the home follow-up protocol (7- and 30-day calls, high-sensitivity urine pregnancy test [UPT]), follow-up by intended method (home or health care), and number of call attempts. Results: LTFU rates for the home group (n = 23, 17%) were noninferior to the health care group (n = 60, 22%, p = 0.24). Rates of complications requiring intervention (p = 0.83) and possible ongoing pregnancy (p = 0.72) among the home group were similar to the health care group. Ninety-seven (71%) home group patients completed the initial call, 79 (58%) completed the UPT, and 86 (69%) completed the 30-day call. Ninety-five (70%) home group patients followed up by intended method, comparable with the health care group (n = 199, 73%, p = 0.56). Staff made a median of 3 (interquartile range: 2-4) calls per home group patient. Conclusions: Remote MAB LTFU rates were noninferior to in-person LTFU rates.

Medication Abortion and Abortion Pill Reversal: An Exploratory Analysis on the Influence of Others in Women's Decision-Making

Introduction As medication abortion accounts for a growing share of abortions in the United States, an increasing number of women are seeking abortion pill reversal (APR). These decisions are typically not made in isolation. However, little research exists on women's APR decision-making and the role played by people close to them. Methods We surveyed women who contacted a national hotline for information on APR and who completed a two-week treatment protocol with progesterone (n = 67). We analyzed women's open-ended answers using thematic analysis to identify memorable messages about medication abortion and APR. Participants' communication with other people in their lives was assessed using the Isolation subscale of the Individual Level Abortion Stigma (ILAS) scale, and decision-making difficulty was assessed using a Likert scale. Results Thirty-six respondents met the eligibility criteria and filled out the ILAS and decision-difficulty scales. Women tended to talk with family and friends about their medication abortion decisions, while they typically sought information online when deciding about APR. Women reported greater stigma in their disclosures about their abortions than in their disclosures about APR (p = 0.006). Conclusion Memorable messages influence women's decisions to pursue medication abortion and APR.

The Provision of Abortion Care via Telehealth in the United States: A Rapid Review

INTRODUCTION

The recent Supreme Court decision Dobbs v. Jackson Women's Health that has overruled Roe v. Wade has resulted in severe limitations of abortion access throughout the United States. Telehealth has been put forth as one solution for improving access for reproductive health care, including abortion services. Telehealth has demonstrated safety and efficacy in several health care disciplines; however, its use for abortion care and services has not been explored and synthesized.

METHODS

As part of a larger review on telehealth and general reproductive health, our team identified a moderate amount of literature on telehealth and abortion care. We conducted a rapid review searching for eligible studies in MEDLINE, Embase, and CINAHL. Information was extracted from each included study to explore 4 key areas of inquiry: (1) clinical effectiveness, (2) patient and provider experiences, (3) barriers and facilitators, and (4) the impact of the coronavirus disease 2019 (COVID-19) pandemic.

RESULTS

Twenty-five studies on the use of telehealth for providing abortion services published between 2011 and 2022 were included. Telehealth for medical abortion increased during the COVID-19 pandemic and was found to be safe and clinically effective, with high patient satisfaction. Overall, telehealth improved access and removed barriers for patients including lack of transportation. Legal restrictions in certain states were cited as the primary barriers. Studies contained limited information on the perspectives and experiences of health care providers and diverse patient populations.

DISCUSSION

Abortion care via telehealth is safe and effective with high satisfaction and may also remove barriers to care including transportation and fear. Removing restrictions on telehealth for the provision of abortion services may further improve access to care and promote greater health equity.

The Association Between Self-Managed versus Clinician-Managed Abortion and Self-Reported Abortion Complications: A Cross-Sectional Analysis in India

Purpose

To examine the association between self-managed abortion and the self-reported experience of abortion complications in India, a country with a high incidence of self-managed abortion.

Patients and Methods

The study used a cross-sectional multivariable logistic regression analysis of data from the National Family Health Survey (NFHS-4) of 2015-2016 to compare the odds of self-reported complications experienced during abortion between self-managed and clinician-managed abortions in India.

Results

On average, self-managed abortions occurred earlier in gestation than clinician-managed abortions, 7.8 weeks and 11.3 weeks, respectively (p < 0.001). Self-managed abortion was associated with fewer self-reported abortion-related complications than clinician-managed abortions when adjusted for covariates not including gestational age (Adjusted Odds Ratio (aOR) 0.82, 95% confidence interval (CI) 0.69, 0.97). However, once adjusted for gestational age, there was no longer a clinically meaningful or statistically significant difference in the odds of self-reported complications between self-managed and clinician-managed abortions (aOR = 0.98, 95% CI 0.81, 1.18).

Conclusion

These findings suggest that people in India are using safe methods to self-manage abortions and support the hypothesis that self-managed abortion can improve access to abortion and reproductive choice without increasing risk.

History and Politics of Medication Abortion in the United States and the Rise of Telemedicine and Self-Managed Abortion

This article examines the decades-long campaign to increase access to abortion pills in the United States, including advocates' work to win US Food and Drug Administration approval of mifepristone and misoprostol for abortion, the continuing restrictions on mifepristone, and the multiple strategies advocates have pursued to challenge these restrictions, including lobbying the FDA to remove the restrictions, obtaining a limited research exemption from FDA restrictions, and suing the FDA during the COVID-19 pandemic. The article pays particular attention to the influence of research conducted on the safety and efficacy of medication abortion as well as research on the impact of increased availability of abortion pills through telemedicine during the pandemic. The article also addresses self-managed abortion, wherein people obtain and use mifepristone and/or misoprostol outside the formal health care system, and it documents the growing network of organizations providing logistical, medical, and legal support to people self-managing abortion. The article concludes with reflections on the role abortion pills might play in the post-Roe era amid increasingly divergent abortion access trends across different regions of the United States.

Facility-Based Tests for Assessment of Outcome Following Medication Abortion provided via Telemedicine

OBJECTIVE

To assess whether planning high sensitivity urine pregnancy tests (HSPT) rather than facility-based tests for medication abortion follow-up may increase risk of unplanned clinical visits or procedural completion of the abortion.

STUDY DESIGN

We used data from the TelAbortion Project, a 5-year study assessing the safety and feasibility of providing mifepristone and misoprostol by telemedicine and mail in the United States. We categorized participants by whether the pre-treatment follow-up plan included HSPT at home 3-5 weeks after treatment or facility-based tests (ultrasound or serum HCG) within 2 weeks after treatment. We used multivariable logistic regression to compare likelihood of post-treatment unplanned, abortion-related clinical visits and procedural intervention in these groups.

RESULTS

Of 1,324 patients who planned HSPT follow-up and 576 who planned facility-based tests, 85% and 83%, respectively, provided outcome information. Post-treatment clinical visits were less frequent in the HSPT group (19%) than in the facility-based test group (79%); most of the latter were to obtain the planned test. However, unplanned, abortion-related visits were significantly more common in the HSPT group (adjusted risk difference: 6.5%; p<0.01). The likelihood of procedural completion did not differ by group. Planned follow-up test was not associated with delay in procedural completion or detection of ongoing pregnancy.

CONCLUSIONS

Follow-up of medication abortion with home HSPT was associated with fewer post-treatment clinical visits, modestly more unplanned, abortion-related clinical visits, and no increase in risk of procedural interventions or delayed identification or management of treatment failures. This option is an appropriate follow-up approach after medication abortion.

IMPLICATIONS

Use of home high-sensitivity pregnancy tests rather than facility-based tests for outcome assessment after medication abortion is associated with a modest increase in unplanned clinical visits but does not lead to an increase in procedural interventions or delays identification and management of treatment failure.

Assessing the need for on-campus medication abortion at California Community Colleges

Objective: No studies have assessed the need for abortion access at California Community Colleges (CCCs), despite recent research and legislative attention toward on-campus medication abortion access at California's public universities, and the fact that CCCs enroll more than twice the number of students per year as the public universities. Methods: A demographic analysis compares student populations at California's public universities and CCCs using publicly-available data. Monthly demand for medication abortion among CCC students is estimated based on campus enrollment data, and age-, method- and state-adjusted abortion rates. Results: There is demographic similarity amongst these student populations with respect to gender and age makeup, supporting the use of methods created to estimate abortion demand in California public university students in this study. It is estimated that in total, CCC students seek 865 - 1,109 medication abortions each month. Conclusions: There is a clear need for medication abortion access at CCCs.

Provider Mistrust and Telemedicine Abortion Care Preferences Among Patients in Ohio, West Virginia, and Kentucky

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.

Society for Maternal-Fetal Medicine Special Statement: Telemedicine in obstetrics-quality and safety considerations

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.

The role of community and culture in abortion perceptions, decisions, and experiences among Asian Americans

Introduction

Culture and community can play a role in views, stigma, and access related to abortion. No research to date has documented the influence of culture and community attitudes on Asian American (AA) experiences accessing abortion care in the United States (US). This paper aims to fill gaps in research and understand how cultural and community views influence medication abortion access and experiences among AAs.

Methods

We used a community-based participatory research approach, which included collaboration among experts in public health, advocates, practitioners, and community partners to understand abortion knowledge, attitudes, and experiences among AAs. Using a semi-structured interview guide, we interviewed twenty-nine eligible people of reproductive age over 18 that self-identified as Asian American or mixed race including Asian American, Native Hawaiian, and/or Pacific Islander (AANHPI), and had a medication abortion in the US between January 2016 and March 2021. Interviews were analyzed and coded in NVivo 12 using a modified grounded theory approach.

Results

Participants described various influences of religion negatively impacting acceptability of abortion among their family and community. Lack of openness around sexual and reproductive health (SRH) topics contributed to stigma and influenced most participants' decision not to disclose their abortion to family members, which resulted in participants feeling isolated throughout their abortion experience. When seeking abortion care, participants preferred to seek care with providers of color, especially if they were AANHPI due to past experiences involving stigma and judgment from White providers. Based on their experiences, respondents recommended ways to improve the abortion experience for AAs in the US including, (1) more culturally aware abortion providers from one's community who better understand their needs; (2) clinics providing abortion services located in or near AA communities with signage in local languages; and (3) tailored mental health resources with culturally aware therapists.

Conclusion

This study demonstrates ways in which culture and community opinions toward SRH can influence both the acceptability of abortion and experiences seeking abortion care among AAs. It is important to consider family and community dynamics among AAs to better tailor services and meet the needs of AAs seeking abortion care in the US.

Medication abortion: State of information on Student Health Center websites

Objective: To document the information on medication abortion on university Student Health Center (SHC) websites. Study Sample: Four-year bachelors granting public universities' Student Health Center websites. Methods: We conduct thematic content analysis for medication abortion-related information on 547 SHC websites in the United States as of August 2022 using computer-assisted software. We validate the software with human annotation. Results: Medication abortion is mentioned on 23 (4%) university SHC websites, and in 13 (57%) of these websites, it is only mentioned to exclude it from definitions of emergency contraception. Only two websites, 6% of the California public schools included in the sample, advertise medication abortion services through their SHC websites. One hundred fifteen (21%) university websites provide links to Planned Parenthood that gives information on how to navigate abortion access across all 50 states. Conclusion: There is inadequate information on SHC websites regarding medication abortion services and how to access them.

Documenting activism and advocacy around medication abortion in Central, East, and West Africa

Medication abortion, a safe and effective method for terminating pregnancy in the first and second trimester, can reduce overall maternal mortality. However, little is known about how advocates for abortion view medication abortion in their communities, particularly where abortion is legally restricted. We conducted in-depth interviews (2018-2019; N=24) with health workers and community leaders in the Democratic Republic of the Congo, Kenya, Nigeria, Malawi, and Tanzania identified from the Mobilizing Activists Around Medication Abortion (MAMA) network. Interviews focused on the role of advocacy in medication abortion provision. Participants identified benefits of medication abortion to women, including privacy, accessibility, and safety, and community benefits, including perceived reduction in maternal mortality. Participants described challenges to providing support for medication abortion, including difficulties operating in legally restrictive environments and stigma. Findings highlight the role of grassroots advocacy to overcome challenges and provide an alternative model of abortion access and care to women.

PAPP-A as a screening tool for assessment of gestational age before medication abortion in an intended-use population

Introduction: Prior studies indicate that PAPP-A could serve as a marker of gestational age (GA) with the potential to determine eligibility for medication abortion. The authors validated the relationship between PAPP-A and GA in an actual-use population. Materials & methods: The authors collected blood samples, medical histories and ultrasound-determined GA from patients presenting for abortion services. They measured PAPP-A using two immunoassays and assessed diagnostic accuracy for predicting GA ≥71 days. Results: The Ansh Labs and R&D Systems immunoassays produced an area under the ROC curve of 0.982 (95% CI: 0.958-0.994) and 0.986 (95% CI: 0.963-0.996), respectively, for predicting GA ≥71 days. Conclusion: This validation study in an intended-use population confirmed that PAPP-A has a strong ability to distinguish pregnancies above and below 71 days' gestation. Clinical trial registration: NCT04232189 (ClinicalTrials.gov).

It's just I wish the process had a bit more humanity to it … a bit more holistic": a qualitative, community-led medication abortion study with Black and Latinx Women in Georgia, USA

Traditional family planning research has excluded Black and Latinx leaders, and little is known about medication abortion (MA) among racial/ethnic minorities, although it is an increasingly vital reproductive health service, particularly after the fall of Roe v. Wade. Reproductive justice (RJ) community-based organisation (CBO) SisterLove led a study on Black and Latinx women's MA perceptions and experiences in Georgia. From April 2019 to December 2020, we conducted key informant interviews with 20 abortion providers and CBO leaders and 32 in-depth interviews and 6 focus groups (n = 30) with Black and Latinx women. We analysed data thematically using a team-based, iterative approach of coding, memo-ing, and discussion. Participants described multilevel barriers to and strategies for MA access, wishing that "the process had a bit more humanity  …  [it] should be more holistic." Barriers included (1) sociocultural factors (intersectional oppression, intersectional stigma, and medical experimentation); (2) national and state policies; (3) clinic- and provider-related factors (lack of diverse clinic staff, long waiting times); and (4) individual-level factors (lack of knowledge and social support). Suggested solutions included (1) social media campaigns and story-sharing; (2) RJ-based policy advocacy; (3) diversifying clinic staff, offering flexible scheduling and fees, community integration of abortion, and RJ abortion funds; and (4) social support (including abortion doulas) and comprehensive sex education. Findings suggest that equitable MA access for Black and Latinx communities in the post-Roe era will require multi-level intervention, informed by community-led evidence production; holistic, de-medicalised, and human rights-based care models; and intersectional RJ policy advocacy.

Patient-controlled intravenous versus on-demand oral, intramuscular or intravenous administration of oxycodone during medical induced abortion from 64 to 128 days of gestation: a randomized controlled trial

OBJECTIVE

To compare oxycodone administration via intravenous patient-controlled analgesia (IVPCA) vs on-demand administration during late-first- and second-trimester medically induced abortion.

STUDY DESIGN

A prospective randomized controlled study. We enrolled women between 64 to 128 days of gestation in the study between June 2016 and August 2018. Participants were randomized to receive oxycodone either via IVPCA or given on-demand orally, intramuscularly or intravenously. Pain intensity and satisfaction with care were measured using the visual analogue scale (VAS, 0-100mm).

RESULTS

Altogether 99 participants were randomized: 48 in IVPCA group and 51 in on-demand group. Median gestational age was similar between groups (74 days [Interquartile range, IQR 69-81] in the IVPCA group vs 72 [69-80] in the control group, p=0.587). Peak maximal pain was severe in both groups (median pain VAS was 62 [IQR 44-84] and 71 [IQR 56-90], p=0.52). The odds for severe pain (highest pain VAS≥70) were similar between the groups (IVPCA group OR 0.51 [95% Confidence Interval 0.22-1.18], p=0.118). In contrast, the odds for mild or tolerable pain (highest pain VAS≤40) were higher in the IVPCA group (OR 4.06 [95% CI 1.05-16.04], p=0.043). Nevertheless, satisfaction with care was high (VAS 94 [89-100]) in both groups. Of those experiencing severe pain, 94.0% declared pain medication as adequate.

CONCLUSIONS

Women often experience severe pain during medical abortion irrespective of the mode of opiate administration. Oxycodone administration via IVPCA permits women to self-administer analgesics when experiencing pain, raising the odds for mild or tolerable pain during abortion care. Satisfaction with care was high.

Exploring Illinois Contraceptive Providers' Interest in Medication Abortion Training

OBJECTIVE

To explore Illinois contraceptive providers' interest in medication abortion training.

STUDY DESIGN

We surveyed Illinois contraceptive providers to explore associations between interest in medication abortion training and provider, practice, and patient variables.

RESULTS

Of 1040 reachable, eligible contacts, 251 responded to the survey (24% response rate) and more than half (56%) expressed interest in medication abortion training. Providers with the highest interest in medication abortion training were those with <2 days' formal contraceptive training (n=31; 76%) and those who received Title X funding (n= 32; 81%).

CONCLUSIONS

Findings suggest interest in medication abortion training among Illinois contraceptive providers.

IMPLICATIONS

Our findings suggest some contraceptive providers may be interested in training opportunities around medication abortion. More research is needed to understand whether additional training could increase the number of providers able to counsel, refer, and provide medication abortion.

Remote Delivery in Reproductive Health Care: Operation of Direct-to-Patient Telehealth Medication Abortion Services in Diverse Settings

PURPOSE

Established models of reproductive health service delivery were disrupted by the coronavirus disease 2019 (COVID-19) pandemic. This study examines rapid innovation of remote abortion service operations across health care settings and describes the use of telehealth consultations with medications delivered directly to patients.

METHODS

We conducted semi-structured interviews with 21 clinical staff from 4 practice settings: family planning clinics, online medical services, and primary care practices-independent or within multispecialty health systems. Clinicians and administrators described their telehealth abortion services. Interviews were recorded, transcribed, and analyzed. Staff roles, policies, and procedures were compared across practice settings.

RESULTS

Across all practice settings, telehealth abortion services consisted of 5 operational steps: patient engagement, care consultations, payment, medication dispensing, and follow-up communication. Online services and independent primary care practices used asynchronous methods to determine eligibility and complete consultations, resulting in more efficient services (2-5 minutes), while family planning and health system clinics used synchronous video encounters requiring 10-30 minutes of clinician time. Family planning and health system primary care clinics mailed medications from clinic stock or internal pharmacies, while independent primary care practices and online services often used mail-order pharmacies. Online services offered patients asynchronous follow-up; other practice settings scheduled synchronous appointments.

CONCLUSIONS

Rapid innovations implemented in response to disrupted in-person reproductive health care included remote medication abortion services with telehealth assessment/follow-up and mailed medications. Though consistent operational steps were identified across health care settings, variation allowed for adaptation of services to individual sites. Understanding remote abortion service operations may facilitate dissemination of a range of patient-centered reproductive health services.Annals "Online First" article.

Mifepristone, preemption, and public health federalism

On June 24, 2022, the Supreme Court issued an opinion in which five justices voted to overturn Roe v Wade. Even before the final opinion issued, scholars and advocates had begun to consider legal strategies that might mitigate the decision's anticipated harmful consequences. One such strategy involves challenging state restrictions on Food and Drug Administration (FDA)-approved pregnancy termination drugs on preemption grounds. This article begins by exploring how these challenges might fare-considering both drug-specific restrictions and complete bans on abortion-arguing that there are compelling legal grounds on which courts should conclude that many state restrictions are preempted. Importantly, although these state restrictions have arisen within a larger debate about reproductive health care, this is far from the only area in which states seek to regulate prescription drugs. States have long regulated drugs in ways that diverge from FDA, arguably increasingly so in recent years. Accordingly, the article investigates the implications that preemption challenges in the abortion context may have for other areas of state drug regulation, making the case that the benefits of public health federalism need not be undermined by successful preemption challenges in the abortion arena.

Effectiveness and safety of a direct-to-patient telehealth service providing medication abortion targeted at rural and remote populations: Cross-sectional findings from Marie Stopes Australia

OBJECTIVES

We assessed the safety and effectiveness of direct-to-patient telehealth provision of medication abortion in Australia.

STUDY DESIGN

We included all medication abortions (January 2017-December 2018) from Marie Stopes Australia's patient management and adverse event reporting systems. We defined effectiveness as whether the patient had a continuing pregnancy, incomplete abortion, and/or subsequent vacuum aspiration or procedural abortion and safety as whether the patient experienced any adverse event.

RESULTS

Direct-to-patient telehealth was more effective than in-clinic provision (97.2% versus 95.4%). The proportion of adverse events did not differ between groups.

CONCLUSIONS

This direct-to-patient telehealth service is safe and effective.

Accuracy of self-assessment of gestational duration among people seeking abortion

BACKGROUND

Mifepristone, used together with misoprostol, is approved by the United States Food and Drug Administration for medication abortion through 10 weeks' gestation. Although in-person ultrasound is frequently used to establish medication abortion eligibility, previous research demonstrates that people seeking abortion early in pregnancy can accurately self-assess gestational duration using the date of their last menstrual period.

OBJECTIVE

In this study, we establish the screening performance of a broader set of questions for self-assessment of gestational duration among a sample of people seeking abortion at a wide range of gestations.

STUDY DESIGN

We surveyed patients seeking abortion at 7 facilities before ultrasound and compared self-assessments of gestational duration using 11 pregnancy dating questions with measurements on ultrasound. For individual pregnancy dating questions and combined questions, we established screening performance focusing on metrics of diagnostic accuracy, defined as the area under the receiver operating characteristic curve, sensitivity (or the proportion of ineligible participants who correctly screened as ineligible for medication abortion), and proportion of false negatives (ie, the proportion of all participants who erroneously screened as eligible for medication abortion). We tested for differences in sensitivity across individual and combined questions using McNemar's test, and for differences in accuracy using the area under the receiver operating curve and Sidak adjusted P values.

RESULTS

One-quarter (25%) of 1089 participants had a gestational duration of >70 days on ultrasound. Using the date of last menstrual period alone demonstrated 83.5% sensitivity (95% confidence interval, 78.4-87.9) in identifying participants with gestational durations of >70 days on ultrasound, with an area under the receiver operating characteristic curve of 0.82 (95% confidence interval, 0.79-0.85) and a proportion of false negatives of 4.0%. A composite measure of responses to questions on number of weeks pregnant, date of last menstrual period, and date they got pregnant demonstrated 89.1% sensitivity (95% confidence interval, 84.7-92.6) and an area under the receiver operating curve of 0.86 (95% confidence interval, 0.83-0.88), with 2.7% of false negatives. A simpler question set focused on being >10 weeks or >2 months pregnant or having missed 2 or more periods had comparable sensitivity (90.7%; 95% confidence interval, 86.6-93.9) and proportion of false negatives (2.3%), but with a slightly lower area under the receiver operating curve (0.82; 95% confidence interval, 0.79-0.84).

CONCLUSION

In a sample representative of people seeking abortion nationally, broadening the screening questions for assessing gestational duration beyond the date of the last menstrual period resulted in improved accuracy and sensitivity of self-assessment at the 70-day threshold for medication abortion. Ultrasound assessment for medication abortion may not be necessary, especially when requiring ultrasound could increase COVID-19 risk or healthcare costs, restrict access, or limit patient choice.

U.S. Abortion Care Providers' Perspectives on Self-Managed Abortion

State-level restrictions on abortion access may prompt greater numbers of people to self-manage their abortion. The few studies exploring perspectives of providers towards self-managed abortion are focused on physicians and advanced practice clinicians. Little is known about the wider spectrum of abortion care providers who encounter self-managed abortion in their clinic-based work. To gain a deeper understanding of this issue and inform future care delivery, we conducted in-depth interviews with 46 individuals working in a range of positions in 46 abortion clinics across 29 states. Our interpretative analysis resulted in themes shaped by beliefs about safety and autonomy, and a tension between the two: that self-managed abortion is too great a risk, that people are capable of self-managing an abortion, and that people have a right to a self-managed abortion. Our findings highlight the importance of increasing knowledge and clarifying values among all abortion care providers, including clinic staff.

Addressing Structural Inequities, a Necessary Step Toward Ensuring Equitable Access to Telehealth for Medication Abortion Care During and Post COVID-19

Telehealth, one of the newest health innovations, has been promoted as a tool to enhance access to health care services in ways that center patient needs. However, integrating telehealth within an inequitable health system undermines its potential. This perspective highlights policies and practices that foster structural inequities and names their impact on the use and acceptability of telehealth for medication abortion among specific communities of color. Communities of color have a higher prevalence of abortion use but face many barriers, including financial and geographic barriers, to abortion access. Preliminary evidence on telehealth for medication abortion shows that it is highly acceptable, accommodating of patient needs, and may allow patients to access abortion care at earlier gestational ages. However, evidence during the COVID-19 pandemic shows that utilization of telehealth is lower among communities of color. We describe how systemic barriers, including regulations on or laws banning telehealth for medication abortion, disinvestments in digital access, and restrictions on public insurance coverage, could perpetuate lower utilization of telehealth for medication abortion care among communities of color. We call for systems changes that will remove these barriers and make this health care innovation available to all who may desire it.

Integrating mifepristone into primary care in Canada's capital: A multi-methods exploration of the Medical Abortion Access Project

OBJECTIVES

Following the 2017 introduction of mifepristone in Canada and both ensuing regulatory changes and increased demand for medication abortion care, Planned Parenthood Ottawa created the Medical Abortion Access Project (MAAP). This study aimed to document outcomes, identify facilitators and barriers, and distill learnings from an initiative that sought to recruit and support primary care clinicians in providing mifepristone/misoprostol in Canada's capital.

METHODS

We employed a multi-methods evaluation strategy that included reviewing MAAP-related documents, evaluating the project log, and conducting in-depth interviews with clinicians at five sites. In the final analytic phase, we integrated the findings from the different evaluation components.

RESULTS

From May 2017 through July 2018, the MAAP helped 14 primary care facilities in Ottawa become medication abortion providers; nine began providing mifepristone/misoprostol to existing patients and five began offering mifepristone/misoprostol to the public. The program recruited four new pharmacies to stock the combination package and trained two sonography clinics in abortion-related protocols. Program participants identified patient demand as a key driver of medication abortion provision but required information and logistical support from the MAAP to operationalize service delivery. New abortion providers reflected positively on the community of practice that the MAAP created, which enabled them to offer and receive technical and emotional support from colleagues across the city.

CONCLUSIONS

A number of primary care clinicians in Ottawa were able to successfully integrate medication abortion care into their practices with MAAP support. Future research should explore whether this type of community-based intervention can be replicated in other settings.

IMPLICATIONS

Evidence-based regulation of mifepristone by health authorities is a critical step to increasing access to medication abortion care. However, deregulation alone was insufficient to integrate medication abortion services into primary care in Ottawa. Community-based programs like the MAAP can help providers make sense of shifting regulations and practice guidelines, overcome logistical barriers, and ultimately increase access to this medically necessary service. Establishing and facilitating communities of practice is especially important for new primary care providers.

Patient and provider experiences using a site-to-site telehealth model for medication abortion

BACKGROUND

In the site-to-site telehealth for medication abortion model, patients visit a health center to meet with a remote clinician using telehealth technology. This model is safe, effective, and acceptable to patients and providers. The objective of this study was to document the experiences of patients and providers using telehealth for medication abortion in Planned Parenthood health centers across different geographical contexts in the United States.

METHODS

We conducted in-depth interviews with Planned Parenthood medication abortion patients who either met with a clinician at the clinic via telehealth or in-person about their experiences receiving care. We also interviewed Planned Parenthood staff members about their experiences implementing telehealth for medication abortion at their health center.

RESULTS

We interviewed 29 patients who received care at Planned Parenthood health centers in five states. Both telehealth and in-person patients described positive interactions with health center staff and clinicians. The vast majority of telehealth patients said that they felt comfortable speaking with the clinician over telehealth and had no trouble using the telehealth technology. We interviewed 12 providers, including clinicians and administrative staff, who worked in seven states. Providers largely thought that telehealth for medication abortion expanded access to medication abortion.

CONCLUSIONS

Across different locations, our findings indicate that patients found telehealth for medication abortion services to be highly acceptable and providers found that telehealth services may help improve medication abortion access. As the use of telehealth for medication abortion expands, future research should include additional measures of quality to ensure that services are acceptable across different identities and experiences, including age, race, gender, and income level.

Knowledge, Practice and Associated Factors Towards Medication Abortion Among Reproductive-Age Women in Sexual and Reproductive Health Clinics of Addis Ababa, Ethiopia, 2018: Cross-Sectional Study

Background

Abortion rates following unintended pregnancies are increasing in developing countries, and unsafe abortion is a commonly neglected reproductive health-care problem. In Ethiopia, the number of women receiving treatment for complications from unsafe abortion is increasing. Improving the level of knowledge of reproductive-age women on medication abortion contributes to the prevention of unsafe abortion. Therefore, the purpose of this study was to assess knowledge, and practice of medication abortion and associated factors among women in SRH clinics of Addis Ababa, Ethiopia, 2018.

Methods

A cross-sectional quantitative study design was conducted to collect data from 30th February to March 30, 2018. Study participants were selected by using a convenient sampling technique. The data were coded and entered into EpiData version 4.2, and SPSS version 23 was used for analysis. Bivariate and multivariate analysis with 95% CI were employed. The strength of association was declared at a P value <0.05.

Results

The overall knowledge and practice of medication abortion were 72.1%, and 33%, respectively. Participants level of education (AOR=3.54, 95% CI (1.02, 12.26)), father education (AOR=2.80, 95% CI (1.42, 5.52)), participants way of living (AOR=6.08, 95% CI (2.41, 15.33)), income (AOR=2.19, 95% CI (1.02, 4.75)), and history of unwanted pregnancy (AOR=11.7, 95% CI (1.11, 12.46)) were some of the factors associated with knowledge and practice of medication abortion.

Conclusion

This study provided that women were relatively knowledgeable but their practice on medication abortion was low. The low practice of medication abortion call health-care providers to give due attention to awareness creation and strengthened action to provide quality maternal care for childbearing mothers towards medication abortion and unsafe abortion in particular.

Abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States

Background

Transgender, nonbinary, and gender-expansive people who were assigned female or intersex at birth experience pregnancy and have abortions. Scarce data have been published on individual abortion experiences or preferences of this understudied population.

Objective

This study aimed to fill existing evidence gaps on the abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States to inform policies and practices to improve access to and quality of abortion care for this population.

Study Design

In 2019, we recruited transgender, nonbinary, and gender-expansive people who were assigned female or intersex at birth at the age of ≥18 years from across the United States to participate in an online survey about sexual and reproductive health recruited through The Population Research in Identities and Disparities for Equality Study and online postings. We descriptively analyzed closed- and open-ended survey responses related to pregnancy history, abortion experiences, preferences for abortion method, recommendations to improve abortion care for transgender, nonbinary, and gender-expansive people, and respondent sociodemographic characteristics.

Results

Most of the 1694 respondents were <30 years of age. Respondents represented multiple gender identities and sexual orientations and resided across all 4 United States Census Regions. Overall, 210 respondents (12%) had ever been pregnant; these 210 reported 433 total pregnancies, of which 92 (21%) ended in abortion. For respondents’ most recent abortion, 41 (61%) were surgical, 23 (34%) were medication, and 3 (5%) were another method (primarily herbal). Most recent abortions took place at ≤9 weeks’ gestation (n=41, 61%). If they were to need an abortion today, respondents preferred medication abortion over surgical abortion in a 3:1 ratio (n=703 vs n=217), but 514 respondents (30%) did not know which method they would prefer. The reasons for medication abortion preference among the 703 respondents included a belief that it is the least invasive method (n=553, 79%) and the most private method (n=388, 55%). To improve accessibility and quality of abortion care for transgender, nonbinary, and gender-expansive patients, respondents most frequently recommended that abortion clinics adopt gender-neutral or gender-affirming intake forms, that providers use gender-neutral language, and that greater privacy be incorporated into the clinic.

Conclusion

These data contribute substantially to the evidence base on individual experiences of and preferences for abortion care for transgender, nonbinary, and gender-expansive people. Findings can be used to adapt abortion care to better include and affirm the experiences of this underserved population.

Studying Accompaniment model Feasibility and Effectiveness (SAFE) Study: study protocol for a prospective observational cohort study of the effectiveness of self-managed medication abortion

INTRODUCTION

A range of barriers deter or prevent people from accessing facility-based abortion care. As a result, people are obtaining and using abortifacient medications to end their pregnancies outside of the formal healthcare system, without clinical supervision. One model of self-managed abortion has come to be known as the 'accompaniment' model, in which grassroots organisations provide pregnant people with evidence-based counselling and support through the medication abortion process. Data are needed to understand the safety and effectiveness of this increasingly common model of abortion care.

METHODS AND ANALYSIS

This is a large, prospective, observational study in Argentina and Nigeria. All people who contact one of two accompaniment groups seeking information for their own self-managed medication abortion, are ages 13 years and older, have no contraindications for medication abortion, are within the gestational range supported by the group (up to 12 weeks' gestation for the primary outcome) and are willing to be contacted for follow-up will be recruited. Participants will respond to an interviewer-administered baseline survey at enrolment, and 1-4 additional surveys over 6 weeks to ascertain whether they obtain medications for abortion, dosing and route of administration of medications, physical and emotional experience of medication abortion self-management, and effectiveness and safety outcomes. Analyses will include estimates of the primary outcome: the proportion of participants that report a complete abortion without surgical intervention at last recorded follow-up; as well as secondary outcomes including a pseudo-experimental test of non-inferiority of the effectiveness of self-managed medication abortion as compared with clinical medication abortion.

ETHICS AND DISSEMINATION

We describe the ethical considerations and protections for this study, as well the creation of a study-specific Data Monitoring and Oversight Committee. We describe dissemination plans to ensure that study results are shared widely with all relevant audiences, particularly researchers, advocates, policymakers and clinicians.

TRIAL REGISTRATION NUMBER

ISRCTN95769543.

Medication to Manage Abortion and Miscarriage

Abortion and miscarriage are common, affecting millions of US women each year. By age 45, one in four women in the USA will have had an abortion, and at least as many will have had a miscarriage. Most individuals seeking abortion services do so before 10 weeks' gestation when medication abortions are a safe and effective option, using a regimen of oral mifepristone followed by misoprostol tablets. When a pregnancy is non-viable before 13 weeks' gestation, it is referred to as an early pregnancy loss or miscarriage and can be managed using the same mifepristone and misoprostol regimen. Given their safety and efficacy, mifepristone and misoprostol can be offered in ambulatory settings without special equipment or on-site emergency services. As more patients find it difficult to access clinical care when faced with an undesired pregnancy or a miscarriage, it is important for general internists and primary care providers to become familiar with how to use medications to manage these common conditions. We summarize the most recent evidence regarding the use of mifepristone with misoprostol for early abortion and miscarriage. We discuss clinical considerations and resources for integrating mifepristone and misoprostol into clinical practice. By learning to prescribe mifepristone and misoprostol, clinicians can expand access to time-sensitive health services for vulnerable populations.

Knowledge, interest, and motivations surrounding self-managed medication abortion among patients at three Texas clinics

BACKGROUND

A rapid increase in restrictive abortion legislation in the United States has sparked renewed interest in self-managed abortion as a response to clinic access barriers. Yet little is known about knowledge of, interest in, and experiences of self-managed medication abortion among patients who obtain abortion care in a clinic.

OBJECTIVES

We examined patients' knowledge of, interest in, and experience with self-managed medication abortion before presenting to the clinic. We characterized the clinic- and person-level factors associated with these measures. Finally, we examined the reasons why patients express an interest in or consider self-management before attending the clinic.

MATERIALS AND METHODS

We surveyed 1502 abortion patients at 3 Texas clinics in McAllen, San Antonio, and Fort Worth. All individuals seeking abortion care who could complete the survey in English or Spanish were invited to participate in an anonymous survey conducted using iPads. The overall response rate was 90%. We examined the prevalence of 4 outcome variables, both overall and separately by site: (1) knowledge of self-managed medication abortion; (2) having considered self-managing using medications before attending the clinic; (3) interest in medication self-management as an alternative to accessing care at the clinic; and (4) having sought or tried any method of self-management before attending the clinic. We used binary logistic regression models to explore the clinic- and patient-level factors associated with these outcome variables. Finally, we analyzed the reasons reported by those who had considered medication self-management before attending the clinic, as well as the reasons reported by those who would be interested in medication self-management as an alternative to in-clinic care.

RESULTS

Among all respondents, 30% knew about abortion medications available outside the clinic setting (37% in Fort Worth, 33% in McAllen, 19% in San Antonio, P < .001), and among those with prior knowledge, 28% had considered using this option before coming to the clinic (36% in McAllen, 25% in Fort Worth, 21% in San Antonio, P = .028). Among those without prior knowledge of self-management, 39% expressed interest in this option instead of coming to the clinic (54% in San Antonio, 30% in McAllen, 29% in Fort Worth, P < .001). Overall, 13% had sought out or tried any method of self-management before presenting to the clinic (16% in McAllen and 15% in Fort Worth vs 9% in San Antonio, P < .001). Experiencing barriers to clinic access was associated with having considered medication self-management (odds ratio, 2.2; 95% confidence interval, 1.7-3.0) and with seeking or trying any method of self-management before attending the clinic (odds ratio, 1.9; 95% confidence interval, 1.3-2.7). Difficulty affording the cost of in-clinic care was the most commonly cited reason for having considering medication self-management before attending the clinic. Reasons for interest in medication self-management as an alternative to clinic care included both access barriers and preferences for the privacy and comfort of home.

CONCLUSION

Considering or attempting self-managed abortion may be part of the pathway to seeking in-clinic care, particularly among those experiencing access barriers. However, considerable interest in medication self-management as an alternative to the clinic also suggests a demand for more autonomous abortion care options.

Second-trimester medication abortion outside the clinic setting: an analysis of electronic client records from a safe abortion hotline in Indonesia

INTRODUCTION

Unsafe abortion past the first trimester disproportionately accounts for the majority of global abortion-related morbidity and mortality; research that documents the safety, feasibility and acceptability of existing models for providing information and support to women who self-manage outside of formal clinic settings is needed.

METHODS

This study is a retrospective analysis of anonymised electronic client records from callers to a safe abortion hotline in Indonesia. Between July 2012 and October 2016, a total of 96 women contacted the hotline for information on medication abortion beyond 12 weeks' gestation and are included in this study. Descriptive statistics were calculated regarding pregnancy termination status, client experience with warning signs of potential complications, and medical care seeking and treatment.

RESULTS

Ninety-six women with pregnancies beyond the first trimester called the hotline for information on medication abortion; 91 women received counselling support from the hotline. Eighty-three women (91.2%) successfully terminated their pregnancies using medication and did not seek medical care. Five women exhibited warning signs of potential complications and sought medical care; one woman sought care after a failed abortion. Two women were lost to follow-up and the outcomes of their pregnancies are unknown.

CONCLUSIONS

Evidence from our analysis suggests that a model of remote provision of support for abortions later in pregnancy by non-medically trained, skilled abortion counsellors could be a safe alternative for women in need of abortions beyond 12 weeks' gestation in a legally restrictive context. Further examination and documentation of the model is warranted.

Sociodemographic Characteristics of Women Able to Obtain Medication Abortion Before and After Ohio's Law Requiring Use of the Food and Drug Administration Protocol

Purpose: In 2011, a law went into effect in Ohio that regulates how abortion care providers can offer medication abortion to their patients. We sought to evaluate changes in sociodemographic characteristics of Ohio medication abortion patients before and after the implementation of this law. Methods: We used a retrospective cohort design, comparing characteristics of women obtaining a medication abortion at four abortion facilities before and after the law. We used chart data from January 2010 to January 2011 and February 2011 to October 2014. For any significant changes in sociodemographics found before and after the law, we used stratified cross-tabulations to disentangle whether they were likely related to the restricted gestational limit imposed by the law (lowered from 9 to 7 weeks gestation), or whether they were likely related to other burdens brought on by the law, such as increased costs and visits. Results: Women obtaining a medication abortion after the law were more likely to be older (p=0.01), have higher levels of education (p<0.001), be of white race (p<0.001), have private insurance (p=0.001), have no children (p=0.002), and reside in a higher income zip code (p=0.03). Both the reduced gestational limit and the increased costs and visits likely contributed to declines among black women and women with lower levels of education. The reduced gestational limit for medication abortion likely contributed to a decline among younger women and Medicaid recipient groups. The increased costs and visits imposed by the law likely contributed to the decline in medication abortion among women with no insurance and women with children. Conclusion: The lower gestational limit, higher cost, and time and travel burdens exacted by Ohio's medication abortion law were associated with disproportionate reductions in medication abortion among the most disadvantaged groups. The law was associated with reduced access among women who were younger, of black race, less educated, and in lower socioeconomic groups.

Contraception after medication abortion in the United States: results from a cluster randomized trial

BACKGROUND

Understanding how contraceptive choices and access differ for women having medication abortions compared to aspiration procedures can help to identify priorities for improved patient-centered postabortion contraceptive care.

OBJECTIVE

The objective of this study was to investigate the differences in contraceptive counseling, method choices, and use between medication and aspiration abortion patients.

STUDY DESIGN

This subanalysis examines data from 643 abortion patients from 17 reproductive health centers in a cluster, randomized trial across the United States. We recruited participants aged 18-25 years who did not desire pregnancy and followed them for 1 year. We measured the effect of a full-staff contraceptive training and abortion type on contraceptive counseling, choice, and use with multivariable regression models, using generalized estimating equations for clustering. We used survival analysis with shared frailty to model actual intrauterine device and subdermal implant initiation over 1 year.

RESULTS

Overall, 26% of participants (n = 166) had a medication abortion and 74% (n = 477) had an aspiration abortion at the enrollment visit. Women obtaining medication abortions were as likely as those having aspiration abortions to receive counseling on intrauterine devices or the implant (55%) and on a short-acting hormonal method (79%). The proportions of women choosing to use these methods (29% intrauterine device or implant, 58% short-acting hormonal) were also similar by abortion type. The proportions of women who actually used short-acting hormonal methods (71% medication vs 57% aspiration) and condoms or no method (20% vs 22%) within 3 months were not significantly different by abortion type. However, intrauterine device initiation over a year was significantly lower after the medication than the aspiration abortion (11 per 100 person-years vs 20 per 100 person-years, adjusted hazard ratio, 0.50; 95% confidence interval, 0.28-0.89). Implant initiation rates were low and similar by abortion type (5 per 100 person-years vs 4 per 100 person-years, adjusted hazard ratio, 2.41; 95% confidence interval, 0.88-6.59). In contrast to women choosing short-acting methods, relatively few of those choosing a long-acting method at enrollment, 34% of medication abortion patients and 53% of aspiration abortion patients, had one placed within 3 months. Neither differences in health insurance nor pelvic examination preferences by abortion type accounted for lower intrauterine device use among medication abortion patients.

CONCLUSION

Despite similar contraceptive choices, fewer patients receiving medication abortion than aspiration abortion initiated intrauterine devices over 1 year of follow-up. Interventions to help patients receiving medication abortion to successfully return for intrauterine device placement are warranted. New protocols for same-day implant placement may also help patients receiving medication abortion and desiring a long-acting method to receive one.

Building Bridges: A Case for Community Health Worker Provision of Misoprostol-Only Abortion in the First Trimester

INTRODUCTION

The consequences of unsafe abortion are devastating to women, their families, and their communities. Medication abortion presents an important alternative to harmful self-induction practices and surgical intervention under questionable circumstances. In settings where mifepristone is unavailable, the use of misoprostol alone is a safe and effective option for terminating an unwanted pregnancy. Studies have demonstrated the safety and efficacy of administration of misoprostol by community health workers (CHW) for indications such as postpartum hemorrhage and treatment of incomplete abortion.

OBJECTIVES

The current study assesses the safety and efficacy of CHW managing misoprostol-only abortion in the first trimester.

METHODS

A retrospective review of clinical files of women who received abortion services in three countries in Latin America between April 2009 and December 2015 included analysis of 173 cases.

RESULTS

In 94% of cases, the pregnancy was terminated without any further intervention. In the remaining cases, clients were referred for manual vacuum aspiration. In four cases, a complication was reported by the provider. In one, the complication was promptly resolved through referral to a higher level of care; in the remaining three, the complication was resolved directly by the provider. In 98% of cases, women reported being satisfied with the treatment they received.

CONCLUSION

This study demonstrates that CHW are able to provide misoprostol-only abortion services to women effectively and safely. The benefits of this model of care also extend beyond the abortion service: CHW are able to offer women a comprehensive range of quality health services, including contraceptive services, increasing access to vital healthcare in areas with few other options.

Knowledge of medication abortion among adolescent medicine providers

PURPOSE

Adolescents are at high risk for unintended pregnancy and abortion. The purpose of this study was to understand whether providers caring for adolescents have the knowledge to counsel accurately on medication abortion, a suitable option for many teenagers seeking to terminate a pregnancy.

METHODS

Using an online questionnaire, a survey related to medication abortion was administered to U.S. providers in the Society for Adolescent Health and Medicine. We conducted χ(2) analyses to evaluate the knowledge of medication abortion by reported adolescent medicine fellowship training, and to compare responses to specific knowledge questions by medication abortion counseling. Furthermore, we examined the relationship between providers' self-assessed and actual knowledge using ANOVA.

RESULTS

We surveyed 797 providers, with a 54% response rate. Almost 25% of respondents incorrectly believed that medication abortion was not very safe, 40% misidentified that it was < 95% effective, and 32% did not select the correct maximum recommended gestational age (7-9 weeks). Providers had difficulty identifying that serious complications of medication abortion are rare. Those who counseled on medication abortion had more accurate information in all knowledge categories, except for expected outcomes. Medication abortion knowledge did not differ by adolescent medicine fellowship completion. Only 32% of respondents had very good knowledge, and self-assessed knowledge minimally predicted actual knowledge (r(2) = .08).

CONCLUSIONS

Knowledge regarding medication abortion safety, effectiveness, expected outcomes, and complications is suboptimal even among adolescent medicine fellowship trained physicians, and self-assessment poorly predicts actual knowledge. To ensure pregnant teenagers receive accurate counseling on all options, adolescent medicine providers need better education on medication abortion.