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

No-Test Telehealth Medication Abortion Services Provided by US-Based Clinicians in 21 States and the District of Columbia, 2020‒2022

Objectives. To evaluate the association between distance from closest abortion facility and number of fulfilled requests through no-test telehealth medication abortion (NTMA) asynchronous service. Methods. Using deidentified 2020-2022 electronic medical record data from Aid Access users in US states where NTMA is prescribed by US-based clinicians, we describe individual user demographics and their resident county characteristics. We conducted a county-level geospatial analysis of distance to abortion facility (Myers Abortion Facility Database) on fulfilled requests using Poisson regression. Results. US-based clinicians fulfilled NTMA requests to 8411 individuals in 21 states and the District of Columbia. Each 100-mile increase in distance to an abortion facility increased per-capita NTMA by 61% (95% confidence interval [CI] = 26%, 86%). Most individuals were aged 20 to 29 years (54%), had no living children (57%), were less than 6 weeks' gestation (62%), and lived in urban areas (65%). Almost half (49%) lived in higher socially vulnerable counties compared with 17% in less socially vulnerable counties. Conclusions. In the United States, telehealth medication abortion is a critically important service for individuals who are young, socially vulnerable, and living in counties far from abortion care facilities. Public Health Implications. With abortion now banned or highly restricted in 22 US states, telehealth abortion services are necessary to maintain essential reproductive health services. (Am J Public Health. 2025;115(2):221-231. https://doi.org/10.2105/AJPH.2024.307892).

Factors Affecting Willingness to Provide Medication Abortion Among North American Society for Pediatric and Adolescent Gynecology Members Caring for Adolescents and Young Adults Following the Dobbs Decision

STUDY OBJECTIVE

To assess willingness to provide medication abortion among North American Society for Pediatric and Adolescent Gynecology (NASPAG) clinicians caring for adolescents and young adults (AYA) following Dobbs v. Jackson Women's Health Organization.

DESIGN

Cross-sectional online survey.

METHODS

Potential participants received an e-mail invitation via the NASPAG listserv. A 43-item questionnaire queried demographics, practice setting, abortion training and practice, willingness to provide medication abortion, potential or real barriers to providing medication abortion, and sentiments of abortion. Descriptive statistics, χ2, and Fisher's exact tests were used.

RESULTS

Of the 70 participants, 51% were willing to provide a medication abortion for an adolescent who requested it in their clinical practice. The most common barriers to providing medication abortion were legislative restrictions (47%) and dispensing pills from clinic (33%). Participants' willingness to provide a medication abortion differed by type of practice (P = .001), availability of mifepristone (P = .006), perception of state's abortion policy (P = .001), concern about legislative restrictions (P = .008), experience providing abortion (P = .04), and receipt of medication abortion training (P = .02). Willingness to provide medication abortion also differed based on various sentiments of abortion measured but not on opinion regarding legality of abortion for adolescents (P = .49).

CONCLUSIONS

Perception of state's abortion rights and concern about legislative restrictions influenced NASPAG clinicians' willingness to provide medication abortion for adolescents. Interventions to minimize legislative interference with medical care, increase abortion training, and implement medication abortion in pediatric settings may expand AYA medication abortion access.

Demand for abortion training and technical assistance in primary care: Unmet need and programmatic interventions

OBJECTIVE

Quantify primary care provider requests for abortion training and technical assistance (TA) and availability of programs to support abortion provision.

STUDY DESIGN

We reviewed requests for training and TA from four programs focused on capacity building for abortion care. Collectively, these programs serve every region of the United States.

RESULTS

Between January 1, 2021 - September 30, 2022, the programs received 207 requests for training and/or TA from individuals and organizations in 30 states. Approximately 60% of requests went unfulfilled due to programs' capacity constraints.

CONCLUSIONS

Unmet demand for training and TA to integrate abortion into primary care is significant. Increasing the availability of training and TA could increase the abortion workforce and improve access to care.

Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion After In-Person Screening

Importance

Before 2021, the US Food and Drug Administration required mifepristone to be dispensed in person, limiting access to medication abortion.

Objective

To estimate the effectiveness, acceptability, and feasibility of dispensing mifepristone for medication abortion using a mail-order pharmacy.

Design, Setting, and Participants

This prospective cohort study was conducted from January 2020 to May 2022 and included 11 clinics in 7 states (5 abortion clinics and 6 primary care sites, 4 of which were new to abortion provision). Eligible participants were seeking medication abortion at 63 or fewer days' gestation, spoke English or Spanish, were age 15 years or older, and were willing to take misoprostol buccally. After assessing eligibility for medication abortion through an in-person screening, mifepristone and misoprostol were prescribed using a mail-order pharmacy. Patients had standard follow-up care with the clinic. Clinical information was collected from medical records. Consenting participants completed online surveys about their experiences 3 and 14 days after enrolling. A total of 540 participants were enrolled; 10 withdrew or did not take medication. Data were analyzed from August 2022 to December 2023.

Intervention

Mifepristone, 200 mg, and misoprostol, 800 µg, prescribed to a mail-order pharmacy and mailed to participants instead of dispensed in person.

Main Outcomes and Measures

Proportion of patients with a complete abortion with medications only, reporting satisfaction with the medication abortion, and reporting timely delivery of medications.

Results

Clinical outcome information was obtained and analyzed for 510 abortions (96.2%) among 506 participants (median [IQR] age, 27 [23-31] years; 506 [100%] female; 194 [38.3%] Black, 88 [17.4%] Hispanic, 141 [27.9%] White, and 45 [8.9%] multiracial/other individuals). Of these, 436 participants (85.5%; 95% CI, 82.2%-88.4%) received medications within 3 days. Complete abortion occurred after medication use in 499 cases (97.8%; 95% CI, 96.2%-98.9%). There were 24 adverse events (4.7%) for which care was sought for medication abortion symptoms; 3 patients (0.6%; 95% CI, 0.1%-1.7%) experienced serious adverse events requiring hospitalization (1 with blood transfusion); however, no adverse events were associated with mail-order dispensing. Of 477 participants, 431 (90.4%; 95% CI, 87.3%-92.9%) indicated that they would use mail-order dispensing again for abortion care, and 435 participants (91.2%; 95% CI, 88.3%-93.6%) reported satisfaction with the medication abortion. Findings were similar to those of other published studies of medication abortion with in-person dispensing.

Conclusions and Relevance

The findings of this cohort study indicate that mail-order pharmacy dispensing of mifepristone for medication abortion was effective, acceptable to patients, and feasible, with a low prevalence of serious adverse events. This care model should be expanded to improve access to medication abortion services.

Primary care and abortion provider perspectives on mail-order medication abortion: a qualitative study

BACKGROUND

This qualitative study aims to assess perspectives of clinicians and clinic staff on mail-order pharmacy dispensing for medication abortion.

METHODS

Participants included clinicians and staff involved in implementing a mail-order dispensing model for medication abortion at eleven clinics in seven states as part of a prospective cohort study, which began in January 2020 (before the FDA removed the in-person dispensing requirement for mifepristone). From June 2021 to July 2022, we invited participants at the participating clinics, including six primary care and five abortion clinics, to complete a semi-structured video interview about their experiences. We then conducted qualitative thematic analysis of interview data, summarizing themes related to perceived benefits and concerns about the mail-order model, perceived patient interest, and potential barriers to larger-scale implementation.

RESULTS

We conducted 24 interviews in total with clinicians (13 physicians and one nurse practitioner) and clinic staff (n = 10). Participants highlighted perceived benefits of the mail-order model, including its potential to expand abortion services into primary care, increase patient autonomy and privacy, and to normalize abortion services. They also highlighted key logistical, clinical, and feasibility concerns about the mail-order model, and specific challenges related to integrating abortion into primary care.

CONCLUSION

Clinicians and clinic staff working in primary care and abortion clinics were optimistic that mail-order dispensing of medication abortion can improve the ability of some providers to provide abortion and enable more patients to access services. The feasibility of mail-order pharmacy dispensing of medication abortion following the Supreme Court Dobbs decision is to be determined.

TRIAL REGISTRATION

Registry: Clinicaltrials.gov.

TRIAL REGISTRATION NUMBER

NCT03913104. Date of registration: first submitted on April 3, 2019 and first posted on April 12, 2019.

Primary Care Clinicians' Interest In, and Barriers To, Medication Abortion

PURPOSE

Providing medication abortion in the primary care setting is a promising way to increase access to abortion, a threatened service in many States. This study aimed to characterize primary care clinicians' interest in prescribing medication abortion, what barriers they face in adding this service, and what support they need.

METHODS

Data were collected from 162 practicing primary care clinicians in Minnesota using an online survey with closed- and open-ended response options. Data were analyzed using descriptive statistics, group comparison analyses, and content analysis for the open-ended questions.

RESULTS

Participants represented a diverse range of ages, years in practice, credentials, genders, and urban/rural practice settings, and held mixed knowledge and attitudes around medication abortion. All demographic groups surveyed expressed interest in prescribing medication abortion, with the strongest interest represented among younger respondents, women, and those practicing in urban settings. Clinicians who provide prenatal care or who already work with these medications in other contexts were more likely to want to add medication abortion to their practices. The most common barrier to providing medication abortion was a lack of knowledge about organizational policies and about the medications themselves. To empower clinicians to provide medication abortion, respondents voiced needing their health systems to build clear processes and wanting supportive networks of other clinicians for collaboration.

CONCLUSIONS

Given the interest of primary care clinicians in providing medication abortion, health systems have a valuable opportunity to increase access.

Mifepristone Use Among Obstetrician-Gynecologists in Massachusetts: Prevalence and Predictors of Use

OBJECTIVES

We estimated the prevalence of mifepristone use for evidence-based indications among obstetrician-gynecologists in independent practice in Massachusetts and explored the demographic and practice-related factors associated with use.

METHODS

We used data from a cross-sectional survey administered to Massachusetts obstetrician-gynecologists identified from the American Medical Association Physician Masterfile. We measured the prevalence of mifepristone use for four clinical scenarios: early pregnancy loss, medication abortion, cervical preparation before dilation and evacuation procedures, and cervical preparation before induction of labor. Multivariate regression was used to calculate the odds of mifepristone use for these scenarios based on practice type, years in practice, physician sex, and history of medication abortion training.

RESULTS

A total of 198 obstetrician-gynecologists responded to the survey (response rate = 29.0%); this analysis was limited to 158 respondents who were not in residency or fellowship. Overall, 46.0% used mifepristone for early pregnancy loss and 38.6% for medication abortion. Fewer used mifepristone for cervical preparation before dilation and evacuation (26.0%) or before induction of labor (26.4%). Respondents in academic practice settings, with more years in practice, of female sex, and with sufficient medication abortion training were significantly more likely to use mifepristone for one or more evidence-based clinical indications.

CONCLUSIONS

Sufficient medication abortion training during residency significantly predicts whether obstetrician-gynecologists use mifepristone in practice. The U.S. Supreme Court's overturning of Roe v. Wade will allow state-level abortion bans and restrictions to be in effect, which will reduce exposure to abortion training during residency. Increasing training in and utilization of mifepristone are critical for equitable access to reproductive health services. Further interventions may need to be developed to increase mifepristone use in nonacademic practice settings.

Mifepristone implementation in primary care: Clinician and staff insights from a pilot learning collaborative

OBJECTIVES

The ExPAND Mifepristone (ExPAND) learning collaborative aims to support primary care providers in overcoming logistical barriers to mifepristone provision. This qualitative study describes clinician and staff perspectives on the impact of ExPAND in two federally qualified health center networks (FQHCs).

STUDY DESIGN

Researchers conducted semi-structured qualitative interview with a purposive sample of clinicians, staff, and leadership from two Illinois FQHCs. We analyzed transcripts in batches using modified grounded theory to identify themes regarding the reception of ExPAND and barriers to and facilitators of mifepristone implementation.

RESULTS

Participants (n = 13) expressed strong support for providing mifepristone for miscarriage management at their clinics. Most also personally supported mifepristone for abortion care. Many participants felt that ExPAND reflected their clinics' values, as it strengthens the primary care relationship, emphasizes patient-centered care, and addresses disparities in access. Barriers to implementation included fear that providing abortion care would jeopardize FQHC funding and logistical hurdles due to the coronavirus disease pandemic.

CONCLUSIONS

Participants felt that mifepristone provision in primary care was an important service, and that ExPAND helped achieve that goal. Future clinics participating in ExPAND would benefit from education about how FQHCs can provide mifepristone for abortion care while complying with federal funding restrictions.

IMPLICATIONS

Learning collaboratives like ExPAND can prepare primary care clinics to provide mifepristone. Participants describe a clear benefit of mifepristone integration to their patients, and they report mifepristone integration aligns with clinic values.

Information on medication abortion provided by family planning clinics in California

OBJECTIVES

To assess access to abortion pills offered by clinics providing state-funded family planning services in California.

METHODS

We attempted to make two scripted calls to a 20% random sample of family planning clinics in California, stratified by county, as "secret shoppers" in 2020 and 2021.

RESULTS

Clinic staff responded to 407 calls. Only 50 respondents (12%) reported their clinic offered abortion pills and 23 respondents (6%) accurately indicated to callers that abortion pills were available free to low-income individuals in California. Most (68%) clinics that did not offer abortion pills could not direct callers to a clinic that did offer abortion pills.

CONCLUSIONS

Efforts are needed to increase the number of clinics providing medication abortion services in California. Clinic staff need training to provide accurate information about medication abortion.

Medication Abortion: A Comprehensive Review

This chapter provides an overview of evidence-based guidelines for medication abortion in the first trimester. We discuss regimens, both FDA-approved and other clinical-based protocols, and will briefly discuss novel self-managed abortion techniques taking place outside the formal health care system. Overview of patient counseling and pain management are presented with care to include guidance on "no touch" regimens that have proven both feasible and effective. We hope that this comprehensive review helps the health care community make strides to increase access to abortion in a time when reproductive health care is continuously restricted.

Management of early pregnancy loss among obstetrician-gynecologists in Massachusetts and barriers to mifepristone use

OBJECTIVES

To measure the prevalence of early pregnancy loss management types among obstetrician-gynecologists in Massachusetts, and delineate barriers, facilitators, demographic and practice-related factors associated with mifepristone use for early pregnancy loss.

STUDY DESIGN

We surveyed a census of obstetrician-gynecologists in Massachusetts. Descriptive statistics measured the prevalence of offering expectant, misoprostol-alone, mifepristone and misoprostol, dilation and curettage in the office and operating room, and multivariate logistic regression analysis evaluated barriers and facilitators to mifepristone use. Data were weighted to account for nonresponders.

RESULTS

198 obstetrician-gynecologists responded to the survey (response rate=29%). Participants most commonly offered expectant management (98%), dilation and curettage in the operating room (94%), and misoprostol-only medication management (80%). Fewer offered mifepristone-misoprostol (51%) or dilation and curettage in an office setting (45%). Those in private practice or other practice types had lower odds of offering mifepristone-misoprostol than those in academic practice (private practice: aOR 0.34, 95% confidence interval [CI] [0.19, 0.61]). Female physicians had higher odds of offering mifepristone-misoprostol (aOR 1.97, 95% CI [1.11, 3.49]). Obstetrician-gynecologists who included medication abortion in their practice had much higher odds of using mifepristone for early pregnancy loss (aOR 25.06, 95% CI [14.52, 43.24]). The Food and Drug Administration Risk and Evaluation Management Strategies Program was a primary barrier among those not using mifepristone (54%).

CONCLUSIONS

Many obstetrician-gynecologists do not offer mifepristone-based regimens for early pregnancy loss, which are more efficacious than misoprostol-only regimens. The Food and Drug Administration Risk Evaluation and Mitigation Strategies Program is a major barrier to mifepristone use.

IMPLICATIONS

Half of obstetrician-gynecologists in Massachusetts do not use mifepristone for early pregnancy loss management. Major barriers include lack of experience with mifepristone and the Food and Drug Administration Risk Evaluation and Mitigation Strategies Program regulations. Removing medically unnecessary regulations and increasing education on mifepristone via access to abortion care experts may increase uptake of this practice.

Mifepristone use for early pregnancy loss: A qualitative study of barriers and facilitators among OB/GYNS in Massachusetts, USA

CONTEXT

Early pregnancy loss (EPL) affects 1 million patients in the United States (US) annually, but integration of mifepristone into EPL care may be complicated by regulatory barriers, practice-related factors, and abortion stigma.

METHODS

We conducted qualitative, semi-structured interviews among obstetrician-gynecologists in independent practice in Massachusetts, US on mifepristone use for EPL. We recruited participants via professional networks and purposively sampled for mifepristone use, practice type, time in practice, and geographic location within Massachusetts until we reached thematic saturation. We analyzed interviews using inductive and deductive coding under a thematic analysis framework to identify facilitators of and barriers to mifepristone use.

RESULTS

We interviewed 19 obstetrician-gynecologists; 12 had used mifepristone for EPL and 7 had not. Participants were in private practice (n = 12), academic practice (n = 6), or worked at a federally qualified health center (n = 1). Seven had fellowship training, including four in complex family planning. The most common facilitators of mifepristone use for EPL were access to the expertise or protocols of local-regional experts, leadership from a "champion," prior experience with abortion care, and hospital capacity constraints during the COVID-19 pandemic. The most common barriers were related to the Mifepristone Risk Evaluation and Mitigation Strategy (REMS) Program imposed by the US Food and Drug Administration (FDA). Additionally, mifepristone's affiliation with abortion was a barrier to its use in EPL for some obstetrician-gynecologists.

CONCLUSION

The FDA Mifepristone REMS Program presents substantial barriers to obstetrician-gynecologists incorporating mifepristone into their EPL care.

Abortion providers in the United States: expanding beyond obstetrics and gynecology

In the years preceding the Dobbs v Jackson Women's Health Organization (2022) decision, there had been a shift in the demographics of abortion providers. Although most abortion providers were obstetricians-gynecologists, there had been a rapid increase in the number of internal medicine and family medicine physicians and advanced practice clinicians providing abortion care. As discourse about limiting abortion access has gained volume over the past few years, so have the number of legislative restrictions aimed at preventing people from seeking abortions. Among these are laws and policies targeted at reducing the number of providers and clinics providing abortion care, resulting in an absence of training, high case volume, and institutional restrictions. With the overturning of Roe v Wade, the landscape of abortion provision will continue to shift further. Action needs to be taken to expand the types of providers getting trained and providing abortions to ensure access for those seeking abortions.

Assessment of the Risk Evaluation and Mitigation Strategy (REMS) for Phentermine-Topiramate to Prevent Exposure During Pregnancy

BACKGROUND

The U.S. Food and Drug Administration approved phentermine-topiramate for obesity in 2012 and required a Risk Evaluation and Mitigation Strategy (REMS) to prevent prenatal exposure. No such requirement was introduced for topiramate.

OBJECTIVE

To evaluate the rate of prenatal exposure, contraceptive use, and pregnancy testing among patients with phentermine-topiramate compared with topiramate or other antiobesity medications (AOMs).

DESIGN

Retrospective cohort study.

SETTING

Nationwide health insurance claims database.

PARTICIPANTS

Females aged 12 to 55 years with no infertility diagnosis or sterilization procedure. Patients with other indications for topiramate were excluded to identify a cohort that was likely treated for obesity.

MEASUREMENTS

Patients initiated use of phentermine-topiramate, topiramate, or an AOM (liraglutide, lorcaserin, or bupropion-naltrexone). Pregnancy at treatment initiation, conception during treatment, contraceptive use, and pregnancy testing outcomes were ascertained. Measurable confounders were adjusted for, and extensive sensitivity analyses were done.

RESULTS

A total of 156 280 treatment episodes were observed. Adjusted prevalence of pregnancy at treatment initiation was 0.9 versus 1.6 per 1000 episodes (prevalence ratio, 0.54 [95% CI, 0.31 to 0.95]) for phentermine-topiramate versus topiramate. The incidence rate of conception during treatment was 9.1 versus 15.0 per 1000 person-years (rate ratio, 0.61 [CI, 0.40 to 0.91]) for phentermine-topiramate versus topiramate. Both outcomes were similarly lower for phentermine-topiramate compared with AOM. Prenatal exposure was marginally lower in topiramate users compared with AOM users. Approximately 20% of patients in all cohorts had at least 50% of treatment days covered by contraceptives. Few patients had pregnancy tests before treatment (≤5%), but this was more common among phentermine-topiramate users.

LIMITATIONS

Outcome misclassification; unmeasured confounding due to lack of prescriber data to account for possible clustering and spillover effects.

CONCLUSION

Prenatal exposure seemed to be significantly lower among phentermine-topiramate users under the REMS. Pregnancy testing and contraceptive use appeared to be inadequate for all groups, which deserves attention to prevent the remaining potential exposures.

PRIMARY FUNDING SOURCE

None.

Barriers to abortion provision in primary care in New England, 2019-2020: A qualitative study

OBJECTIVE

To assess barriers to and facilitators of abortion provision among abortion-trained primary care providers.

STUDY DESIGN

We conducted 21 qualitative in-depth interviews with 20 abortion-trained family physicians and one internal medicine physician in five New England states. We dual-coded interviews, using a consensus method to agree upon final coding schema. Through iterative dialogue, using an inductive content analysis approach, we synthesized the themes and identified patterns within each domain of inquiry.

RESULTS

The most commonly reported barriers were a lack of organizational support, the Hyde Amendment, which prevents the use of federal funds for most abortion care, and the mifepristone Risk Evaluation and Mitigation Strategy, a federal regulation which prohibits routine mifepristone pharmacy dispensing. The logistical barriers created by these policies require cooperation from additional stakeholders, creating more opportunities for abortion stigma and moral opposition to arise. Other salient barriers included inter-specialty tension (particularly with obstetrician-gynecologists), perceived need for pre-abortion ultrasound, absence of a clinician support network, and lack of knowledge of existing resources for establishing abortion care in primary care.

CONCLUSIONS

Increased abortion provision in primary care is one of many necessary responses to the human rights crisis produced by the Dobbs decision. Eliminating the Hyde Amendment and ending federal regulations restricting pharmacy dispensing of mifepristone are key interventions to address barriers to primary care abortion provision. Building interspecialty partnerships between family medicine and OB/GYN and spreading awareness of the evidence-based ultrasound-as-needed protocol and other educational resources are also likely to increase primary care abortion access.

IMPLICATIONS

By exploring barriers to and facilitators of primary care abortion provision, this study outlines a targeted approach to support increased access to abortions. In states with legal abortion post-Roe, it is important that motivated and trained primary care providers can offer abortions, rather than referring patients to overburdened specialty clinics.

Mifepristone: A Safe Method of Medical Abortion and Self-Managed Medical Abortion in the Post-Roe Era

BACKGROUND

The U.S. Supreme Court's Dobbs v. Jackson Women's Health Organization decision on June 24, 2022 effectively overturned federal constitutional protections for abortion that have existed since 1973 and returned jurisdiction to the states. Several states implemented abortion bans, some of which banned abortion after 6 weeks and others that permit abortion under limited exceptions, such as if the health or the life of the woman is in danger. Other states introduced bills that define life as beginning at fertilization. As a result of these new and proposed laws, the future availability of mifepristone, one of two drugs used for medical abortion in the United States, has become the topic of intense debate and speculation.

AREAS OF UNCERTAINTY

Although its safety and effectiveness has been confirmed by many studies, the use of mifepristone has been politicized regularly since its approval. Areas of future study include mifepristone for induction termination and fetal demise in the third trimester and the management of leiomyoma.

DATA SOURCES

PubMed, Society of Family Planning, American College of Obstetrician and Gynecologists, the World Health Organization.

THERAPEUTIC ADVANCES

The use of no-touch medical abortion, which entails providing a medical abortion via a telehealth platform without a screening ultrasound or bloodwork, expanded during the COVID-19 pandemic, and studies have confirmed its safety. With the Dobbs decision, legal abortion will be less accessible and, consequently, self-managed abortion with mifepristone and misoprostol will become more prevalent.

CONCLUSIONS

Mifepristone and misoprostol are extremely safe medications with many applications. In the current changing political climate, physicians and pregnancy-capable individuals must have access to these medications.