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Dunlop H, Sinay AM, Kerestes C. Telemedicine Abortion. Clin Obstet Gynecol 2023; 66:725-738. [PMID: 37910115 DOI: 10.1097/grf.0000000000000818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Telemedicine has become a substantial part of abortion care in recent years. In this review, we discuss the history and regulatory landscape of telemedicine for medication abortion in the United States, different models of care for telemedicine, and the safety and effectiveness of medication abortion via telemedicine, including using history-based screening protocols for medication abortion without ultrasound. We also explore the acceptability of telemedicine for patients and their perspectives on its benefits, as well as the use of telemedicine for other parts of abortion care. Telemedicine has expanded access to abortion for many, although there remain limitations to its implementation.
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Affiliation(s)
| | - Anne-Marie Sinay
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Courtney Kerestes
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
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2
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Li F, Han M, Zhang J, Ji J, Wu Y, Wei J. Effects of medical abortion assisted by traditional Chinese medicine: A network meta-analysis of randomized controlled trials. Int J Gynaecol Obstet 2023. [PMID: 38037875 DOI: 10.1002/ijgo.15272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/04/2023] [Accepted: 11/11/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND To what extent traditional Chinese medicine (TCM) combined with mifepristone and misoprostol is beneficial for improving the complete abortion rate and duration of vaginal bleeding has been a subject of debate in the field of medical abortion. OBJECTIVE To assess the evidence regarding the complete abortion rate and duration of vaginal bleeding of medical abortion assisted by different kinds of TCM. SEARCH STRATEGY We searched electronic databases such as PubMed, Web of Science and Cochrane Library database, China National Knowledge Internet, Wan fang Database, VIP Database, and China Biology Medicine disc from 2000 to February 15, 2023. SELECTION CRITERIA The control group was medical abortion with mifepristone and misoprostol, and the experimental group was medical abortion assisted by TCM. DATA COLLECTION AND ANALYSIS Major data extraction included sample size, age, medicine used for abortion, outcome measures. RevMan 5.3 and Stata 15.1 software were used to assess the literature quality and perform network meta-analysis, respectively. MAIN RESULTS A total of 73 randomized controlled trials (RCTs) with 11 683 patients and nine kinds of TCM were included in this study. Compared with mifepristone and misoprostol, eight kinds of TCM had statistical significance in improving the complete abortion rate. The effect value of Sancao decoction was 5.86 (95% confidence interval [CI] 2.53-13.58). Seven kinds of TCM shortened the duration of vaginal bleeding. The effect value of comfrey and trichosanthin decoction was -8.75 (95% CI -10.86 to -6.64). CONCLUSIONS This network meta-analysis showed that Lenge Zhumo decoction and Sancao decoction could have a large beneficial effect on complete abortion rate in medical abortion during early pregnancy, and comfrey and trichosanthin decoction could be the best TCM for shortening the duration of vaginal bleeding.
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Affiliation(s)
- Fuxing Li
- Department of Epidemiology, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Mei Han
- Department of Epidemiology, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jiayu Zhang
- Department of Epidemiology, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Jingru Ji
- Department of Obstetrics, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yanfei Wu
- Department of Chinese Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Junni Wei
- Department of Epidemiology, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
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3
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Downey MM, Daniel C, McGlynn-Wright A, Haugeberg K. Protect and Control: Coverture's Logics Across Welfare Policy and Abortion Law. PSYCHOLOGY OF WOMEN QUARTERLY 2023; 47:478-493. [PMID: 38606316 PMCID: PMC11008606 DOI: 10.1177/03616843231186320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
In the aftermath of Dobbs v. Jackson Women's Health Organization, which overturned the federal constitutional right to abortion, states have begun to recriminalize the procedure. These abortion bans raise important questions about the political and social status of women and pregnant people in the United States. Moreover, restrictions in social welfare programs such as the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children and Temporary Assistance for Needy Families, which serve low-income pregnant people and parents, raise similar questions. The regulation and administration of all three are framed by race, class, and gender. To understand how these restrictions (a) claim to protect women but ultimately function to control, police, and surveil and (b) rely on imagined, stereotype-laden psychological states such as vulnerability, irresponsibility, or irrationality, we turn to the British Common Law doctrine of coverture, which subsumed a married woman's legal, financial, and political identities under her husband's. The American colonies, and later, states of the United States, drew from British Common Law to craft laws that regulated relationships between men and women. Taken together, this analysis can provide a more comprehensive accounting of the cumulative harms experienced by women, poor people, people of color, and pregnant people in today's health and social welfare landscape. We conclude with recommendations for psychologists and other mental health providers to address, in practice and advocacy, the ethical dilemmas and obligations raised by the reach of coverture's logics in people's lives.
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Affiliation(s)
| | - Clare Daniel
- Newcomb Institute, Tulane University, New Orleans,
USA
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4
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Rowlands S, Harrison-Woolrych M. Improving access to medicines for early medical abortion: learning from experiences of medicines licensing and service delivery. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:234-237. [PMID: 37640520 DOI: 10.1136/bmjsrh-2023-201949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Sam Rowlands
- Department of Medical Science & Public Health, Bournemouth University, Poole, UK
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5
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Neill S, Mokashi M, Goldberg A, Fortin J, Janiak E. Mifepristone use for early pregnancy loss: A qualitative study of barriers and facilitators among OB/GYNS in Massachusetts, USA. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2023; 55:210-217. [PMID: 37394759 DOI: 10.1363/psrh.12237] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
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.
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Affiliation(s)
- Sara Neill
- Department of Obstetrics, Gynecology, & Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - Alisa Goldberg
- Department of Obstetrics, Gynecology, & Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| | - Jennifer Fortin
- ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
| | - Elizabeth Janiak
- Department of Obstetrics, Gynecology, & Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- ASPIRE Center for Sexual and Reproductive Health, Planned Parenthood League of Massachusetts, Boston, Massachusetts, USA
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6
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Behonick D. Assessing the need for on-campus medication abortion at California Community Colleges. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2023; 71:813-820. [PMID: 34212823 DOI: 10.1080/07448481.2021.1908308] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
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.
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Affiliation(s)
- Dani Behonick
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
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7
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Fay KE, Alemu H, Perritt J. Self-managed abortion: Toxic legislation, non-toxic medication. Am J Emerg Med 2023; 64:193-194. [PMID: 36344352 PMCID: PMC9845147 DOI: 10.1016/j.ajem.2022.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Kathryn E. Fay
- Harvard Medical School, Department of Obstetrics, Gynecology, and Reproductive Biology, 25 Shattuck Street, Boston, MA 02115, United States of America
| | - Hanney Alemu
- Northeastern University, 360 Huntington Ave, Boston, MA 02115, United States of America
| | - Jamila Perritt
- Physicians for Reproductive Health, 1430 Broadway, Suite 1614, New York, NY 10018, United States of America
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8
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Kaiser JE, Kurtz T, Glasser A, Brintz BJ, Gawron LM, Turok DK, Sanders JN. Mifepristone for miscarriage treatment in Utah: A survey of clinician knowledge and assessment of an educational video on future use. AEM EDUCATION AND TRAINING 2022; 6:e10834. [PMID: 36562027 PMCID: PMC9764035 DOI: 10.1002/aet2.10834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/07/2022] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
Objectives We aimed to: (a) describe current use of mifepristone for early pregnancy loss (EPL) management in Utah, (b) identify predictors of knowledge pre- and posteducational video, and (c) explore postvideo impacts on the likelihood to use mifepristone. Mifepristone is subject to the Food and Drug Administration's (FDA) Risk Evaluation and Mitigation Strategy (REMS) requirements. Methods Between September 2020 and March 2021 we surveyed Utah clinicians from six specialties caring for people experiencing EPL, recruited through professional organizations and hospital listservs. Participants viewed a 3.5-minute educational video on mifepristone for EPL and completed pre- and postvideo questionnaires. We evaluated predictors of high prevideo and improved postvideo knowledge using random forest regression conditional importance measures and partial dependency plots. We described current mifepristone use and video effects on likelihood to use mifepristone. Results Of 506 participants, most specialize in emergency medicine (172, 34%) and practice in private settings (253, 51%). Two-thirds had heard of mifepristone (328/471, 70%). Of 176/471 (37%) attempting provision of mifepristone, actual provision occurred for 59% (104/176). Baseline knowledge scores were low (mean 4.81/13 [37%] correct). Predictors of high prevideo knowledge include provision or attempted provision of mifepristone, having heard of mifepristone, providing EPL management expectantly or via medication, and specialty type. Mean postvideo knowledge scores improved by 3.27 points (68% improvement, paired t-test; 95% confidence interval 2.82-3.72, p < 0.0001). Postvideo, 66% (242/364) stated they are much more or somewhat more likely to use mifepristone, with compliance with FDA requirements cited as a barrier to utilization. Conclusions Among Utah providers, baseline mifepristone knowledge and use for EPL management are low. An educational video improved knowledge and likelihood of use, but FDA REMS requirements continue to be a barrier to including mifepristone in medication management of EPL.
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Affiliation(s)
- Jennifer E. Kaiser
- Division of Family Planning, Department of Obstetrics and GynecologyUniversity of UtahSalt Lake CityUtahUSA
| | - Theresa Kurtz
- Department of Obstetrics and GynecologyUniversity of UtahSalt Lake CityUtahUSA
| | - Annabah Glasser
- University of Utah Spencer Eccles School of MedicineSalt Lake CityUtahUSA
| | - Benjamin J. Brintz
- University of Utah, Study Design and Biostatistics CenterSalt Lake CityUtahUSA
| | - Lori M. Gawron
- Division of Family Planning, Department of Obstetrics and GynecologyUniversity of UtahSalt Lake CityUtahUSA
| | - David K. Turok
- Division of Family Planning, Department of Obstetrics and GynecologyUniversity of UtahSalt Lake CityUtahUSA
| | - Jessica N. Sanders
- Division of Family Planning, Department of Obstetrics and GynecologyUniversity of UtahSalt Lake CityUtahUSA
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9
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Madera M, Johnson DM, Broussard K, Tello-Pérez LA, Ze-Noah CA, Baldwin A, Gomperts R, Aiken ARA. Experiences seeking, sourcing, and using abortion pills at home in the United States through an online telemedicine service. SSM. QUALITATIVE RESEARCH IN HEALTH 2022; 2:100075. [PMID: 37503356 PMCID: PMC10372773 DOI: 10.1016/j.ssmqr.2022.100075] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
A growing number of people in the United States seek to self-manage their abortions by self-sourcing abortion medications online. Prior research focuses on people's motivations for seeking self-management of abortion and experiences trying to obtain medications. However, little is known about the experiences of people in the U.S. who actually complete a self-managed abortion using medications they self-sourced online. We conducted anonymous in-depth interviews with 80 individuals who sought abortion medications through Aid Access, the only online telemedicine service that provides abortion medications in all 50 U.S. states. Through grounded theory analysis we identified five key themes: 1) participants viewed Aid Access as a "godsend"; 2) Fears of scams, shipping delays, and surveillance made ordering pills online a "nerve-racking" experience; 3) a "personal touch" calmed fears and fostered trust in Aid Access; 4) participants were worried about the "what ifs" of the self-managed abortion experience; and 5) overall, participants felt that online telemedicine met their important needs. Our findings demonstrate that online telemedicine provided by Aid Access not only provided a critical service, but also offered care that participants deemed legitimate and trustworthy.
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Affiliation(s)
| | | | | | | | | | - Aleta Baldwin
- California State University, Sacramento, Sacramento, CA, USA
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10
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Munro SB, Dunn S, Guilbert ER, Norman WV. Advancing Reproductive Health through Policy-Engaged Research in Abortion Care. Semin Reprod Med 2022; 40:268-276. [PMID: 36746159 DOI: 10.1055/s-0042-1760213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Mifepristone medication abortion was first approved in China and France more than 30 years ago and is now used in more than 60 countries worldwide. It is a highly safe and effective method that has the potential to increase population access to abortion in early pregnancy, closer to home. In both Canada and the United States, the initial regulations for distribution, prescribing, and dispensing of mifepristone were highly restricted. However, in Canada, where mifepristone was made available in 2017, most restrictions on the medication were removed in the first year of its availability. The Canadian regulation of mifepristone as a normal prescription makes access possible in community primary care through a physician or nurse practitioner prescription, which any pharmacist can dispense. In this approach, people decide when and where to take their medication. We explore how policy-maker-engaged research advanced reproductive health policy and facilitated this rapid change in Canada. We discuss the implications of these policy advances for self-management of abortion and demonstrate how in Canada patients "self-manage" components of the abortion process within a supportive health care system.
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Affiliation(s)
- Sarah B Munro
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sheila Dunn
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Edith R Guilbert
- Department of Obstetrics, Gynecology and Reproduction, Laval University, Québec City, Québec, Canada
| | - Wendy V Norman
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada.,Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
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11
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Abortion as Essential Health Care and the Critical Role Your Practice Can Play in Protecting Abortion Access. Obstet Gynecol 2022; 140:729-737. [PMID: 35947856 PMCID: PMC9575566 DOI: 10.1097/aog.0000000000004949] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/21/2022] [Indexed: 02/05/2023]
Abstract
Few obstetrician-gynecologists (ob-gyns) provide abortion care, resulting in abortion being separated from other reproductive health care. This segregation of services disrupts the ob-gyn patient-clinician relationship, generates needless costs, delays access to abortion care, and contributes to stigma. General ob-gyns have both the skills and the knowledge to incorporate abortion into their clinical practices. In this way, they can actively contribute to the protection of abortion access now with the loss of federal protection for abortion under Roe v Wade . For those who live where abortion remains legal, now is the time to start providing abortions and enhancing your abortion-referral process. For all, regardless of state legislation, ob-gyns must be leaders in advocacy by facilitating abortion care-across state lines, using telehealth, or with self-managed abortion-and avoiding any contribution to the criminalization of those who seek or obtain essential abortion care. Our patients deserve a specialty-wide concerted effort to deliver comprehensive reproductive health care to the fullest extent.
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12
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Hagey JM, Givens M, Bryant AG. Clinical Update on Uses for Mifepristone in Obstetrics and Gynecology. Obstet Gynecol Surv 2022; 77:611-623. [PMID: 36242531 DOI: 10.1097/ogx.0000000000001063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
IMPORTANCE Mifepristone (RU-486) is a selective progesterone receptor modulator that has antagonist properties on the uterus and cervix. Mifepristone is an effective abortifacient, prompting limitations on its use in many countries. Mifepristone has many uses outside of induced abortion, but these are less well known and underutilized by clinicians because of challenges in accessing and prescribing this medication. OBJECTIVES To provide clinicians with a history of the development of mifepristone and mechanism of action and safety profile, as well as detail current research on uses of mifepristone in both obstetrics and gynecology. EVIDENCE ACQUISITION A PubMed search of mifepristone and gynecologic and obstetric conditions was conducted between January 2018 and December 2021. Other resources were also searched, including guidelines from the American College of Obstetricians and Gynecologists and the Society of Family Planning. RESULTS Mifepristone is approved by the Food and Drug Administration for first-trimester medication abortion but has other off-label uses in both obstetrics and gynecology. Obstetric uses that have been investigated include management of early pregnancy loss, intrauterine fetal demise, treatment of ectopic pregnancy, and labor induction. Gynecologic uses that have been investigated include contraception, treatment of abnormal uterine bleeding, and as an adjunct in treatment of gynecologic cancers. CONCLUSIONS AND RELEVANCE Mifepristone is a safe and effective medication both for its approved use in first-trimester medication abortion and other off-label uses. Because of its primary use as an abortifacient, mifepristone is underutilized by clinicians. Providers should consider mifepristone for other indications as clinically appropriate.
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Affiliation(s)
- Jill M Hagey
- Fellow, Division of Complex Family Planning, Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Matthew Givens
- Fellow, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Amy G Bryant
- Associate Professor, Division of Complex Family Planning, Department of Obstetrics and Gynecology, University of North Carolina-Chapel Hill, Chapel Hill, NC
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13
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Janiak E, Belizaire C, Liu J, Fulcher IR. The association of U.S. state-level abortion restrictions with medication abortion service delivery innovations during the early COVID-19 pandemic. Contraception 2022; 113:26-29. [PMID: 35430237 PMCID: PMC9010011 DOI: 10.1016/j.contraception.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To assess whether state-level abortion restrictions resulted in differential uptake of innovative medication abortion practices such as changing ultrasound requirements, offering telehealth, or dispensing medications without a physical exam during the early COVID-19 pandemic. METHODS We used data from a prospective national survey of abortion providers to assess the association between a novel index of state-level abortion hostility and adoption of medication abortion services innovations during the pandemic. RESULTS Clinics in states with low or medium hostility were more likely to adopt innovative practices than those in high or extreme hostility states. CONCLUSIONS Clinics in abortion hostile states were less likely to adopt clinical recommendations and public health best practices for abortion care during the COVID-19 pandemic.
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Affiliation(s)
- Elizabeth Janiak
- Brigham and Women's Hospital, Boston, MA, United States,Harvard Medical School, Boston, MA, United States,Planned Parenthood League of Massachusetts, Boston, MA, United States,Corresponding author
| | - Carmela Belizaire
- Planned Parenthood League of Massachusetts, Boston, MA, United States,Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States
| | - Jessie Liu
- Planned Parenthood League of Massachusetts, Boston, MA, United States,Harvard College, Cambridge, MA, United States
| | - Isabel R. Fulcher
- Harvard Medical School, Boston, MA, United States,Planned Parenthood League of Massachusetts, Boston, MA, United States
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14
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Dunn S, Munro S, Devane C, Guilbert E, Jeong D, Stroulia E, Soon JA, Norman WV. A Virtual Community of Practice to Support Physician Uptake of a Novel Abortion Practice: Mixed Methods Case Study. J Med Internet Res 2022; 24:e34302. [PMID: 35511226 PMCID: PMC9121225 DOI: 10.2196/34302] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/17/2022] [Accepted: 03/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Virtual communities of practice (VCoPs) have been used to support innovation and quality in clinical care. The drug mifepristone was introduced in Canada in 2017 for medical abortion. We created a VCoP to support implementation of mifepristone abortion practice across Canada. Objective The aim of this study was to describe the development and use of the Canadian Abortion Providers Support-Communauté de pratique canadienne sur l’avortement (CAPS-CPCA) VCoP and explore physicians’ experience with CAPS-CPCA and their views on its value in supporting implementation. Methods This was a mixed methods intrinsic case study of Canadian health care providers’ use and physicians’ perceptions of the CAPS-CPCA VCoP during the first 2 years of a novel practice. We sampled both physicians who joined the CAPS-CPCA VCoP and those who were interested in providing the novel practice but did not join the VCoP. We designed the VCoP features to address known and discovered barriers to implementation of medication abortion in primary care. Our secure web-based platform allowed asynchronous access to information, practice resources, clinical support, discussion forums, and email notices. We collected data from the platform and through surveys of physician members as well as interviews with physician members and nonmembers. We analyzed descriptive statistics for website metrics, physicians’ characteristics and practices, and their use of the VCoP. We used qualitative methods to explore the physicians’ experiences and perceptions of the VCoP. Results From January 1, 2017, to June 30, 2019, a total of 430 physicians representing all provinces and territories in Canada joined the VCoP and 222 (51.6%) completed a baseline survey. Of these 222 respondents, 156 (70.3%) were family physicians, 170 (80.2%) were women, and 78 (35.1%) had no prior abortion experience. In a survey conducted 12 months after baseline, 77.9% (120/154) of the respondents stated that they had provided mifepristone abortion and 33.9% (43/127) said the VCoP had been important or very important. Logging in to the site was burdensome for some, but members valued downloadable resources such as patient information sheets, consent forms, and clinical checklists. They found email announcements helpful for keeping up to date with changing regulations. Few asked clinical questions to the VCoP experts, but physicians felt that this feature was important for isolated or rural providers. Information collected through member polls about health system barriers to implementation was used in the project’s knowledge translation activities with policy makers to mitigate these barriers. Conclusions A VCoP developed to address known and discovered barriers to uptake of a novel medication abortion method engaged physicians from across Canada and supported some, including those with no prior abortion experience, to implement this practice. International Registered Report Identifier (IRRID) RR2-10.1136/bmjopen-2018-028443
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Affiliation(s)
- Sheila Dunn
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Sarah Munro
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.,Centre for Health Evaluation and Outcome Science, University of British Columbia, Vancouver, BC, Canada
| | - Courtney Devane
- School of Nursing, Faculty of Applied Science, University of British Columbia, Vancouver, BC, Canada
| | - Edith Guilbert
- Department of Obstetrics, Gynecology and Reproduction, Laval University, Quebec City, QC, Canada
| | - Dahn Jeong
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Eleni Stroulia
- Department of Computer Science, Faculty of Science, University of Alberta, Edmonton, AB, Canada
| | - Judith A Soon
- Contraception and Abortion Research Team, Women's Health Research Institute, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Wendy V Norman
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada.,Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Ralph LJ, Ehrenreich K, Barar R, Biggs MA, Morris N, Blanchard K, Kapp N, Moayedi G, Perritt J, Raymond EG, White K, Grossman D. Accuracy of self-assessment of gestational duration among people seeking abortion. Am J Obstet Gynecol 2022; 226:710.e1-710.e21. [PMID: 34922922 DOI: 10.1016/j.ajog.2021.11.1373] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 11/15/2021] [Accepted: 11/24/2021] [Indexed: 11/01/2022]
Abstract
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.
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Zettler PJ, Sarpatwari A. State Restrictions on Mifepristone Access - The Case for Federal Preemption. N Engl J Med 2022; 386:705-707. [PMID: 35020981 DOI: 10.1056/nejmp2118696] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Patricia J Zettler
- From the Moritz College of Law, the Drug Enforcement and Policy Center, and the James Comprehensive Cancer Center, Ohio State University, Columbus (P.J.Z.); and the Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (A.S.)
| | - Ameet Sarpatwari
- From the Moritz College of Law, the Drug Enforcement and Policy Center, and the James Comprehensive Cancer Center, Ohio State University, Columbus (P.J.Z.); and the Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (A.S.)
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Adashi EY, Rajan RS, O'Mahony DP, Cohen IG. The Next Two Decades of Mifepristone at FDA: History as Destiny. Contraception 2022; 109:1-7. [DOI: 10.1016/j.contraception.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 11/25/2022]
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Razon N, Wulf S, Perez C, McNeil S, Maldonado L, Fields AB, Carvajal D, Logan R, Dehlendorf C. Exploring the impact of mifepristone's Risk Evaluation and Mitigation Strategy (REMS) on the integration of medication abortion into US family medicine primary care clinics. Contraception 2022; 109:19-24. [PMID: 35131289 PMCID: PMC9018589 DOI: 10.1016/j.contraception.2022.01.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 01/22/2023]
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LaRoche KJ, Wylie A, Persaud M, Foster AM. Integrating mifepristone into primary care in Canada's capital: A multi-methods exploration of the Medical Abortion Access Project. Contraception 2022; 109:37-42. [PMID: 35031301 DOI: 10.1016/j.contraception.2022.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 01/01/2022] [Accepted: 01/03/2022] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Kathryn J LaRoche
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada; School of Public Health, Indiana University, Bloomington, IN, USA
| | | | - Mira Persaud
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Angel M Foster
- Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada.
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20
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Schummers L, Darling EK, Dunn S, McGrail K, Gayowsky A, Law MR, Laba TL, Kaczorowski J, Norman WV. Abortion Safety and Use with Normally Prescribed Mifepristone in Canada. N Engl J Med 2022; 386:57-67. [PMID: 34879191 DOI: 10.1056/nejmsa2109779] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In the United States, mifepristone is available for medical abortion (for use with misoprostol) only with Risk Evaluation and Mitigation Strategy (REMS) restrictions, despite an absence of evidence to support such restrictions. Mifepristone has been available in Canada with a normal prescription since November 2017. METHODS Using population-based administrative data from Ontario, Canada, we examined abortion use, safety, and effectiveness using an interrupted time-series analysis comparing trends in incidence before mifepristone was available (January 2012 through December 2016) with trends after its availability without restrictions (November 7, 2017, through March 15, 2020). RESULTS A total of 195,183 abortions were performed before mifepristone was available and 84,032 after its availability without restrictions. After the availability of mifepristone with a normal prescription, the abortion rate continued to decline, although more slowly than was expected on the basis of trends before mifepristone had been available (adjusted risk difference in time-series analysis, 1.2 per 1000 female residents between 15 and 49 years of age; 95% confidence interval [CI], 1.1 to 1.4), whereas the percentage of abortions provided as medical procedures increased from 2.2% to 31.4% (adjusted risk difference, 28.8 percentage points; 95% CI, 28.0 to 29.7). There were no material changes between the period before mifepristone was available and the nonrestricted period in the incidence of severe adverse events (0.03% vs. 0.04%; adjusted risk difference, 0.01 percentage points; 95% CI, -0.06 to 0.03), complications (0.74% vs. 0.69%; adjusted risk difference, 0.06 percentage points; 95% CI, -0.07 to 0.18), or ectopic pregnancy detected after abortion (0.15% vs. 0.22%; adjusted risk difference, -0.03 percentage points; 95% CI, -0.19 to 0.09). There was a small increase in ongoing intrauterine pregnancy continuing to delivery (adjusted risk difference, 0.08 percentage points; 95% CI, 0.04 to 0.10). CONCLUSIONS After mifepristone became available as a normal prescription, the abortion rate remained relatively stable, the proportion of abortions provided by medication increased rapidly, and adverse events and complications remained stable, as compared with the period when mifepristone was unavailable. (Funded by the Canadian Institutes of Health Research and the Women's Health Research Institute.).
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Affiliation(s)
- Laura Schummers
- From the Department of Family Practice (L.S., W.V.N.) and the Centre for Health Services and Policy Research, School of Population and Public Health (K.M., M.R.L.), University of British Columbia, Vancouver, ICES (L.S., E.K.D., A.G.) and the Department of Obstetrics and Gynecology (E.K.D.), McMaster University, Hamilton, ON, the Department of Family and Community Medicine, University of Toronto, and the Women's College Research Institute, Women's College Hospital, Toronto (S.D.), and the Department of Family and Emergency Medicine, University of Montreal, Montreal (J.K.) - all in Canada; the Centre for Health Economics Research and Evaluation, University of Technology, Sydney (T.-L.L.); and the Department of Public Health, Environments, and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London (W.V.N.)
| | - Elizabeth K Darling
- From the Department of Family Practice (L.S., W.V.N.) and the Centre for Health Services and Policy Research, School of Population and Public Health (K.M., M.R.L.), University of British Columbia, Vancouver, ICES (L.S., E.K.D., A.G.) and the Department of Obstetrics and Gynecology (E.K.D.), McMaster University, Hamilton, ON, the Department of Family and Community Medicine, University of Toronto, and the Women's College Research Institute, Women's College Hospital, Toronto (S.D.), and the Department of Family and Emergency Medicine, University of Montreal, Montreal (J.K.) - all in Canada; the Centre for Health Economics Research and Evaluation, University of Technology, Sydney (T.-L.L.); and the Department of Public Health, Environments, and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London (W.V.N.)
| | - Sheila Dunn
- From the Department of Family Practice (L.S., W.V.N.) and the Centre for Health Services and Policy Research, School of Population and Public Health (K.M., M.R.L.), University of British Columbia, Vancouver, ICES (L.S., E.K.D., A.G.) and the Department of Obstetrics and Gynecology (E.K.D.), McMaster University, Hamilton, ON, the Department of Family and Community Medicine, University of Toronto, and the Women's College Research Institute, Women's College Hospital, Toronto (S.D.), and the Department of Family and Emergency Medicine, University of Montreal, Montreal (J.K.) - all in Canada; the Centre for Health Economics Research and Evaluation, University of Technology, Sydney (T.-L.L.); and the Department of Public Health, Environments, and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London (W.V.N.)
| | - Kimberlyn McGrail
- From the Department of Family Practice (L.S., W.V.N.) and the Centre for Health Services and Policy Research, School of Population and Public Health (K.M., M.R.L.), University of British Columbia, Vancouver, ICES (L.S., E.K.D., A.G.) and the Department of Obstetrics and Gynecology (E.K.D.), McMaster University, Hamilton, ON, the Department of Family and Community Medicine, University of Toronto, and the Women's College Research Institute, Women's College Hospital, Toronto (S.D.), and the Department of Family and Emergency Medicine, University of Montreal, Montreal (J.K.) - all in Canada; the Centre for Health Economics Research and Evaluation, University of Technology, Sydney (T.-L.L.); and the Department of Public Health, Environments, and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London (W.V.N.)
| | - Anastasia Gayowsky
- From the Department of Family Practice (L.S., W.V.N.) and the Centre for Health Services and Policy Research, School of Population and Public Health (K.M., M.R.L.), University of British Columbia, Vancouver, ICES (L.S., E.K.D., A.G.) and the Department of Obstetrics and Gynecology (E.K.D.), McMaster University, Hamilton, ON, the Department of Family and Community Medicine, University of Toronto, and the Women's College Research Institute, Women's College Hospital, Toronto (S.D.), and the Department of Family and Emergency Medicine, University of Montreal, Montreal (J.K.) - all in Canada; the Centre for Health Economics Research and Evaluation, University of Technology, Sydney (T.-L.L.); and the Department of Public Health, Environments, and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London (W.V.N.)
| | - Michael R Law
- From the Department of Family Practice (L.S., W.V.N.) and the Centre for Health Services and Policy Research, School of Population and Public Health (K.M., M.R.L.), University of British Columbia, Vancouver, ICES (L.S., E.K.D., A.G.) and the Department of Obstetrics and Gynecology (E.K.D.), McMaster University, Hamilton, ON, the Department of Family and Community Medicine, University of Toronto, and the Women's College Research Institute, Women's College Hospital, Toronto (S.D.), and the Department of Family and Emergency Medicine, University of Montreal, Montreal (J.K.) - all in Canada; the Centre for Health Economics Research and Evaluation, University of Technology, Sydney (T.-L.L.); and the Department of Public Health, Environments, and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London (W.V.N.)
| | - Tracey-Lea Laba
- From the Department of Family Practice (L.S., W.V.N.) and the Centre for Health Services and Policy Research, School of Population and Public Health (K.M., M.R.L.), University of British Columbia, Vancouver, ICES (L.S., E.K.D., A.G.) and the Department of Obstetrics and Gynecology (E.K.D.), McMaster University, Hamilton, ON, the Department of Family and Community Medicine, University of Toronto, and the Women's College Research Institute, Women's College Hospital, Toronto (S.D.), and the Department of Family and Emergency Medicine, University of Montreal, Montreal (J.K.) - all in Canada; the Centre for Health Economics Research and Evaluation, University of Technology, Sydney (T.-L.L.); and the Department of Public Health, Environments, and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London (W.V.N.)
| | - Janusz Kaczorowski
- From the Department of Family Practice (L.S., W.V.N.) and the Centre for Health Services and Policy Research, School of Population and Public Health (K.M., M.R.L.), University of British Columbia, Vancouver, ICES (L.S., E.K.D., A.G.) and the Department of Obstetrics and Gynecology (E.K.D.), McMaster University, Hamilton, ON, the Department of Family and Community Medicine, University of Toronto, and the Women's College Research Institute, Women's College Hospital, Toronto (S.D.), and the Department of Family and Emergency Medicine, University of Montreal, Montreal (J.K.) - all in Canada; the Centre for Health Economics Research and Evaluation, University of Technology, Sydney (T.-L.L.); and the Department of Public Health, Environments, and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London (W.V.N.)
| | - Wendy V Norman
- From the Department of Family Practice (L.S., W.V.N.) and the Centre for Health Services and Policy Research, School of Population and Public Health (K.M., M.R.L.), University of British Columbia, Vancouver, ICES (L.S., E.K.D., A.G.) and the Department of Obstetrics and Gynecology (E.K.D.), McMaster University, Hamilton, ON, the Department of Family and Community Medicine, University of Toronto, and the Women's College Research Institute, Women's College Hospital, Toronto (S.D.), and the Department of Family and Emergency Medicine, University of Montreal, Montreal (J.K.) - all in Canada; the Centre for Health Economics Research and Evaluation, University of Technology, Sydney (T.-L.L.); and the Department of Public Health, Environments, and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London (W.V.N.)
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Skuster P, Dhillon J, Li J. Easing of Regulatory Barriers to Telemedicine Abortion in Response to COVID-19. Front Glob Womens Health 2021; 2:705611. [PMID: 34901929 PMCID: PMC8652224 DOI: 10.3389/fgwh.2021.705611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 10/15/2021] [Indexed: 11/13/2022] Open
Abstract
For many people seeking abortion during the continuing COVID-19 pandemic, telemedicine abortion is the safest and most acceptable method, posing lower risk of exposure to the virus. In addition, by reducing in-person visits with health care providers, increased use of telemedicine for abortion can reduce pressure on overburdened health systems. Given the benefits of telemedicine during the pandemic, government agencies in several countries took measures to temporarily allow telemedicine abortion. We conducted key-word English-language searches to identify examples of government action to remove regulatory barriers to the practice of telemedicine abortion in response to the pandemic. We found instances of government agencies in eight countries taking steps to ease regulatory barriers to telemedicine abortion. Telemedicine abortion is safe, cost-effective, and may be the preferred method of abortion during acute periods of COVID-19 transmission, as well as after the pandemic has abated. As one step to expanding access to abortion with medicine where abortion is legal, health agencies and other regulatory bodies can take steps to remove barriers specific to telemedicine abortion.
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Affiliation(s)
- Patty Skuster
- Temple University Beasley School of Law, Philadelphia, PA, United States
| | | | - Jessica Li
- School of Law, University of California, Berkeley, Berkeley, CA, United States
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22
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Johnson DM, Madera M, Gomperts R, Aiken AR. The economic context of pursuing online medication abortion in the United States. SSM. QUALITATIVE RESEARCH IN HEALTH 2021; 1:100003. [PMID: 35368445 PMCID: PMC8976452 DOI: 10.1016/j.ssmqr.2021.100003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Access to in-clinic abortion has become increasingly restricted in the U.S. and for many, the high cost of care is a significant barrier. However, little is known about how financial circumstances shape the alternate pathways to abortion care people seek when the clinic is out of reach. In a unique sample of people who used medication abortion pills from Aid Access, a non-profit telemedicine service, we examine the impact of economic circumstances on abortion care pathway decision-making and experiences seeking care. Between June and August 2019, we conducted 80 anonymous, semi-structured in-depth interviews with U.S. residents who self-managed their own abortions using medication abortion pills from Aid Access. Participants were asked about their experiences seeking abortion, and their motivations for using the service. We coded interviews using an iteratively developed coding guide and performed thematic analyses to identify key themes. The unaffordable cost of in-clinic abortion was a key reason why participants sought care using online telemedicine. Experiences of personal financial hardship exacerbated by restrictive policies impacted participants' ability to access the clinic. For participants with children, their financial decisions were further guided by the concerns of providing economic stability for their family. Although telemedicine was considered more affordable than in-clinic care, for some, the suggested donation of $90 still posed a financial burden and accessing pills at no cost or a reduced cost was necessary. The availability of affordable telemedicine and policy interventions addressing Medicaid and insurance coverage for abortion would democratize abortion access for populations with low incomes.
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23
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Atay H, Perivier H, Gemzell-Danielsson K, Guilleminot J, Hassoun D, Hottois J, Gomperts R, Levrier E. Why women choose at-home abortion via teleconsultation in France: drivers of telemedicine abortion during and beyond the COVID-19 pandemic. BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:285-292. [PMID: 34321255 PMCID: PMC8326025 DOI: 10.1136/bmjsrh-2021-201176] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/24/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES In an attempt to understand the demand and main drivers of telemedicine abortion, we analysed the requests that Women on Web (WoW), an online telemedicine abortion service operating worldwide, received from France throughout 2020. METHODS We conducted a parallel, convergent, mixed-methods study among 809 consultations received from France at WoW between 1 January and 31 December 2020. We performed a cross-sectional study of data obtained from the WoW consultation survey and a manifest content analysis of anonymised email correspondence of 140 women consulting with the WoW helpdesk from France. FINDINGS We found that women encounter macro-level, individual-level and provider-level constraints while trying to access abortion in France. The preferences and needs over secrecy (n=356, 46.2%), privacy (n=295, 38.3%) and comfort (n=269, 34.9%) are among the most frequent reasons for women from France to choose telemedicine abortion through WoW. The COVID-19 pandemic seems to be an important driver for resorting to telemedicine (n=236, 30.6%). The lockdowns had a significant impact on the number of consultations received at WoW from France, increasing from 60 in March to 128 in April during the first lockdown and from 54 in October to 80 in November during the second lockdown. CONCLUSIONS The demand for at-home medical abortion via teleconsultation increased in France during the lockdowns. However, drivers of telemedicine abortion are multidimensional and go beyond the conditions unique to the pandemic.
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Affiliation(s)
- Hazal Atay
- Sciences Po Paris, CEVIPOF - Centre for Political Research, Paris, France
- Women on Web International Foundation, Toronto, Ontario, Canada
- Sciences Po Paris, LIEPP - The Laboratory for Interdisciplinary Evaluation of Public Policy, Paris, France
| | - Helene Perivier
- Sciences Po Paris, OFCE - French Economic Observatory, Paris, France
| | | | | | | | | | | | - Emmanuelle Levrier
- Sciences Po Paris, LIEPP - The Laboratory for Interdisciplinary Evaluation of Public Policy, Paris, France
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24
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Upadhyay UD, Cartwright AF, Grossman D. Barriers to abortion care and incidence of attempted self-managed abortion among individuals searching Google for abortion care: A national prospective study. Contraception 2021; 106:49-56. [PMID: 34560051 DOI: 10.1016/j.contraception.2021.09.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 09/13/2021] [Accepted: 09/15/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Studies on self-managed abortion conducted at abortion clinics may exclude those facing the greatest barriers to care. We aimed to assess association of attempted self-managed abortion with reported barriers to abortion care. STUDY DESIGN We used data from the Google Ads Abortion Access Study, a prospective cohort study that recruited people searching for abortion care on Google between August 2017 and April 2018. We used a stratified sampling design recruiting by state to ensure representation from all 50 states. Participants completed an online baseline survey and follow-up 4 weeks later. We modeled the adjusted odds of attempting self-managed abortion using multivariable logistic regression, with random effects for state of residence. We assessed attempted self-managed abortion at follow-up by asking: "Did you take or try to do any of the following to try to end this pregnancy?" with a closed-ended list of methods. RESULTS Among 856 participants with follow-up data, 28% (95% confidence interval [95% CI]: 25%-31%) reported attempting self-managed abortion. Most common methods used were: herbs, supplements, or vitamins (52%); emergency contraception or many contraceptive pills (19%); mifepristone and/or misoprostol (18%); and abdominal or other physical trauma (18%). Participants still seeking abortion at 4 weeks were more likely to attempt self-management (33%) than those planning to carry to term (20%, p < 0.001). Reporting having to keep the abortion a secret, fearing for one's safety/well-being, needing to gather money for travel or the abortion, or living further from an abortion facility as barriers were associated with higher odds of attempts. CONCLUSIONS Attempted self-managed abortion is higher among people facing barriers to abortion care. IMPLICATIONS Reducing financial and distance barriers, such as by removing legal restrictions on abortion, could help reduce attempted self-managed abortion. Additionally, removing restrictions on telehealth for abortion could reduce attempted self-managed abortion. Efforts are needed to permanently remove United States Food and Drug Administration (FDA) regulations and state policies prohibiting telehealth for medication abortion, thereby allowing individuals to end their pregnancies without a clinic visit.
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Affiliation(s)
- Ushma D Upadhyay
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, CA, United States.
| | - Alice F Cartwright
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco (UCSF), San Francisco, CA, United States
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25
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Munro S, Wahl K, Soon JA, Guilbert E, Wilcox ES, Leduc-Robert G, Ansari N, Devane C, Norman WV. Pharmacist dispensing of the abortion pill in Canada: Diffusion of Innovation meets integrated knowledge translation. Implement Sci 2021; 16:76. [PMID: 34344393 PMCID: PMC8330203 DOI: 10.1186/s13012-021-01144-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Since Canadian drug regulatory approval of mifepristone for medical abortion in 2015 and its market availability in January 2017, the role of pharmacists in abortion provision has changed rapidly. We sought to identify the factors that influenced the initiation and provision of medical abortion from the perspectives of Canadian pharmacists, bridging two frameworks - Diffusion of Innovation in Health Service Organizations and integrated knowledge translation. METHODS We conducted one-on-one semi-structured interviews with pharmacists residing in Canada who intended to stock and dispense mifepristone within the first year of availability. Our data collection, analysis, and interpretation were guided by reflexive thematic analysis and supported by an integrated knowledge translation partnership with pharmacy stakeholders. RESULTS We completed interviews with 24 participants from across Canada: 33% had stocked and 21% had dispensed mifepristone. We found that pharmacists were willing and able to integrate medical abortion care into their practice and that those who had initiated practice were satisfied with their dispensing experience. Our analysis indicated that several key Diffusion of Innovation constructs impacted the uptake of mifepristone, including: innovation (relative advantage, complexity and compatibility, technical support), system readiness (innovation-system fit, dedicated time, resources), diffusion and dissemination (expert opinion, boundary spanners, champions, social networks, peer opinions), implementation (external collaboration), and linkage. Participants' experiences suggest that integrated knowledge translation facilitated evidence-based changes to mifepristone dispensing restrictions, and communication of those changes to front line pharmacists. CONCLUSIONS We illustrate how Diffusion of Innovation and integrated knowledge translation may work together as complimentary frameworks for implementation science research. Unlike in the USA, UK, and other highly regulated settings globally, pharmacists in Canada are permitted to dispense mifepristone for medical abortion. We contribute to literature that shows that mifepristone dispensed outside of hospitals, clinics, and medical offices is safe and acceptable to both patients and prescribers. This finding is of particular importance to the current COVID-19 pandemic response and calls for continued and equitable access to abortion care in primary practice.
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Affiliation(s)
- Sarah Munro
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada. .,Department of Obstetrics & Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Kate Wahl
- Department of Obstetrics & Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Judith A Soon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Edith Guilbert
- Department of Obstetrics, Gynaecology and Reproduction, Laval University, Quebec City, Quebec, Canada
| | - Elizabeth S Wilcox
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Genevieve Leduc-Robert
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nadra Ansari
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Courtney Devane
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wendy V Norman
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada.,Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Medication Abortion With Pharmacist Dispensing of Mifepristone. Obstet Gynecol 2021; 137:613-622. [PMID: 33706339 PMCID: PMC7984759 DOI: 10.1097/aog.0000000000004312] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/22/2020] [Indexed: 11/26/2022]
Abstract
Medication abortion with pharmacist-dispensed mifepristone is effective, with a low prevalence of adverse events, and patients are satisfied with the model of care. To estimate effectiveness and acceptability of medication abortion with mifepristone dispensed by pharmacists.
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Kaller S, Muñoz MGI, Sharma S, Tayel S, Ahlbach C, Cook C, Upadhyay UD. Abortion service availability during the COVID-19 pandemic: Results from a national census of abortion facilities in the U.S. Contracept X 2021; 3:100067. [PMID: 34308330 PMCID: PMC8292833 DOI: 10.1016/j.conx.2021.100067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 11/26/2022] Open
Abstract
Objective This study assessed the impact of COVID-19 on abortion services in all 50 United States states and the District of Columbia. Study design ANSIRH's Abortion Facility Database is a systematic collection of data on all publicly-advertising abortion facilities in the United States, updated annually through online searches and mystery shopper phone calls. Research staff updated the database in May-August 2020, assessing the number of facilities that closed, limited or stopped providing abortions, and provided telehealth options in summer 2020 due to COVID-19. We describe these changes using frequencies and highlighting themes and examples from coded qualitative data. Results Located primarily in the South and Midwest, 24 of 751 facilities that were open in 2019 temporarily closed due to the pandemic, with 9 still closed by August 2020. Other facilities described suspending abortions, referring abortion patients to other facilities, or limiting services to medication abortion. While most facilities required in-person visits for reasons like state abortion restrictions, 22% (n = 150) offered phone or telehealth consultations, no-test visits, or medication abortion by mail to reduce or eliminate patient time in the clinic. Some facilities used creative strategies to reduce COVID-19 risk like allowing patients to wait for visits in their cars or offering drive-through medication pick-up. Conclusions The COVID-19 pandemic caused several disruptions to abortion service availability, including closures. To reduce in-person visit time, some clinics shifted to offering medication abortion (versus procedural) or telehealth. While the pandemic and abortion restrictions increased barriers to abortion provision, facilities were resilient and adapted to provide safe care for their patients. Implications Barriers to abortion access were exacerbated during the COVID-19 pandemic, particularly in areas of the country with more restrictive policies toward abortion. Telehealth care protocols offered by many abortion facilities provide an option to reduce or eliminate in-person visits.
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Affiliation(s)
- Shelly Kaller
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, Oakland, CA, United States
| | - M G Isabel Muñoz
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, Oakland, CA, United States
| | - Subeksha Sharma
- University of California, Berkeley, School of Public Health, CA, United States
| | - Salma Tayel
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, United States
| | - Chris Ahlbach
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, Oakland, CA, United States
| | - Clara Cook
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, Oakland, CA, United States
| | - Ushma D Upadhyay
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, Oakland, CA, United States
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Obstetrician-gynecologist willingness to provide medication abortion with removal of the in-person dispensing requirement for mifepristone. Contraception 2021; 104:73-76. [DOI: 10.1016/j.contraception.2021.03.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/24/2021] [Accepted: 04/01/2021] [Indexed: 11/20/2022]
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Expanding access to medication abortion through pharmacy dispensing of mifepristone: Primary care perspectives from Illinois. Contraception 2021; 104:98-103. [DOI: 10.1016/j.contraception.2021.03.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 03/14/2021] [Accepted: 03/21/2021] [Indexed: 11/24/2022]
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Godfrey EM, Fiastro AE, Jacob-Files EA, Coeytaux FM, Wells ES, Ruben MR, Sanan SS, Bennett IM. Factors associated with successful implementation of telehealth abortion in 4 United States clinical practice settings. Contraception 2021; 104:82-91. [DOI: 10.1016/j.contraception.2021.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/19/2021] [Accepted: 04/19/2021] [Indexed: 11/28/2022]
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Kerestes C, Delafield R, Elia J, Chong E, Kaneshiro B, Soon R. “It was close enough, but it wasn't close enough”: A qualitative exploration of the impact of direct-to-patient telemedicine abortion on access to abortion care. Contraception 2021; 104:67-72. [DOI: 10.1016/j.contraception.2021.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
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Contraception Special Issue on the mifepristone Risk Evaluation and Mitigation Strategy (REMS). Contraception 2021; 104:1-3. [PMID: 34130794 DOI: 10.1016/j.contraception.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Family medicine provision of online medication abortion in three US states during COVID-19. Contraception 2021; 104:54-60. [PMID: 33939985 PMCID: PMC8086374 DOI: 10.1016/j.contraception.2021.04.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To examine provision of direct-to-patient medication abortion during COVID-19 by United States family physicians through a clinician-supported, asynchronous online service, Aid Access. STUDY DESIGN We analyzed data from United States residents in New Jersey, New York, and Washington who requested medication abortion from 3 family physicians using the online service from Aid Access between April and November 2020. This study seeks to examine individual characteristics, motivations, and geographic locations of patients receiving abortion care through the Aid Access platform. RESULTS Over 7 months, three family physicians using the Aid Access platform provided medication abortion care to 534 residents of New Jersey, New York, and Washington. There were no demographic differences between patients seeking care in these states. A high percentage (85%) were less than 7 weeks gestation at the time of their request for care. The reasons patients chose Aid Access for abortion services were similar regardless of state residence. The majority (71%) of Aid Access users lived in urban areas. Each family physician provided care to most counties in their respective states. Among those who received services in the three states, almost one-quarter (24%) lived in high Social Vulnerability Index (SVI) counties, with roughly one-third living in medium-high SVI counties (33%), followed by another quarter (26%) living in medium-low SVI counties. CONCLUSIONS Family physicians successfully provided medication abortion in three states using asynchronous online consultations and medications mailed directly to patients. IMPLICATIONS Primary care patients are requesting direct-to-patient first trimester abortion services online. By providing abortion care online, a single provider can serve the entire state, thus greatly increasing geographic access to medication abortion.
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Stone RH, Rafie S. Medication abortion: Advocating for mifepristone dispensing by pharmacists. Contraception 2021; 104:31-32. [DOI: 10.1016/j.contraception.2021.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
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Abortion exceptionalism and the mifepristone REMS. Contraception 2021; 104:8-11. [DOI: 10.1016/j.contraception.2021.03.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/26/2021] [Accepted: 03/30/2021] [Indexed: 11/19/2022]
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Kaller S, Morris N, Biggs MA, Baba CF, Rafie S, Raine-Bennett TR, Creinin MD, Berry E, Micks EA, Meckstroth KR, Averbach S, Grossman D. Pharmacists' knowledge, perspectives, and experiences with mifepristone dispensing for medication abortion. J Am Pharm Assoc (2003) 2021; 61:785-794.e1. [PMID: 34281806 DOI: 10.1016/j.japh.2021.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND The U.S. Food and Drug Administration (FDA) restricts dispensing of mifepristone for medication abortion to certified health care providers at clinical facilities, thus prohibiting pharmacist dispensing. Allowing mifepristone dispensing by pharmacists could improve access to medication abortion. OBJECTIVE To assess the feasibility of pharmacists dispensing mifepristone to patients who have undergone evaluation for eligibility and counseling for medication abortion by a clinician. METHODS Before providing a study training on medication abortion, we administered baseline surveys to pharmacists who participated in a multisite mifepristone-dispensing intervention. The survey assessed medication abortion knowledge-using a 15-item score-and perceptions about the benefits and challenges of the model. We administered follow-up surveys in the study's final month that also assessed the pharmacists' satisfaction and experiences with mifepristone dispensing. To investigate the association of the study intervention with the pharmacists' knowledge, perceptions, and experiences dispensing mifepristone, we conducted multivariable linear regression analyses using generalized estimating equation models, accounting for clustering by individual. RESULTS Among the 72 pharmacists invited from 6 pharmacies, 47 (65%) completed the baseline surveys, and 56 (78%) received training. At the study's end (mean 18 months later), 43 of the 56 pharmacists who received training (77%) completed the follow-up surveys. At follow-up, 36 (83%) respondents were very or somewhat satisfied with mifepristone dispensing, and 24 (56%) reported experiencing no challenges dispensing mifepristone. Four (6%) of the 72 pharmacists invited objected to participating in mifepristone dispensing. In regression analyses, average knowledge scores, perceived ease of implementation, and level of support for the pharmacist-dispensing model were higher at follow-up (P < 0.001). CONCLUSION Most pharmacists were willing to be trained, dispensed mifepristone with few challenges when given the opportunity, were satisfied with the model, and had higher knowledge levels at follow-up. Our findings support removal of FDA's restriction on pharmacist dispensing of mifepristone.
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Aiken ARA, Starling JE, Gomperts R. Factors Associated With Use of an Online Telemedicine Service to Access Self-managed Medical Abortion in the US. JAMA Netw Open 2021; 4:e2111852. [PMID: 34019085 PMCID: PMC8140373 DOI: 10.1001/jamanetworkopen.2021.11852] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE People in the US have been seeking self-managed abortions outside the formal health care system using medications obtained through online telemedicine. However, little is known about this practice, including potential motivating factors. OBJECTIVE To examine individual reasons for accessing medication abortion through an online telemedicine service as well as associations between state- and county-level factors and the rate of requests. DESIGN, SETTING, AND PARTICIPANTS This population-based cross-sectional study examined all requests for self-managed medication abortion through an online consultation form available from Aid Access, a telemedicine service in the US, between March 20, 2018, and March 20, 2020. MAIN OUTCOMES AND MEASURES Individual-level reasons for accessing the telemedicine service were examined as well as the rate of requests per 100 000 women of reproductive age by state. Zip code data provided by individuals making requests were used to examine county-level factors hypothesized to be associated with increased demand for self-managed abortion: distance to a clinic (calculated using location data for US abortion clinics) and the population proportion identifying as a member of a racial/ethnic minority group, living below the federal poverty level, and having broadband internet access (calculated using census data). RESULTS During the 2-year study period, 57 506 individuals in 2458 counties in 50 states requested self-managed medication abortion; 52.1% were aged 20 to 29 years (mean [SD] age, 25.9 [6.7] years), 50.0% had children, and 99.9% were 10 weeks' pregnant or less. The most common reasons cited by individuals making requests were the inability to afford in-clinic care (73.5%), privacy (49.3%), and clinic distance (40.4%). States with the highest rate of requests were Louisiana (202.7 per 100 000 women) and Mississippi (199.9 per 100 000 women). At the county level, an increase of 1 SD (47 miles) in distance to the nearest clinic was significantly associated with a 41% increase in requests (incidence rate ratio, 1.41; 95% CI, 1.31-1.51; P < .001), and a 10% increase in the population living below the federal poverty level was significantly associated with a 20% increase in requests (incidence rate ratio, 1.20; 95% CI, 1.13-1.28; P < .001). CONCLUSIONS AND RELEVANCE In this cross-sectional study, clinic access barriers were the most commonly cited reason for requesting self-managed medication abortion using an online telemedicine service. At the county level, distance to an abortion clinic and living below the federal poverty level were associated with a higher rate of requests. State and federal legislation could address these access barriers.
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Affiliation(s)
- Abigail R. A. Aiken
- LBJ School of Public Affairs, The University of Texas at Austin
- Population Research Center, The University of Texas at Austin
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Perspectives of internal medicine physicians regarding medication abortion provision in the primary care setting. Contraception 2021; 104:420-425. [PMID: 33894250 DOI: 10.1016/j.contraception.2021.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/12/2021] [Accepted: 04/14/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To better understand medication abortion attitudes and interest in future provision among Internal Medicine primary care providers (IM PCPs), and to characterize barriers to provision. STUDY DESIGN We conducted a survey with IM attendings and trainees at a large academic medical center in Western Pennsylvania. We used descriptive statistics to characterize attitudes towards medication abortion provision, including the belief that it is within their scope of practice and interest in future provision, and to explore perceived barriers to provision. We used logistic regression models to assess factors associated with each of these attitudes. RESULTS Of 397 eligible attendings and trainees, 121 (30%) completed the survey. Among those surveyed, 44% believed medication abortion is within the scope of practice of IM PCPs with trainees and female-identifying providers being significantly more likely to believe medication abortion is within their scope of practice compared to attending physicians and male physicians (60% vs 30%, p < 0.01 and 53% vs 31%, p = 0.01, respectively). Similarly, 43% endorsed interest in future provision, with trainees (67% vs 23%, p < 0.001) and female providers (54% vs 27%, p = 0.002) being more likely to express interest. The most cited barriers to provision included limited training in residency (70%) and low familiarity with abortion medications (57%). CONCLUSIONS Many IM providers- particularly trainees- believe medication abortion is within their scope of practice and would like to provide this care. Interventions are needed to provide education and assistance complying with state and federal regulations to enable safe and efficient medication abortion provision by IM providers. IMPLICATIONS IM departments and residency programs should seek to ensure training is offered to clinicians interested in providing medication abortion as a part of their primary care practice.
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Tschann M, Ly ES, Hilliard S, Lange HLH. Changes to medication abortion clinical practices in response to the COVID-19 pandemic. Contraception 2021; 104:77-81. [PMID: 33894247 PMCID: PMC8059330 DOI: 10.1016/j.contraception.2021.04.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To document medication abortion clinical practice changes adopted by providers in response to the COVID-19 pandemic. STUDY DESIGN Longitudinal descriptive study, comprised of three online surveys conducted between April to December, 2020. We recruited sites from email lists of national abortion and family planning organizations. RESULTS Seventy-four sites opted to participate. We analyzed 55/74 sites (74%) that provided medication abortion and completed all three surveys. The total number of abortion encounters reported by the sites remained consistent throughout the study period, though medication abortion encounters increased while first-trimester aspiration abortion encounters decreased. In response to the COVID-19 pandemic, sites reduced the number of in-person visits associated with medication abortion and confirmation of successful termination. In February 2020, considered prepandemic, 39/55 sites (71%) required 2 or more patient visits for a medication abortion. By April 2020, 19/55 sites (35%) reported reducing the total number of in-person visits associated with a medication abortion. As of October 2020, 37 sites indicated newly adopting a practice of offering medication abortion follow-up with no in-person visits. CONCLUSIONS Sites quickly adopted protocols incorporating practices that are well-supported in the literature, including forgoing Rh-testing and pre-abortion ultrasound in some circumstances and relying on patient report of symptoms or home pregnancy tests to confirm successful completion of medication abortion. Importantly, these practices reduce face-to-face interactions and the opportunity for virus transmission. Sustaining these changes even after the public health crisis is over may increase patient access to abortion, and these impacts should be evaluated in future research. IMPLICATIONS STATEMENT Medication abortion serves a critical function in maintaining access to abortion when there are limitations to in-person clinic visits. Sites throughout the country successfully and quickly adopted protocols that reduced visits associated with the abortion, reducing in-person screenings, relying on telehealth, and implementing remote follow-up.
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Affiliation(s)
- Mary Tschann
- Society of Family Planning and Society of Family Planning Research Fund, Denver, CO, United States
| | - Elizabeth S Ly
- Society of Family Planning and Society of Family Planning Research Fund, Denver, CO, United States
| | - Sara Hilliard
- Society of Family Planning and Society of Family Planning Research Fund, Denver, CO, United States
| | - Hannah L H Lange
- Society of Family Planning and Society of Family Planning Research Fund, Denver, CO, United States.
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LaRoche KJ, Jozkowski KN, Crawford BL, Haus KR. Attitudes of US adults toward using telemedicine to prescribe medication abortion during COVID-19: A mixed methods study. Contraception 2021; 104:104-110. [PMID: 33848466 PMCID: PMC8053404 DOI: 10.1016/j.contraception.2021.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 10/30/2022]
Abstract
OBJECTIVES We explored public opinion about using telemedicine to provide medication abortion during the COVID-19 pandemic in 2020. We also investigated the associations between socio-demographic characteristics and support for using telemedicine in this context and explored factors that influenced respondents' attitudes on the topic. STUDY DESIGN In a nationally representative, web-based survey of US adults (n = 711), we asked open- and closed-ended questions about using telemedicine to prescribe medication abortion during COVID-19. We used multinomial logistic regression to assess the relationship between socio-demographic characteristics, endorsement of abortion labels, and political affiliation and support for telemedicine in this circumstance. Then, we conducted content and thematic analyses with the open-ended data to explore what influenced respondents' opinions. RESULTS Overall, 332 (44%) of respondents supported using telemedicine for medication abortion during the pandemic; 237 (35%) opposed and 138 (21%) were unsure. Respondents who identified as prochoice were more likely to support using telemedicine for abortion during the pandemic than those who identified as prolife were to oppose it in this context (RRR 2.95; 95% CI 1.31-6.64). Via our content and thematic analysis, we identified that concerns about safety, the legitimacy of telemedicine, and the belief that abortion should occur as early in the pregnancy as possible influenced respondents' beliefs about using telemedicine for medication abortion. CONCLUSIONS More respondents supported using telemedicine for medication abortion during COVID-19 than opposed it. Among respondents who expressed support, most thought that medication abortion was safe and that telemedicine was equivalent to the in-person provision of care. IMPLICATIONS There appears to be support among US adults for the provision of medication abortion via telemedicine during COVID-19. Policymakers may consider public sentiment as well as clinical evidence when considering legislation about abortion.
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Affiliation(s)
- Kathryn J LaRoche
- Indiana University Bloomington, School of Public Health, Bloomington IN, United States
| | - Kristen N Jozkowski
- Indiana University Bloomington, School of Public Health, Bloomington IN, United States; Indiana University, The Kinsey Institute for Research in Sex, Gender, and Reproduction, Bloomington IN, United States.
| | - Brandon L Crawford
- Indiana University Bloomington, School of Public Health, Bloomington IN, United States
| | - Katherine R Haus
- Indiana University Bloomington, School of Public Health, Bloomington IN, United States
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Beshar I, Thomson K, Byrne J. Misoprostol-augmented induction of labour for third trimester fetal demise in a patient with prior hysterotomies. BMJ Case Rep 2021; 14:14/1/e239872. [PMID: 33514616 PMCID: PMC7849869 DOI: 10.1136/bcr-2020-239872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
A 31-year-old G3P2002 with history of two prior caesarean sections presented with influenza-like illness, requiring intubation secondary to acute respiratory distress syndrome. Investigations revealed intrauterine fetal demise at 30-week gestation.She soon deteriorated with sepsis and multiple organs impacted. Risks of the gravid uterus impairing cardiopulmonary function appeared greater than risks of delivery, including that of uterine rupture. Vaginal birth after caesarean was achieved with misoprostol and critical care status rapidly improved.Current guidelines for management of fetal demise in patients with prior hysterotomies are mixed: although the American College of Obstetricians and Gynecologists recommends standard obstetric protocols rather than misoprostol administration for labour augmentation, there is limited published data citing severe maternal morbidity associated with misoprostol use. This case report argues misoprostol-augmented induction of labour can be a reasonable option in a medically complex patient with fetal demise and prior hysterotomies.
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Affiliation(s)
- Isabel Beshar
- Stanford University School of Medicine, Stanford, California, USA
| | - Karolina Thomson
- Obstetrics & Gynecology, Santa Clara Valley Medical Center, San Jose, California, USA
| | - James Byrne
- Maternal Fetal Medicine, Obstetrics and Gynecology, Santa Clara Valley Medical Center, San Jose, California, USA,Maternal Fetal Medicine, Obstetrics & Gynecology, Stanford University School of Medicine, Stanford, California, USA
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Brown BL, Wood SF, Sarpatwari A. Ensuring Safe Access to Mifepristone During the Pandemic and Beyond. Ann Intern Med 2021; 174:105-106. [PMID: 33085508 PMCID: PMC7592805 DOI: 10.7326/m20-6671] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This article discusses the risk evaluation and mitigation strategy (REMS) program imposed by the Food and Drug Administration for mifepristone.
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Affiliation(s)
- Beatrice L Brown
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (B.L.B., A.S.)
| | - Susan F Wood
- George Washington University Milken Institute School of Public Health, Washington, DC (S.F.W.)
| | - Ameet Sarpatwari
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (B.L.B., A.S.)
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Connor J, Madhavan S, Mokashi M, Amanuel H, Johnson NR, Pace LE, Bartz D. Health risks and outcomes that disproportionately affect women during the Covid-19 pandemic: A review. Soc Sci Med 2020; 266:113364. [PMID: 32950924 PMCID: PMC7487147 DOI: 10.1016/j.socscimed.2020.113364] [Citation(s) in RCA: 253] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/31/2020] [Accepted: 09/09/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Covid-19 pandemic is straining healthcare systems in the US and globally, which has wide-reaching implications for health. Women experience unique health risks and outcomes influenced by their gender, and this narrative review aims to outline how these differences are exacerbated in the Covid-19 pandemic. OBSERVATIONS It has been well described that men suffer from greater morbidity and mortality once infected with SARS-CoV-2. This review analyzed the health, economic, and social systems that result in gender-based differences in the areas healthcare workforce, reproductive health, drug development, gender-based violence, and mental health during the Covid-19 pandemic. The increased risk of certain negative health outcomes and reduced healthcare access experienced by many women are typically exacerbated during pandemics. We assess data from previous disease outbreaks coupled with literature from the Covid-19 pandemic to examine the impact of gender on women's SARS-CoV-2 exposure and disease risks and overall health status during the Covid-19 pandemic. CONCLUSIONS Gender differences in health risks and implications are likely to be expanded during the Covid-19 pandemic. Efforts to foster equity in health, social, and economic systems during and in the aftermath of Covid-19 may mitigate the inequitable risks posed by pandemics and other times of healthcare stress.
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Affiliation(s)
| | | | | | | | - Natasha R Johnson
- Harvard Medical School, Boston, MA, USA; Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, MA, USA
| | - Lydia E Pace
- Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Mary Horrigan Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, MA, USA
| | - Deborah Bartz
- Harvard Medical School, Boston, MA, USA; Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, MA, USA; Mary Horrigan Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, MA, USA
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Upadhyay UD, Schroeder R, Roberts SC. Adoption of no-test and telehealth medication abortion care among independent abortion providers in response to COVID-19. Contracept X 2020; 2:100049. [PMID: 33305255 PMCID: PMC7718446 DOI: 10.1016/j.conx.2020.100049] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/07/2020] [Accepted: 11/16/2020] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Access to abortion care in the United States (US) is restricted by numerous logistical and financial barriers, which have been further intensified by the COVID-19 pandemic. We sought to understand the ways in which COVID-19 prompted changes in clinical practices in abortion care among independent abortion clinics. STUDY DESIGN We surveyed independent US abortion clinics and documented changes in practice regarding the provision of abortion since March 1, 2020. RESULTS Among about 153 independent clinics invited, 100 clinics contributed relevant data and were included in the analytic sample. A total of 87% reported changes in protocols in response to the COVID-19 pandemic. Reported changes included moving to telehealth (phone or video) for follow-up (71%), starting or increasing telehealth for patient consultations and screening (41%), reducing Rh testing (43%) and other tests (42%), and omitting the preabortion ultrasound (15%). A total of 20% reported allowing quick pickup of medication abortion pills, and 4% began mailing medications directly to patients after a telehealth consultation. Clinical practice changes were reported throughout all regions of the US, but facilities in the Northeast (73%) were more likely to report starting or increasing telehealth than facilities in the South (23%, p < .001). CONCLUSION The COVID-19 pandemic accelerated use of telehealth among independent abortion clinics, but many clinics, particularly those in the South, have been unable to make these changes. Other practices such as reducing preabortion ultrasounds were less common in all regions despite clinical guidelines and evidence supporting such changes in practice and positive benefits for public health and patient-centered care. IMPLICATIONS The COVID-19 pandemic has created a window of opportunity to remove barriers to abortion, including expanding telehealth and reducing preabortion tests. Clinics can strive for a culture shift towards simplifying the provision of medication abortion and routinely avoiding preabortion tests and in-person visits. Such changes in practice could have positive benefits for public health and patient-centered care.
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Affiliation(s)
- Ushma D. Upadhyay
- Advancing New Standards in Reproductive Health (ANSIRH), Dept. of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612
| | - Rosalyn Schroeder
- Advancing New Standards in Reproductive Health (ANSIRH), Dept. of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612
| | - Sarah C.M. Roberts
- Advancing New Standards in Reproductive Health (ANSIRH), Dept. of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612
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Abstract
PURPOSE OF REVIEW To review the current state of self-managed or self-induced abortion in the United States and the emerging legal, political, and research questions surrounding this issue. RECENT FINDINGS With the exponential rise of restrictive antiabortion laws in the United States, it has become increasingly difficult to access safe and legal abortion services. One response to this hostile environment for reproductive care access is an increased interest in methods of self-induced or self-managed abortions, primarily by medications sourced outside the medical setting. Medication abortion is established as a safe and effective method of ending a pregnancy. Compared with clinic-based care, the two most pressing concerns regarding the safety of self-managed abortion are that people seeking abortion will incorrectly self-identifying as appropriate candidates and that they will not know or be able to access medical care if needed. There is therefore an increasing need for medical providers to learn about and researchers to evaluate the incidence, safety and efficacy of self-management of abortion. Simultaneously, reproductive law experts must continue to develop and educate on the legal frameworks to protect and decriminalize people seeking self-managed abortion as well as their care providers. SUMMARY Emerging research suggests that abortion outside the medical setting, or self-managed abortion, is an overall safe and effective way to end a pregnancy. However, significant legal barriers and stigma remain. The safest environment for self-managed abortion (SMA) is one where accurate information is available, medical care is accessible when needed, and all methods of abortion remain legal.
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Demand for Self-Managed Online Telemedicine Abortion in the United States During the Coronavirus Disease 2019 (COVID-19) Pandemic. Obstet Gynecol 2020; 136:835-837. [PMID: 32701762 PMCID: PMC7505141 DOI: 10.1097/aog.0000000000004081] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Increased demand for self-managed medication abortion in states with in-clinic restrictions or high infection rates during the coronavirus disease 2019 (COVID-19) pandemic demonstrates the need for remote abortion care models.
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Romanis EC, Parsons JA. Legal and policy responses to the delivery of abortion care during COVID-19. Int J Gynaecol Obstet 2020; 151:479-486. [PMID: 32931598 PMCID: PMC9087790 DOI: 10.1002/ijgo.13377] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Access to abortion care has long been a global challenge, even in jurisdictions where abortion is legal. The COVID-19 pandemic has exacerbated barriers to access, thereby preventing many women from terminating unwanted pregnancies for an extended period. In this paper, we outline existing and COVID-specific barriers to abortion care and consider potential solutions, including the use of telemedicine, to overcome barriers to access during the pandemic and beyond. We explore the responses of governments throughout the world to the challenge of abortion access during the pandemic, which are an eclectic mix of progressive, neutral, and regressive policies. Finally, we call on all governments to recognize abortion as essential healthcare and act to ensure that the law does not continue to interfere with providers' ability to adapt to circumstances and to guarantee safe and appropriate care not only during the pandemic, but permanently.
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Affiliation(s)
- Elizabeth Chloe Romanis
- Centre for Ethics and Law in the Life Sciences, Durham Law School, Durham University, Durham, UK
| | - Jordan A Parsons
- Centre for Ethics in Medicine, Bristol Medical School, University of Bristol, Bristol, UK
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Summit AK, Lague I, Dettmann M, Gold M. Barriers to and Enablers of Abortion Provision for Family Physicians Trained in Abortion During Residency. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2020; 52:151-159. [PMID: 33051986 DOI: 10.1363/psrh.12154] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 05/11/2020] [Accepted: 05/26/2020] [Indexed: 06/11/2023]
Abstract
CONTEXT Although some family medicine residency programs include routine opt-out training in early abortion, little is known about abortion provision by trainees after residency graduation. A better understanding of the barriers to and enablers of abortion provision by trained family physicians could improve residency training and shape other interventions to increase abortion provision and access. METHODS Twenty-eight U.S. family physicians who had received abortion training during residency were interviewed in 2017, between two and seven years after residency graduation. The doctors, identified using databases of abortion-trained physicians maintained by residency programs, were recruited by e-mail. In phone interviews, they described their postresidency abortion provision experiences. All interviews were transcribed, coded and analyzed using Dedoose, and a social-ecological framework was employed to guide investigation and analysis. RESULTS Although many of the physicians were motivated to provide abortion care, only a minority did so. Barriers to and enablers of abortion provision were found on all levels of the social-ecological model-legal, institutional, social and individual-and included state-specific laws and restrictions on federal funding; religious affiliation or policies prohibiting abortion within particular health systems; mentorship, colleagues' support and the stigma of being an abortion provider; and geographic location, time management and individuals' prioritization of abortion provision. CONCLUSIONS Clinical training alone may not be sufficient for family medicine physicians to overcome the barriers to postresidency abortion provision. To increase abortion provision and access, organizations and advocates should work to strengthen enablers of provision, such as strong mentorship and support networks.
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Munro S, Guilbert E, Wagner MS, Wilcox ES, Devane C, Dunn S, Brooks M, Soon JA, Mills M, Leduc-Robert G, Wahl K, Zannier E, Norman WV. Perspectives Among Canadian Physicians on Factors Influencing Implementation of Mifepristone Medical Abortion: A National Qualitative Study. Ann Fam Med 2020; 18:413-421. [PMID: 32928757 PMCID: PMC7489974 DOI: 10.1370/afm.2562] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/21/2020] [Accepted: 02/11/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Access to family planning health services in Canada has been historically inadequate and inequitable. A potential solution appeared when Health Canada approved mifepristone, the gold standard for medical abortion, in July 2015. We sought to investigate the factors that influence successful initiation and ongoing provision of medical abortion services among Canadian health professionals and how these factors relate to abortion policies, systems, and service access throughout Canada. METHODS We conducted 1-on-1 semistructured interviews with a national sample of abortion-providing and nonproviding physicians and health system stakeholders in Canadian health care settings. Our data collection, thematic analysis, and interpretation were guided by Diffusion of Innovation theory. RESULTS We conducted interviews with 90 participants including rural practitioners and those with no previous abortion experience. In the course of our study, Health Canada removed mifepristone restrictions. Our results suggest that Health Canada's initial restrictions discouraged physicians from providing mifepristone and were inconsistent with provincial licensing standards, thereby limiting patient access. Once deregulated, remaining factors were primarily related to local and regional implementation processes. Participants held strong perceptions that mifepristone was the new standard of care for medical abortion in Canada and within the scope of primary care practice. CONCLUSION Health Canada's removal of mifepristone restrictions facilitated the implementation of abortion care in the primary care setting. Our results are unique because Canada is the first country to facilitate provision of medical abortion in primary care via evidence-based deregulation of mifepristone.
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Affiliation(s)
- Sarah Munro
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (S.M., K.W.); Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada (S.M, E.S.W.); Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec, Canada (E.G.); Department of Obstetrics and Gynaecology, University of Montreal, Montreal, Quebec, Canada (M.W.); School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (E.S.W.); School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada (C.D.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (S.D.); Women's College Research Institute, Toronto, Ontario, Canada (S.D.); Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada (M.B.); Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada (J.A.S.); Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (M.M., G.L., E.Z); Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (W.V.N.); Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom (W.V.N.)
| | - Edith Guilbert
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (S.M., K.W.); Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada (S.M, E.S.W.); Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec, Canada (E.G.); Department of Obstetrics and Gynaecology, University of Montreal, Montreal, Quebec, Canada (M.W.); School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (E.S.W.); School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada (C.D.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (S.D.); Women's College Research Institute, Toronto, Ontario, Canada (S.D.); Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada (M.B.); Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada (J.A.S.); Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (M.M., G.L., E.Z); Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (W.V.N.); Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom (W.V.N.)
| | - Marie-Soleil Wagner
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (S.M., K.W.); Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada (S.M, E.S.W.); Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec, Canada (E.G.); Department of Obstetrics and Gynaecology, University of Montreal, Montreal, Quebec, Canada (M.W.); School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (E.S.W.); School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada (C.D.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (S.D.); Women's College Research Institute, Toronto, Ontario, Canada (S.D.); Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada (M.B.); Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada (J.A.S.); Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (M.M., G.L., E.Z); Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (W.V.N.); Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom (W.V.N.)
| | - Elizabeth S Wilcox
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (S.M., K.W.); Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada (S.M, E.S.W.); Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec, Canada (E.G.); Department of Obstetrics and Gynaecology, University of Montreal, Montreal, Quebec, Canada (M.W.); School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (E.S.W.); School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada (C.D.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (S.D.); Women's College Research Institute, Toronto, Ontario, Canada (S.D.); Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada (M.B.); Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada (J.A.S.); Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (M.M., G.L., E.Z); Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (W.V.N.); Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom (W.V.N.)
| | - Courtney Devane
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (S.M., K.W.); Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada (S.M, E.S.W.); Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec, Canada (E.G.); Department of Obstetrics and Gynaecology, University of Montreal, Montreal, Quebec, Canada (M.W.); School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (E.S.W.); School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada (C.D.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (S.D.); Women's College Research Institute, Toronto, Ontario, Canada (S.D.); Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada (M.B.); Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada (J.A.S.); Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (M.M., G.L., E.Z); Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (W.V.N.); Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom (W.V.N.)
| | - Sheila Dunn
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (S.M., K.W.); Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada (S.M, E.S.W.); Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec, Canada (E.G.); Department of Obstetrics and Gynaecology, University of Montreal, Montreal, Quebec, Canada (M.W.); School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (E.S.W.); School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada (C.D.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (S.D.); Women's College Research Institute, Toronto, Ontario, Canada (S.D.); Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada (M.B.); Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada (J.A.S.); Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (M.M., G.L., E.Z); Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (W.V.N.); Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom (W.V.N.)
| | - Melissa Brooks
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (S.M., K.W.); Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada (S.M, E.S.W.); Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec, Canada (E.G.); Department of Obstetrics and Gynaecology, University of Montreal, Montreal, Quebec, Canada (M.W.); School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (E.S.W.); School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada (C.D.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (S.D.); Women's College Research Institute, Toronto, Ontario, Canada (S.D.); Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada (M.B.); Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada (J.A.S.); Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (M.M., G.L., E.Z); Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (W.V.N.); Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom (W.V.N.)
| | - Judith A Soon
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (S.M., K.W.); Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada (S.M, E.S.W.); Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec, Canada (E.G.); Department of Obstetrics and Gynaecology, University of Montreal, Montreal, Quebec, Canada (M.W.); School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (E.S.W.); School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada (C.D.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (S.D.); Women's College Research Institute, Toronto, Ontario, Canada (S.D.); Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada (M.B.); Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada (J.A.S.); Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (M.M., G.L., E.Z); Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (W.V.N.); Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom (W.V.N.)
| | - Megan Mills
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (S.M., K.W.); Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada (S.M, E.S.W.); Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec, Canada (E.G.); Department of Obstetrics and Gynaecology, University of Montreal, Montreal, Quebec, Canada (M.W.); School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (E.S.W.); School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada (C.D.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (S.D.); Women's College Research Institute, Toronto, Ontario, Canada (S.D.); Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada (M.B.); Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada (J.A.S.); Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (M.M., G.L., E.Z); Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (W.V.N.); Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom (W.V.N.)
| | - Genevieve Leduc-Robert
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (S.M., K.W.); Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada (S.M, E.S.W.); Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec, Canada (E.G.); Department of Obstetrics and Gynaecology, University of Montreal, Montreal, Quebec, Canada (M.W.); School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (E.S.W.); School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada (C.D.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (S.D.); Women's College Research Institute, Toronto, Ontario, Canada (S.D.); Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada (M.B.); Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada (J.A.S.); Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (M.M., G.L., E.Z); Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (W.V.N.); Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom (W.V.N.)
| | - Kate Wahl
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (S.M., K.W.); Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada (S.M, E.S.W.); Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec, Canada (E.G.); Department of Obstetrics and Gynaecology, University of Montreal, Montreal, Quebec, Canada (M.W.); School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (E.S.W.); School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada (C.D.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (S.D.); Women's College Research Institute, Toronto, Ontario, Canada (S.D.); Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada (M.B.); Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada (J.A.S.); Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (M.M., G.L., E.Z); Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (W.V.N.); Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom (W.V.N.)
| | - Erik Zannier
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (S.M., K.W.); Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada (S.M, E.S.W.); Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec, Canada (E.G.); Department of Obstetrics and Gynaecology, University of Montreal, Montreal, Quebec, Canada (M.W.); School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (E.S.W.); School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada (C.D.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (S.D.); Women's College Research Institute, Toronto, Ontario, Canada (S.D.); Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada (M.B.); Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada (J.A.S.); Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (M.M., G.L., E.Z); Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (W.V.N.); Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom (W.V.N.)
| | - Wendy V Norman
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada (S.M., K.W.); Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada (S.M, E.S.W.); Department of Obstetrics and Gynaecology, Laval University, Quebec City, Quebec, Canada (E.G.); Department of Obstetrics and Gynaecology, University of Montreal, Montreal, Quebec, Canada (M.W.); School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada (E.S.W.); School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada (C.D.); Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (S.D.); Women's College Research Institute, Toronto, Ontario, Canada (S.D.); Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada (M.B.); Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada (J.A.S.); Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (M.M., G.L., E.Z); Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada (W.V.N.); Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom (W.V.N.).
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50
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Abstract
Medication abortion, also referred to as medical abortion, is a safe and effective method of providing abortion. Medication abortion involves the use of medicines rather than uterine aspiration to induce an abortion. The U.S. Food and Drug Administration (FDA)-approved medication abortion regimen includes mifepristone and misoprostol. The purpose of this document is to provide updated evidence-based guidance on the provision of medication abortion up to 70 days (or 10 weeks) of gestation. Information about medication abortion after 70 days of gestation is provided in other ACOG publications [1].
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