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

Society of Family Planning Clinical Recommendation: Medication management for early pregnancy loss

Early pregnancy loss (EPL) occurs in 15% to 20% of clinically recognized pregnancies. We recommend that patients experiencing EPL have equal access to all treatment options, including expectant, medication, and procedural management, when urgent treatment is not necessary (GRADE 1A). We recommend a patient-centered approach that uses shared decision-making to diagnose EPL through ultrasonography, serial quantitative hCG measurements, or symptoms (GRADE 1C). We suggest a shared decision-making approach for continuing expectant management of EPL up to 8 weeks after diagnosis in the absence of medical complications or symptoms requiring urgent intervention (GRADE 2C). We suggest against Rh testing and Rh-immunoglobulin administration before 12 weeks of gestation for patients undergoing medication management of EPL (GRADE 2B). We recommend a combined regimen of mifepristone with misoprostol for medication management of EPL (GRADE 1A), using mifepristone 200 mg orally followed 7 to 48 hours later by misoprostol 800 mcg vaginally or buccally (GRADE 2A). When used without mifepristone, we recommend misoprostol in two or more doses of 600 to 800 mcg sublingually or vaginally at intervals of at least 3 hours (GRADE 1B). We suggest ibuprofen 800 mg orally for pain control during medication management of EPL (GRADE 2A). Clinicians should offer all patients, but not require, in-person confirmation of completed EPL (GRADE 2B). We recommend against using endometrial thickness alone as a criterion for recommending additional intervention after medication management of EPL (GRADE 1B). We recommend institutions and clinicians make thorough efforts to obtain and maintain access to mifepristone in clinical settings where patients receive EPL care (GRADE 1C).

Provision of medication and procedural abortion among Massachusetts obstetrician-gynecologists

OBJECTIVES

The aim of the study was to understand the rates of first-trimester medication and procedural abortion provision, sufficiency in abortion training, and factors associated with abortion provision among obstetrician-gynecologists (OB/GYNs) in Massachusetts.

STUDY DESIGN

Electronically fielded surveys of a census of OB/GYNs in Massachusetts in 2021 queried physicians on abortion provision, training, practice type, and demographics. Using weighting to account for nonresponse, we generated estimates of the proportion of OB/GYNS providing abortion and used multivariate regression analysis to explore factors associated with abortion provision including practice type, physician sex, and sufficient abortion training.

RESULTS

A total of 198 OB/GYNs responded to the survey (response rate = 29%). Of 158 OB/GYNs not in training, 55% provide some abortion care. More respondents reported sufficient training for surgical abortion (84%) than for medication abortion (43%). The most cited reasons for not providing abortion care were lack of integration into their clinical practice (29%), institutional opposition (27%), or personal opposition to abortion (23%). In multivariate analysis, female physicians were more likely to provide abortion care (adjusted odds ratio [aOR] 2.72, 95% CI [1.63-4.55], p < 0.01), and those with insufficient training less likely to provide abortion (aOR 0.18, 95% CI [0.10-0.33], p = 0.01). Those in private practice (aOR 0.47, 95% CI [0.28-0.80], p < 0.01) or "other" practice types (aOR 0.16, 95% CI [0.09-0.27], p < 0.01) were less likely to provide abortion compared to physicians in academic practices.

CONCLUSIONS

Only half of OB/GYNs in a state supportive of abortion provide abortion. Despite high patient interest in medication abortion, a majority of OB/GYNs report insufficient training in medication abortion.

IMPLICATIONS

This study highlights the need for support from practice, institution, and health system leaders to facilitate the provision of abortion care and the need for increased training among OB/GYNs in medication abortion.

Spatial Disparities in Mifepristone Use for Early Miscarriage and Induced Abortion Among Obstetrician-Gynecologists Practicing in Massachusetts

Background

About 25% of pregnancies end in early miscarriage or abortion annually in the United States. While mifepristone is part of the most effective medication regimen for miscarriage and abortion, regulatory burdens and legal restrictions limit its provision in obstetric-gynecological practice. The extent of geographic disparities in mifepristone use is unknown.

Objectives

We sought to ascertain whether regional "deserts" for mifepristone-based miscarriage and abortion care exist in Massachusetts using geographic regions specified by the Commonwealth's Executive Office of Health and Human Services.

Methods

We fielded a cross-sectional survey of obstetrician-gynecologists practicing in Massachusetts. We weighted survey data to account for differential nonresponse by provider sex, region, and years in independent practice.

Results

Among obstetrician-gynecologists in independent practice with region data (n = 148), 51.0% reported using mifepristone for miscarriage and 43.5% for abortion. Significant differences in reported use were observed across regions (p < 0.001 for both indications). Barriers to using mifepristone for miscarriage management also varied across regions. Respondents outside of Boston and Western Massachusetts were more likely to report gaps in knowledge about regulations and prescribing and had less prior experience using mifepristone. In a multivariable model adjusting for provider sex and practice type, obstetrician-gynecologists outside of Boston had significantly lower odds of using mifepristone for miscarriage (adjusted odds ratio [aOR] = 0.14, 95% confidence interval [95% CI] = 0.08-0.25) and abortion (aOR = 0.46, 95% CI = 0.26-0.82), compared to Boston-based obstetrician-gynecologists.

Conclusion

Mifepristone provision varies significantly by Massachusetts region. This may lead to spatial disparities in reproductive health outcomes.

Outcomes After Early Pregnancy Loss Management With Mifepristone Plus Misoprostol vs Misoprostol Alone

Importance

Medication management of early pregnancy loss (EPL), or miscarriage, typically involves the administration of misoprostol with or without pretreatment with mifepristone. Combination treatment with mifepristone plus misoprostol is more effective than misoprostol alone but is underutilized in the US.

Objective

To describe differences in clinical outcomes after EPL management with mifepristone plus misoprostol vs misoprostol alone using commercial claims data.

Design, Setting, and Participants

This retrospective cohort study used national insurance claims data from the IBM MarketScan Research Database. Participants included pregnant people (aged 15-49 years) with private insurance who presented with an initial EPL diagnosis between October 1, 2015, and December 31, 2022.

Exposures

The primary exposure was the medication used to manage EPL (ie, mifepristone plus misoprostol or misoprostol alone). Other exposures of interest included demographic characteristics and location of service.

Main Outcomes and Measures

The primary outcome was subsequent procedural management (eg, uterine aspiration) after EPL diagnosis and medication management. Other outcomes of interest included return visits, hospitalizations, and complications occurring in the subsequent 6 weeks. Descriptive statistics and bivariate analyses were used, and a multivariable logistic regression model was created to examine factors associated with subsequent procedural management.

Results

This study included 31 977 patients (mean [SD] age, 32.7 [5.6] years) with claims for EPL who received medication management. Of these patients, 3.0% received mifepristone plus misoprostol and 97.0% received misoprostol alone. Patients who received misoprostol with pretreatment with mifepristone were less likely to have subsequent uterine aspiration (10.5% vs 14.0%; P = .002), and they were also less likely to have subsequent emergency department (ED) visits for EPL (3.5% vs 7.9%; P < .001). In multivariable analysis, use of mifepristone plus misoprostol was associated with decreased odds of subsequent procedural management (adjusted odds ratio, 0.71 [95% CI, 0.57-0.87]).

Conclusions and Relevance

The findings of this study suggest that mifepristone is underutilized for the medication management of EPL, but its use is associated with a lower need for subsequent uterine aspiration and a decrease in the number of subsequent visits to an ED. Increasing access to mifepristone for EPL management may decrease health care utilization and expenditures.

Abortion Stigma as a Barrier to Mifepristone Use among Obstetrician-Gynecologists in Alabama for Early Pregnancy Loss

OBJECTIVES

The objective of our study was to identify and characterize barriers to mifepristone use among obstetrician-gynecologists (OB-GYNs) for early pregnancy loss in a southern US state.

METHODS

In this qualitative study, we conducted semistructured interviews with 19 OB-GYNs in Alabama who manage early pregnancy loss. The interviews explored participants' knowledge of and experience with mifepristone use for miscarriage management and abortion, along with barriers to and facilitators of clinical mifepristone use. The interviews were coded by multiple study staff using inductive and deductive thematic coding.

RESULTS

Nearly all of the interviewees identified abortion-related stigma as a barrier to mifepristone use. Interviewees often attributed stigma to a lack of knowledge about the clinical use of mifepristone for early pregnancy loss. The stigmatization of mifepristone due to its association with abortion was related to religious and political objections. Many interviewees also described stigma associated with misoprostol use. Although providers believed that mifepristone use for abortion would not be accepted in their practice, most believed that mifepristone could be used successfully for miscarriage management after practice-wide education on its use.

CONCLUSIONS

Mifepristone is strongly associated with abortion stigma among OB-GYNs in Alabama, which is a barrier to its use for miscarriage management. Interventions to decrease abortion stigma and associated stigma surrounding mifepristone are needed to optimize early pregnancy loss care.

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.

Ultrasound-guided manual vacuum aspiration (USG-MVA) with cervical preparation for early pregnancy loss: A cost-effectiveness analysis

BACKGROUND AND AIM

Approximately one in four women will experience a miscarriage in their lifetime. Ultrasound-guided manual vacuum aspiration (USG-MVA) is an ideal outpatient surgical treatment alternative to traditional surgical evacuation. We aimed to examine the cost-effectiveness of US-MVA with cervical preparation for treatment of early pregnancy loss from the perspective of public healthcare provider of Hong Kong.

METHODS

A decision-analytic model was designed to simulate outcomes in a hypothetical cohort of patients with early pregnancy loss on four interventions: (1) US-MVA, (2) misoprostol, (3) surgical evacuation of uterus by dilation and curettage (surgical evacuation), and (4) expectant care. Model inputs were retrieved from published literature and public data. Model outcome measures were total direct medical cost and disutility-adjusted life-year (DALY). Base-case model results were examined by sensitivity analysis.

RESULTS

The expected DALYs (0.00141) and total direct medical cost (USD736) of US-MVA were the lowest of all interventions in base-case analysis, and US-MVA was the preferred cost-effective option. One-way sensitivity analysis showed that the misoprostol group became less costly than the US-MVA group if the evacuation rate of misoprostol (base-case value 0.832) exceeded 0.920. In probabilistic sensitivity analysis, At the willingness-to-pay (WTP) threshold of 49630 USD/DALY averted (1x gross domestic product per capita of Hong Kong), the US-MVA was cost-effective in 72.9% of the time.

CONCLUSIONS

US-MVA appeared to be cost-saving and effective for treatment of early pregnancy loss from the perspective of public healthcare provider of Hong Kong.