Making the case for advance provision of mifepristone and misoprostol for abortion in the United States

Interest in and Support for Alternative Models of Medication Abortion Provision Among Patients Seeking Abortion in the United States

INTRODUCTION

Medication abortion is safe and effective, but restrictions still limit patients from accessing this method. Alternative models of medication abortion provision, namely advance provision, over-the-counter (OTC), and online, could help improve access to care for some, although there is limited evidence about abortion patients' interest in these models.

METHODS

Between 2017 and 2019, we administered a cross-sectional survey to abortion patients at 45 clinics across 15 U.S. states to explore their interest in and support for advance provision, OTC, and online abortion access. We assessed relationships between sociodemographic characteristics and interest in and support for each model using bivariate logistic regressions and present perceived advantages and disadvantages of each model, as described by a subset of participants.

RESULTS

Among 1,965 people enrolled, 1,759 (90%) initiated the survey. Interest in and support for advance provision was highest (72% and 82%, respectively), followed by OTC (63% and 72%) and online access (57% and 70%). In bivariate analyses, non-Hispanic Black and Asian/Pacific Islander respondents expressed lower interest and support for the online model and Alaska Native/Native American respondents expressed higher interest in an OTC model, as compared with white respondents. Among 439 participants naming advantages and disadvantages of each model, the most common advantages included convenience and having the abortion earlier. The most common disadvantages were not seeing a provider first and possibly taking pills incorrectly.

CONCLUSIONS

Although most abortion patients expressed interest in and support for alternative models of medication abortion provision, variation in support across race/ethnicity highlights a need to ensure that abortion care service models meet the needs and preferences of all patients, particularly people from historically underserved populations.

Advance Provision of Mifepristone and Misoprostol via Online Telemedicine in the US

This cross-sectional study examines trends in the demand and characteristics and motivations of individuals who requested advance provision of abortion medications.

Perspectives on Alternative Models of Medication Abortion Provision Among Abortion Patients in the United States

OBJECTIVE

Restrictions on the availability of medication abortion are a barrier to accessing early abortion. People seeking medication abortion may be interested in obtaining the medications through alternative models. The purpose of this study was to explore patient perspectives on obtaining abortion medications in advance of pregnancy or over the counter (OTC).

STUDY DESIGN

Between October 2017 and August 2018, we conducted 30 in-depth interviews with abortion patients who indicated support for alternative models. We recruited patients from 10 abortion clinics in states with a range of policy environments. We analyzed interviews using inductive and deductive iterative techniques.

RESULTS

Participants identified logistical benefits of these alternative models, including eliminating travel to a clinic and multiple appointments, and increased privacy around decision-making. Participants were interested in advance provision for its convenience and the sense of preparedness that would come with having the pills available at home, yet some had concerns about the pills being found or stolen. Privacy was the key factor considered for OTC access, including both the privacy benefits of avoiding a clinic and the concern of having one's privacy compromised within the community if purchasing the medications in public.

CONCLUSIONS

People who have previously had a medication abortion are interested in alternative methods of provision for reasons concerning convenience, privacy, and avoiding burdens related to hostile policy environments, such as long travel distances to clinics and multiple appointments. Concerns around these models were primarily safety concerns for young people. Further research is needed to evaluate the safety, effectiveness, acceptability, and feasibility of these alternative models of providing medication abortion.

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

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

Advance provision of medication for induced abortion: A qualitative study of patient perspectives

OBJECTIVES

To examine potential users' perspectives regarding the provision of abortion medications for future use or "advance provision."

STUDY DESIGN

In this qualitative study, we partnered with an independent reproductive health care clinic in Washington State to conduct semistructured, in-depth interviews with 22 individuals who obtained a medication abortion between August 2021 and January 2022. We asked participants their views on advance provision of abortion medications. Interviews were transcribed and deidentified. Inductive content analysis was used to identify major themes.

RESULTS

Participants in our sample generally reacted positively to the idea of abortion medications for future use. Having pills in advance could improve timeliness and convenience of care and decrease the stigma associated with their use. Participants stressed the importance of adequate information regarding medication use, what to expect, and potential side effects. Most concerns about advance provision related to the safety and efficacy of medication abortion.

CONCLUSIONS

This study found that individuals who recently obtained a medication abortion supported the provision of abortion medications for future use.

IMPLICATIONS

Patient-centered educational materials, with adequate information for self-managing pregnancy termination, can be shared at time of prescription. Clinicians have an opportunity to offer these safe and effective medications in advance of need and increase timely access to this essential health care service. User concerns regarding abortion medications for future use should inform clinical innovation and evaluative research of service options.

Interest in advance provision of abortion pills: a national survey of potential users in the USA

OBJECTIVE

To assess interest in clinician-administered advance provision of abortion pills among potential users in the USA.

METHODS

Using social media advertisements, we recruited people living in the USA who were aged 18-45 years and assigned female at birth, who were not pregnant or planning pregnancy, for an online survey on reproductive health experiences and attitudes. We explored interest in advance provision of abortion pills, participant characteristics, including demographics and pregnancy history, contraceptive use, abortion knowledge and comfort, and healthcare system distrust. We used descriptive statistics to assess interest in advance provision, and ordinal regression modelling to evaluate differences in interest controlling for age, pregnancy history, contraceptive use, familiarity and comfort with medication abortion, and healthcare system distrust, reporting adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs).

RESULTS

From January-February 2022, we recruited 634 diverse respondents from 48 states, among whom 65% were interested, 12% neutral, and 23% disinterested in advance provision. There were no differences among interest groups by US region, race/ethnicity, or income. In the model, variables associated with interest included being aged 18-24 years (aOR 1.9, 95% CI 1.0 to 3.4) versus 35-45 years, using a tier 1 (permanent or long-acting reversible) or tier 2 (short-acting hormonal) contraceptive method (aOR 2.3, 95% CI 1.2 to 4.1, and aOR 2.2, 95% CI 1.2 to 3.9, respectively) versus no contraception, being familiar or comfortable with the medication abortion process (aOR 4.2, 95% CI 2.8 to 6.2, and aOR 17.1, 95% CI 10.0 to 29.0, respectively), and having high healthcare system distrust (aOR 2.2, 95% CI 1.0 to 4.4) versus low distrust.

CONCLUSION

As abortion access becomes more constrained, strategies are needed to ensure timely access. Advance provision is of interest to the majority of those surveyed and warrants further policy and logistical exploration.

Telemedicine as an alternative way to access abortion in Italy and characteristics of requests during the COVID-19 pandemic

INTRODUCTION

Induced abortion is legal in Italy but with restrictions. The online abortion provider Women on Web (WoW) serves as an alternative way to access abortion. The COVID-19 pandemic has affected sexual and reproductive health worldwide. Italy was one of the first countries hit by the pandemic and imposed strict lockdown measures. We aimed to understand why women requested WoW abortion in Italy and how this was affected by the pandemic.

METHODS

We conducted an observational study analysing requests made to WoW before and during the pandemic. We analysed 778 requests for medical abortion from Italy between 1 March 2019 to 30 November 2020 and compared the characteristics of requests submitted before and during the pandemic. We also performed subgroup analysis on teenagers and COVID-19-specific requests.

RESULTS

There was an increase in requests during the COVID-19 pandemic compared with the previous year (12% in the first 9 months). The most common reasons for requesting a telemedicine abortion through WoW were privacy-related (40.9%); however, this shifted to COVID-19-specific (50.3%) reasons during the pandemic. Requests from teenagers (n=61) were more frequently made at later gestational stages (p=0.003), had a higher prevalence of rape (p=0.003) as the cause of unwanted pregnancies, and exhibited less access to healthcare services compared with adult women.

CONCLUSIONS

There was an increase in total demand for self-managed abortion during the pandemic and reasons for requesting an abortion changed, shifting from privacy-related to COVID-19-specific reasons. This study also highlighted the uniquely vulnerable situation of teenagers with unwanted pregnancies seeking self-managed abortion.

Small-molecule profiling for steroid receptor activity using a universal steroid receptor reporter assay

A critical step in the development of novel drug candidates for the treatment of steroid related diseases is ensuring the absence of crosstalk with steroid receptors (SRs). Establishing this SR cross-reactivity profile requires multiple reporter assays as each SR associates with its unique enhancer region, a labor intensive and time-consuming approach. To overcome this need for multi-reporter assays, we established a steroid receptor inducible luciferase reporter assay (SRi-Luc) that allows side-by-side examination of agonistic and antagonistic properties of small-molecules on all steroid receptors. This state-of-the-art SRi-Luc consists of a unique alteration of four distinct keto-steroid- and estrogen response elements. As proof of principle, the SRi-Luc assay was used to profile a set of novel designed steroidal 1,2,3-triazoles. These triazolized steroidal compounds were developed via our in-house triazolization methodology, in which an enolizable ketone is converted into a triazolo-fused or -linked analog by treatment with a primary amine or ammonium salt in the presence of 4-nitrophenyl azide. From these designed steroidal 1,2,3-triazoles, six successfully reduced androgen receptor activity by 40 %. Although opted as antiandrogens, their cross-reactivity with other SRs was apparent in our SRi-Luc assay and rendered them unsuited for further antagonist development and clinical use. Overall, the SRi-Luc overcomes the need of multi-reporter assays for the profiling of small-molecules on all SRs. This not only reduces the risk of introducing biases, it as well accelerates early-stage drug discovery when designing particular SR selective (ant)agonists or characterizing off-target effects of lead molecules acting on any drug target.