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

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.

Pharmacists' experiences dispensing misoprostol and readiness to dispense mifepristone

BACKGROUND

Mifepristone, followed by misoprostol, is commonly used for medication abortion and early miscarriage care. Since mifepristone's approval in 2000, the Food and Drug Administration (FDA) has placed restrictions on where and how it could be dispensed, including applying a Risk Evaluation and Mitigation Strategy in 2011. In December 2021, the FDA removed the in-person dispensing requirement and, in January 2023, began allowing certified pharmacies to dispense the drug directly to patients.

OBJECTIVES

To explore pharmacist knowledge about misoprostol and mifepristone, experience dispensing misoprostol, as well as comfort and readiness to dispense mifepristone should federal regulations allow.

METHODS

We conducted in-depth interviews with 21 U.S.-based pharmacists and pharmacy trainees between June and December of 2021, a time when few pharmacists were allowed to dispense mifepristone.

RESULTS

Participants reported varied knowledge about medications for miscarriage and abortion but described themselves as generally knowledgeable about medications and reported strategies for learning about new medications. Most said they would feel ready to dispense mifepristone, and many described dispensing misoprostol without difficulty. Potential challenges specific to mifepristone dispensing included employer hesitation and colleague refusals. To assure successful dispensing, participants recommended basic training and fact sheets; relationships with prescribers for follow-up; and policies for prescription transfers in the event of refusal.

CONCLUSIONS

We found that nearly all participants would feel ready to dispense mifepristone with some basic training. Pharmacists self-report having the skills and resources to learn about new medications quickly. Our findings support the FDA's rule change allowing pharmacist dispensing of mifepristone and suggest that most challenges would stem from individual or institutional refusals.