RESUMO
BACKGROUND: This qualitative study aims to assess perspectives of clinicians and clinic staff on mail-order pharmacy dispensing for medication abortion. METHODS: Participants included clinicians and staff involved in implementing a mail-order dispensing model for medication abortion at eleven clinics in seven states as part of a prospective cohort study, which began in January 2020 (before the FDA removed the in-person dispensing requirement for mifepristone). From June 2021 to July 2022, we invited participants at the participating clinics, including six primary care and five abortion clinics, to complete a semi-structured video interview about their experiences. We then conducted qualitative thematic analysis of interview data, summarizing themes related to perceived benefits and concerns about the mail-order model, perceived patient interest, and potential barriers to larger-scale implementation. RESULTS: We conducted 24 interviews in total with clinicians (13 physicians and one nurse practitioner) and clinic staff (n = 10). Participants highlighted perceived benefits of the mail-order model, including its potential to expand abortion services into primary care, increase patient autonomy and privacy, and to normalize abortion services. They also highlighted key logistical, clinical, and feasibility concerns about the mail-order model, and specific challenges related to integrating abortion into primary care. CONCLUSION: Clinicians and clinic staff working in primary care and abortion clinics were optimistic that mail-order dispensing of medication abortion can improve the ability of some providers to provide abortion and enable more patients to access services. The feasibility of mail-order pharmacy dispensing of medication abortion following the Supreme Court Dobbs decision is to be determined. TRIAL REGISTRATION: Registry: Clinicaltrials.gov. TRIAL REGISTRATION NUMBER: NCT03913104. Date of registration: first submitted on April 3, 2019 and first posted on April 12, 2019.
Assuntos
Aborto Induzido , Atitude do Pessoal de Saúde , Serviços Postais , Atenção Primária à Saúde , Pesquisa Qualitativa , Humanos , Aborto Induzido/métodos , Aborto Induzido/psicologia , Feminino , Gravidez , Estudos Prospectivos , Adulto , Masculino , Estados Unidos , Pessoa de Meia-Idade , Abortivos/uso terapêutico , Abortivos/administração & dosagemRESUMO
OBJECTIVE: To compare the effectiveness and safety of medication abortion (MAB) via telemedicine versus in-person in pregnant people with less than 12 gestational weeks in Colombia. STUDY DESIGN: A retrospective cohort study was conducted with 23,362 pregnant people who requested MAB service from Profamilia (a Colombian non-governmental organization) in 2021-2022. The outcomes were success and safety of MAB. We performed a descriptive and a multivariate statistical analysis using the binary regression model to obtain an adjusted Odds Ratio (aOR) to identify factors associated with abortion success. RESULTS: In comparison to in-person care (n = 20,289), individuals in telemedicine (n = 3073) were predominantly from urban areas, belonged to a lower socioeconomic stratum, single and did not identify with any ethnic group. In-person users tended to have higher levels of education and accessed the service through private insurance (p < 0,05). There were no differences in the odd of a successful abortion based on the modality of care (aOR 1.18; 95% CI=0.87-1.59). The results were also the same with sensitivity analysis stratified: pregnant people who were nine weeks gestation or less (aOR 0.86; 95% CI=0.63-1.17) or more (aOR 0.87; 95% CI=0.28-2.65). CONCLUSION: Telemedicine is an effective and safe option for MAB, as in-person care. Telemedicine has the potential to increase abortion access by extending the availability of providers and offering people a new option for obtaining care conveniently and privately, especially for women with disadvantaged socioeconomic and educational background. IMPLICATIONS: This study demonstrates that medication abortion (MAB) administered via telemedicine produces outcomes akin to those of in-person care, providing a compelling rationale for its adoption, particularly in underserved regions. This approach can be replicated in other countries in Latin America and the Caribbean.
Assuntos
Aborto Induzido , Telemedicina , Humanos , Feminino , Gravidez , Colômbia , Estudos Retrospectivos , Adulto , Aborto Induzido/métodos , Adulto Jovem , Adolescente , Abortivos/administração & dosagemAssuntos
Abortivos , Aborto Induzido , Mifepristona , Misoprostol , Serviços Postais , Adolescente , Adulto , Feminino , Humanos , Gravidez , Adulto Jovem , Abortivos/administração & dosagem , Abortivos/efeitos adversos , Abortivos/provisão & distribuição , Abortivos/uso terapêutico , Aborto Induzido/métodos , Mifepristona/administração & dosagem , Mifepristona/efeitos adversos , Mifepristona/provisão & distribuição , Mifepristona/uso terapêutico , Misoprostol/administração & dosagem , Misoprostol/efeitos adversos , Misoprostol/provisão & distribuição , Misoprostol/uso terapêutico , Assistência Farmacêutica , Estados Unidos , Resultado do TratamentoRESUMO
INTRODUCTION: Providing abortion in primary care expands access and alleviates delays. The 2020 COVID-19 public health emergency (PHE) led to the expansion of telehealth, including medication abortion (MAB). This study evaluates the accessibility of novel telehealth MAB (teleMAB) initiated during the PHE, with the lifting of mifepristone restrictions, compared with traditional in-clinic MAB offered before the PHE at a Massachusetts safety-net primary care organization. METHODS: We conducted a retrospective electronic medical record review of 267 MABs. We describe sociodemographic, care access, and complete abortion characteristics and compare differences between teleMAB and in-clinic MABs using Chi-squared test, fisher's exact test, independent t test, and Wilcoxon rank sum. We conducted logistic regression to examine differences in time to care (6 days or less vs 7 days or more). RESULTS: 184 MABs were eligible for analysis (137 in-clinic, 47 teleMAB). Patients were not significantly more likely to receive teleMAB versus in-clinic MAB based on race, ethnicity, language, or payment. Completed abortion did not significantly differ between groups (P = .187). Patients received care more quickly when accessing teleMAB compared with usual in-clinic MAB (median 3 days, range 0 to 20 vs median 6 days, range 0 to 32; P < . 001). TeleMAB patients had 2.29 times the odds of having their abortion appointment within 6 days compared with in-clinic (95% CI: 1.13, 4.86). CONCLUSION: TeleMAB in primary care is as effective, timelier, and potentially more accessible than in-clinic MAB when in-person mifepristone regulations were enforced. TeleMAB is feasible and can promote patient-centered and timely access to abortion care.
Assuntos
Aborto Induzido , COVID-19 , Acessibilidade aos Serviços de Saúde , Atenção Primária à Saúde , Telemedicina , Humanos , Feminino , Telemedicina/estatística & dados numéricos , Telemedicina/organização & administração , Telemedicina/métodos , Aborto Induzido/métodos , Aborto Induzido/estatística & dados numéricos , Estudos Retrospectivos , Adulto , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/métodos , Gravidez , Massachusetts , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , SARS-CoV-2 , Adulto Jovem , Mifepristona/administração & dosagem , Mifepristona/uso terapêutico , Abortivos/administração & dosagemRESUMO
OBJECTIVES: Routine ultrasound before medication abortion (MAB) may create an impediment to expanding abortion access. This study examines clinical outcomes of MAB without pretreatment ultrasound evaluation at Planned Parenthood health centers in multiple states. STUDY DESIGN: We conducted a secondary analysis of data from 23 US-based Planned Parenthood affiliates that provided MAB without pretreatment ultrasound for eligible patients from March 2020 to December 2021. Affiliates aggregated electronic health record data from MABs at ≤77 days gestation (based on self-report of last menstrual period) without a pretreatment ultrasound (N = 18,041). Among MABs with known outcomes (N = 9821), we calculated the incidence rates and 95% confidence intervals (CI) for completed abortion, ongoing pregnancy, subsequent procedure, emergency department/hospital visits associated with MAB, ectopic pregnancies, and gestational duration greater than 77 days. RESULTS: Among MABs with known outcomes, 96.3% had a complete abortion (95% CI = 95.9%-96.7%), and 2.0% had an ongoing pregnancy (95% CI = 1.7%-2.3%). Four percent had a subsequent procedure (95% CI = 3.6%-4.4%), and 2.3% had a documented emergency department/hospital visit (95% CI = 2.0%-2.6%). Less than 1% had a confirmed ectopic pregnancy (0.15%, 95% CI = 0.09%-0.25%) and had a gestational duration later identified to be greater than 77 days (0.13%, 95% CI = 0.05%-0.29%). CONCLUSIONS: Our calculated incidence rates of clinical outcomes align with rates from the previous literature on MAB and from the emerging literature on MAB without pretreatment ultrasonography. Findings from this analysis suggest that MAB without pretreatment ultrasound is safe and effective for eligible patients. IMPLICATIONS: This large US study found that medication abortion without pretreatment ultrasonography results in similar clinical outcomes to prepandemic models that include pretreatment ultrasonography. Medication abortion without a pretreatment ultrasound may be adopted by abortion providers seeking to expand options for their patients as access to abortion continues to erode.
Assuntos
Aborto Induzido , Ultrassonografia Pré-Natal , Humanos , Feminino , Gravidez , Aborto Induzido/estatística & dados numéricos , Aborto Induzido/métodos , Estados Unidos , Adulto , Adulto Jovem , Gravidez Ectópica/diagnóstico por imagem , Gravidez Ectópica/epidemiologia , Abortivos/administração & dosagem , Adolescente , Idade Gestacional , Serviço Hospitalar de Emergência/estatística & dados numéricosRESUMO
OBJECTIVES: Entertainment television is an influential source of health information, including about reproductive health. We investigated the association between exposure to television plotlines about medication abortion on audience awareness and beliefs about medication abortion. STUDY DESIGN: We administered a national cross-sectional online survey from December 2021 to January 2022 with a probability-based sample of people assigned female at birth. We asked respondents to select plotlines they had seen from a list of seven that portrayed medication abortion. Among the 3425 people who responded to plotline items, 3340 responded to our outcome measures. Using weighed multivariable analyses, we examined adjusted relationships between exposure to specific types of abortion plotlines and awareness of and beliefs about medication abortion medical safety. RESULTS: We found that audience exposure to medication abortion plotlines in which the medication abortion was obtained from a clinic and portrayed as safe was associated with greater awareness of medication abortion compared to nonexposure (RR: 1.68; 95% CI: 1.17, 2.40). Exposure to plotlines that portrayed MA or self-managed MA as safe was associated with audience beliefs that medication abortion is safe. CONCLUSIONS: This study demonstrates that the content of abortion plotlines and exposure to accurate information may be connected to audience awareness of and beliefs about abortion. IMPLICATIONS: In a climate of misinformation about abortion, audience exposure to medically accurate television plotlines about medication abortion may be an effective way to increase awareness of medication abortion and influence beliefs about medication abortion safety.
Assuntos
Aborto Induzido , Conhecimentos, Atitudes e Prática em Saúde , Televisão , Humanos , Feminino , Aborto Induzido/psicologia , Aborto Induzido/métodos , Adulto , Estudos Transversais , Adulto Jovem , Gravidez , Adolescente , Inquéritos e Questionários , Abortivos/administração & dosagem , Pessoa de Meia-Idade , Instituições de Assistência Ambulatorial , Autogestão/psicologiaRESUMO
Background Second-trimester abortions, constitute 10-15% of global annual abortions, leading to two-thirds of major abortion-related complications. Recognizing the elevated risk, the WHO recommends diverse methods for safe termination. Surgical and medical approaches, particularly using drugs like Mifepristone and Misoprostol, show promising success rates. Objective To analyze the outcomes of second-trimester termination using Mifepristone or PG analogues alone or in combination. Method This is a one-year retrospective study at Tribhuvan University Teaching Hospital analyzing second-trimester terminations, collecting data on demographics, medical history, period of gestation, doses of abotificient drugs, complications, and management. Result In a study of 66 second-trimester abortions, mean age was 28.8±4.96 years, gestational age 20.07±4.3 weeks. Mifepristone and Misoprostol combination succeeded in 66.7% of cases, while 42.2% required repeated Mifepristone doses. Misoprostol use was significantly higher in patients without medical comorbidities (p=0.018), but Mifepristone requirement didn't differ significantly based on medical conditions. Combined Mifepristone and Misoprostol were used more for fetal indications. Notably, the use of Mifepristone and Misoprostol didn't significantly differ for live and intrauterine fetal death cases. Conclusion Mifepristone and Misoprostol effectively terminate second-trimester pregnancies. In high-risk cases, cautious Prostaglandin use is crucial and Mifepristone alone, in divided doses, reduces complications with high success.
Assuntos
Aborto Induzido , Mifepristona , Misoprostol , Segundo Trimestre da Gravidez , Humanos , Feminino , Gravidez , Estudos Retrospectivos , Mifepristona/administração & dosagem , Adulto , Misoprostol/administração & dosagem , Aborto Induzido/métodos , Aborto Induzido/estatística & dados numéricos , Abortivos/administração & dosagemRESUMO
This study assesses changes in online telemedicine requests to self-manage abortions with medications before vs after the Dobbs v Jackson Women's Health Organization Supreme Court decision overturning Roe v Wade.
Assuntos
Abortivos , Aborto Induzido , Autogestão , Decisões da Suprema Corte , Telemedicina , Feminino , Humanos , Gravidez , Aborto Induzido/legislação & jurisprudência , Aborto Induzido/estatística & dados numéricos , Aborto Legal/legislação & jurisprudência , Aborto Legal/métodos , Aborto Legal/estatística & dados numéricos , Autogestão/estatística & dados numéricos , Telemedicina/estatística & dados numéricos , Saúde da Mulher/legislação & jurisprudência , Saúde da Mulher/estatística & dados numéricos , Abortivos/administração & dosagem , Abortivos/uso terapêutico , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Clinical trials have established the high effectiveness and safety of medication abortion in clinical settings. However, barriers to clinical abortion care have shifted most medication abortion use to out-of-clinic settings, especially in the context of the COVID-19 pandemic. Given this shift, we aimed to estimate the effectiveness of self-managed medication abortion (medication abortion without clinical support), and to compare it to effectiveness of clinician-managed medication abortion. METHODS: For this prospective, observational cohort study, we recruited callers from two safe abortion accompaniment groups in Argentina and Nigeria who requested information on self-managed medication abortion. Before using one of two medication regimens (misoprostol alone or in combination with mifepristone), participants completed a baseline survey, and then two follow-up phone surveys at 1 week and 3 weeks after taking pills. The primary outcome was the proportion of participants reporting a complete abortion without surgical intervention. Legal restrictions precluded enrolment of a concurrent clinical control group; thus, a non-inferiority analysis compared abortion completion among those in our self-managed medication abortion cohort with abortion completion reported in historical clinical trials using the same medication regimens, restricted to participants with pregnancies of less than 9 weeks' gestation. This study was registered with ISCRTN, ISRCTN95769543. FINDINGS: Between July 31, 2019, and April 27, 2020, we enrolled 1051 participants. We analysed abortion outcomes for 961 participants, with an additional 47 participants reached after the study period. Most pregnancies were less than 12 weeks' duration. Participants in follow-up self-managed their abortions using misoprostol alone (593 participants) or the combined regimen of misoprostol plus mifepristone (356 participants). At last follow-up, 586 (99%) misoprostol alone users and 334 (94%) combined regimen users had a complete abortion without surgical intervention. For those with pregnancies of less than 9 weeks' gestation, both regimens were non-inferior to medication abortion effectiveness in clinical settings. INTERPRETATION: Findings from this prospective cohort study show that self-managed medication abortion with accompaniment group support is highly effective and, for those with pregnancies of less than 9 weeks' gestation, non-inferior to the effectiveness of clinician-managed medication abortion administered in a clinical setting. These findings support the use of remote self-managed models of early abortion care, as well as telemedicine, as is being considered in several countries because of the COVID-19 pandemic. FUNDING: David and Lucile Packard Foundation. TRANSLATIONS: For the Arabic, French, Bahasa Indonesian, Spanish and Yoruba translations of the Article see Supplementary Materials section.
Assuntos
Aborto Induzido , Autoadministração , Autogestão/métodos , Abortivos/administração & dosagem , Argentina , COVID-19 , Estudos de Coortes , Feminino , Humanos , Mifepristona/administração & dosagem , Misoprostol/administração & dosagem , Nigéria , Gravidez , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. DESIGN: Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS). SETTING: Twenty-eight UK NHS early pregnancy units. SAMPLE: A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage. METHODS: Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets. MAIN OUTCOME MEASURES: Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs). RESULTS: For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. CONCLUSIONS: The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage. TWEETABLE ABSTRACT: The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.
Assuntos
Abortivos/administração & dosagem , Aborto Retido/tratamento farmacológico , Mifepristona/administração & dosagem , Misoprostol/administração & dosagem , Abortivos/economia , Aborto Retido/economia , Adolescente , Adulto , Análise Custo-Benefício , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Humanos , Mifepristona/economia , Misoprostol/economia , Gravidez , Adulto JovemRESUMO
Despite first trimester abortion being common and safe, there are numerousrestrictions that lead to barriers to seeking abortion care. The COVID-19 pandemic hasonly exacerbated these barriers, as many state legislators push to limit abortion accesseven further. During this pandemic, family physicians across the country haveincorporated telemedicine into their practices to continue to meet patient needs.Medication abortion can be offered to patients by telemedicine in most states, andmultiple studies have shown that labs, imaging, and physical exam may not beessential in all cases. Family physicians are well-poised to incorporate medicationabortion into their practices using approaches that limit the spread of the coronavirus,ultimately increasing access to abortion in these unprecedented times.
Assuntos
Abortivos/administração & dosagem , Aborto Induzido/métodos , COVID-19 , Medicina de Família e Comunidade/organização & administração , Acessibilidade aos Serviços de Saúde/organização & administração , Papel do Médico , Telemedicina/organização & administração , COVID-19/epidemiologia , COVID-19/prevenção & controle , Medicina de Família e Comunidade/métodos , Feminino , Humanos , Pandemias , Gravidez , Primeiro Trimestre da Gravidez , Autoadministração , Telemedicina/métodos , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To compare 1- and 2-day drug administration interval between mifepristone and misoprostol for second-trimester pregnancy termination and provide evidence-based recommendations. METHODS: Search strategy: the search was performed in Pubmed, EMBASE, and Cochrane Library for the relevant published studies from their establishment to March 2020. SELECTION CRITERIA: randomized controlled trials (RCTs) comparing 1- and 2-day time interval of mifepristone-misoprostol for termination of pregnancy during second-trimester pregnancy were considered. Data were processed using Revman 5.3 software. RESULTS: Meta-analyses of three RCTs showed no significant difference was reported in the induction-to-abortion time and successful abortion rate between 1- and 2-day mifepristone and misoprostol intervals. Statistical difference was not identified in the induction-to-abortion time between the two drug administration intervals in nulliparous or parous women. CONCLUSIONS: Both 1- and 2-day dosing intervals between mifepristone and misoprostol are suitable for clinical use for second-trimester medical termination of pregnancy.
Assuntos
Aborto Induzido/métodos , Mifepristona/administração & dosagem , Misoprostol/administração & dosagem , Abortivos/administração & dosagem , Abortivos não Esteroides/administração & dosagem , Feminino , Humanos , Gravidez , Segundo Trimestre da Gravidez , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
INTRODUCTION: The safety and acceptability of medical abortion using mifepristone and misoprostol at home at ≤9+0 weeks' gestation is well established. However, the upper gestational limit at which the procedure remains safe and acceptable at home is not known. To inform a national guideline on abortion care we conducted a systematic review to determine what gestational limit for expulsion at home offers the best balance of benefits and harms for women who are having medical abortion. MATERIAL AND METHODS: We searched Embase, MEDLINE, Cochrane Library, Cinahl Plus and Web-of-Science on 2 January 2020 for prospective and retrospective cohort studies with ≥50 women per gestational age group, published in English from 1995 onwards, that included women undergoing medical abortion and compared home expulsion of pregnancies of ≤9+0 weeks' gestational age with pregnancies of 9+1 -10+0 weeks or >10+1 weeks' gestational age, or compared the latter two gestational age groups. We assessed risk-of-bias using the Newcastle-Ottowa scale. All outcomes were meta-analyzed as risk ratios (RR) using the Mantel-Haenszel method. The certainty of the evidence was assessed using GRADE. RESULTS: Six studies (n = 3381) were included. The "need for emergency care/admission to hospital" (RR = 0.79, 95% confidence interval [CI] 0.45-1.4), "hemorrhage requiring transfusion/≥500 mL blood loss" (RR = 0.62, 95% CI 0.11-3.55), patient satisfaction (RR = 0.99, 95% CI 0.95-1.03), pain (RR = 0.91, 95% CI 0.82-1.02), and "complete abortion without the need for surgical intervention" (RR = 1.03, 95% CI 1-1.05) did not differ statistically significantly between the ≤9+0 and >9+0 weeks' gestation groups. The rates of vomiting (RR = 0.8, 95% CI 0.69-0.93) and diarrhea (RR = 0.85, 95% CI 0.73-0.99) were statistically significantly lower in the ≤9+0 weeks group but these differences were not considered clinically important. We found no studies comparing pregnancies of 9+1 -10+0 weeks' gestation with pregnancies of >10+0 weeks' gestation. The certainty of this evidence was predominantly low and mainly compromised by low event rates and loss to follow up. CONCLUSIONS: Women who are having a medical abortion and will be taking mifepristone up to and including 10+0 weeks' gestation should be offered the option of expulsion at home after they have taken the misoprostol. Further research needs to determine whether the gestational limit for home expulsion can be extended beyond 10+0 weeks.
Assuntos
Abortivos/administração & dosagem , Aborto Induzido/métodos , Idade Gestacional , Serviços de Assistência Domiciliar , Mifepristona/administração & dosagem , Misoprostol/administração & dosagem , Feminino , Humanos , GravidezRESUMO
BACKGROUND: Transgender, nonbinary, and gender-expansive people who were assigned female or intersex at birth experience pregnancy and have abortions. Scarce data have been published on individual abortion experiences or preferences of this understudied population. OBJECTIVE: This study aimed to fill existing evidence gaps on the abortion experiences and preferences of transgender, nonbinary, and gender-expansive people in the United States to inform policies and practices to improve access to and quality of abortion care for this population. STUDY DESIGN: In 2019, we recruited transgender, nonbinary, and gender-expansive people who were assigned female or intersex at birth at the age of ≥18 years from across the United States to participate in an online survey about sexual and reproductive health recruited through The Population Research in Identities and Disparities for Equality Study and online postings. We descriptively analyzed closed- and open-ended survey responses related to pregnancy history, abortion experiences, preferences for abortion method, recommendations to improve abortion care for transgender, nonbinary, and gender-expansive people, and respondent sociodemographic characteristics. RESULTS: Most of the 1694 respondents were <30 years of age. Respondents represented multiple gender identities and sexual orientations and resided across all 4 United States Census Regions. Overall, 210 respondents (12%) had ever been pregnant; these 210 reported 433 total pregnancies, of which 92 (21%) ended in abortion. For respondents' most recent abortion, 41 (61%) were surgical, 23 (34%) were medication, and 3 (5%) were another method (primarily herbal). Most recent abortions took place at ≤9 weeks' gestation (n=41, 61%). If they were to need an abortion today, respondents preferred medication abortion over surgical abortion in a 3:1 ratio (n=703 vs n=217), but 514 respondents (30%) did not know which method they would prefer. The reasons for medication abortion preference among the 703 respondents included a belief that it is the least invasive method (n=553, 79%) and the most private method (n=388, 55%). To improve accessibility and quality of abortion care for transgender, nonbinary, and gender-expansive patients, respondents most frequently recommended that abortion clinics adopt gender-neutral or gender-affirming intake forms, that providers use gender-neutral language, and that greater privacy be incorporated into the clinic. CONCLUSION: These data contribute substantially to the evidence base on individual experiences of and preferences for abortion care for transgender, nonbinary, and gender-expansive people. Findings can be used to adapt abortion care to better include and affirm the experiences of this underserved population.
Assuntos
Aborto Induzido/estatística & dados numéricos , Preferência do Paciente/estatística & dados numéricos , Pessoas Transgênero/estatística & dados numéricos , Abortivos/administração & dosagem , Aborto Induzido/métodos , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Gravidez , Inquéritos e Questionários , Estados Unidos , Adulto JovemRESUMO
OBJECTIVE: To assess whether mifepristone pretreatment adversely affects the cost of medical management of miscarriage. METHODS: Decision tree analyses were constructed, and Monte Carlo simulations were run comparing costs of combination therapy (mifepristone and misoprostol) with monotherapy (misoprostol alone) for medical management of miscarriage in multiple scenarios weighing clinical practice, patient income, and surgical evacuation modalities for failed medical management. Rates of completed medical evacuation for each were obtained from a recent randomized controlled trial. RESULTS: In every scenario, combination therapy offered a significant cost advantage over monotherapy. Using a Monte Carlo analysis, cost differences favoring combination therapy ranged from 6.3% to 19.5% in patients making federal minimum wage. The cost savings associated with combination therapy were greatest in scenarios using a staged approach to misoprostol administration and in scenarios using in-operating room dilation and curettage as the only modality for uterine evacuation, a savings of $190.20 (99% CI 189.35-191.07) and $217.85 (99% CI 217.19-218.50) per patient in a low-income wage group, respectively. A smaller difference was seen in scenarios using in-office manual vacuum aspiration to complete medical management failures. As patients' wages increased, the difference in cost between combination therapy and monotherapy increased. CONCLUSION: Mifepristone combined with misoprostol is, overall, more cost effective than monotherapy, and therefore cost should not be a deterrent to its adoption in the management of miscarriage.
Assuntos
Aborto Incompleto , Aborto Induzido , Quimioterapia Combinada , Mifepristona , Misoprostol , Abortivos/administração & dosagem , Abortivos/economia , Aborto Incompleto/induzido quimicamente , Aborto Incompleto/economia , Aborto Incompleto/cirurgia , Aborto Induzido/efeitos adversos , Aborto Induzido/economia , Aborto Induzido/métodos , Análise Custo-Benefício , Dilatação e Curetagem/economia , Dilatação e Curetagem/métodos , Quimioterapia Combinada/economia , Quimioterapia Combinada/métodos , Feminino , Humanos , Mifepristona/administração & dosagem , Mifepristona/economia , Misoprostol/administração & dosagem , Misoprostol/economia , Método de Monte Carlo , Padrões de Prática Médica , GravidezRESUMO
OBJECTIVE: Missed period pills (MPP) are uterine evacuation medications used for treatment of delayed menses without prior pregnancy confirmation. This study explores potential interest in missed period pills in two US states. STUDY DESIGN: We enrolled people seeking pregnancy test services at nine health centers in two US states between June 2015 and October 2017. Participants completed an anonymous questionnaire containing closed- and open-ended questions about background characteristics, reproductive practices, pregnancy feelings and intentions, abortion attitudes, and MPP interest. We used ordered logistic regression to identify factors associated with MPP interest and inductive content analysis to identify recurring qualitative themes related to MPP interest or disinterest. RESULTS: In all, 678 people completed the survey and 286/678 (42%) indicated interest in missed period pills. Interest was greatest (129/185 or 70%) among those who would be unhappy if pregnant. Variables associated with interest in the multivariate analyses were age ≥ 35, nulliparity, prior abortion and contraceptive use, recent use of emergency contraception, pregnancy feelings and intentions, and abortion attitudes (p < .05). Variables not associated with interest included state of residence, educational attainment, ethnicity, religious affiliation, and frequency of religious attendance. Key reasons for interest were to prevent, avoid or terminate pregnancy; and psychological or emotional benefits, including management of abortion stigma. Reasons for non-interest included concerns about safety or side effects, desire to be pregnant or have a baby, and not wanting to abort or hurt the fetus/baby. CONCLUSION: If missed period pills were available in the United States, demand might be substantial and wide-ranging across demographic groups. IMPLICATIONS: Our findings suggest that some people with missed periods do not desire pregnancy confirmation before taking medications that might disrupt a pregnancy. As a result, provision of missed period pills in the United States would expand reproductive service options and could improve the delivery of patient-centered care.
Assuntos
Abortivos/administração & dosagem , Aborto Induzido , Aborto Espontâneo , Abortivos/uso terapêutico , Adulto , Feminino , Humanos , Modelos Logísticos , Gravidez , Saúde Reprodutiva , Inquéritos e Questionários , Estados UnidosRESUMO
OBJECTIVES: To determine the role of baseline ultrasound findings and the changes between ß- human chorionic gonadotropin (hCG) values on day 0 to day 4 in patients receiving single-dose methotrexate (MTX) therapy for tubal ectopic pregnancy. MATERIAL AND METHODS: One hundred fourteen patients who were hospitalized with a diagnosis of ectopic pregnancy and treated with single-dose methotrexate were included in this retrospective study. The successful treatment group (n = 88) comprised patients in whom serum ß-hCG levels were resolved with single-dose methotrexate treatment, and the failed treatment group (n = 26) included patients who received second dose methotrexate and/or surgery. Ultrasound findings, laboratory findings, and serum ß-hCG values at the time of admission and D4 and D7 ß-hCG values were compared. RESULTS: The success rate of single-dose methotrexate treatment was 77.2%. In the successful treatment group, the initial ß-hCG values of the patients were lower than the unsuccessful treatment group (1479.14 ± 1253.49, 4442.88 ± 3392.58, respectively) (p = 0.0001). A decrease of more than 35% between D0-D4 increased the probability of successful treatment (p = 0.017). Although ectopic focus size and abdominal free fluid showed no significant difference between the two groups, endometrial stripe thickness was significantly higher in the unsuccessful treatment group (12.61 ± 5.79, 9.28 ± 3.53) (p = 0.002). CONCLUSIONS: In addition to the basal ß-hCG value, endometrial stripe thickness of ultrasound findings should also be considered in determining patients with a high chance of success in single-dose MTX treatment.ß-hCG changes between D0-D4 may be advantageous in the clinical management of ectopic pregnancy for earlier evaluation.
Assuntos
Abortivos/administração & dosagem , Gonadotropina Coriônica Humana Subunidade beta/sangue , Metotrexato/administração & dosagem , Gravidez Ectópica/diagnóstico por imagem , Ultrassonografia Pré-Natal , Administração Oral , Adulto , Biomarcadores/sangue , Feminino , Humanos , Gravidez , Gravidez Ectópica/sangue , Gravidez Ectópica/tratamento farmacológico , Estudos Retrospectivos , Fatores de TempoRESUMO
Globally, a growing proportion of induced abortions are medical abortions. The procedure has been hailed as a revolutionary technology, which, according to experts, has the potential to transform women's experiences of abortion and the way abortion services are accessed. Noticeably absent in the discourse, however, are women's voices. More specifically, there is a lack of understanding about what shapes women's preferences for medical abortion and the challenges they experience in accessing the drugs for the procedure. We conducted a systematic review of the literature to draw attention to these important issues which exist, but are often embedded within research highlighting other dominating aspects of medical abortions. A comprehensive search of four databases - supplemented by searching reference sections of selected articles, tracking their citations, and hand searching special editions on medical abortion - was conducted. A total of 45 peer-reviewed studies met our inclusion criteria. The studies were assessed for quality and analyzed using a critical interpretive synthesis approach. The findings revealed significant variations in women's preferences for surgical versus medical abortions. Country-specific abortion laws, implementing protocols, side-effects, rates of failures, and the need to verify the abortion shaped women's preference for abortion methods. Overall, women who preferred medical abortions did so because they perceived it as a 'natural' and safe procedure that can be self-conducted at home, thereby reducing their dependency on the health system. However, women face significant barriers to medical abortion care. These include legal requirements around type of provider, site of service, need for follow-up, providers' limited knowledge of the procedure, and preferences for surgical abortions. Borderless internet-based services have enabled some women to circumvent these barriers. Our review suggests that medical abortions are used by women either in countries where the health system is fully supportive or where the health system is completely disengaged, usually due to restricted abortion laws. In those countries where abortions are legal but often difficult to access due to health system barriers, women tend to prefer surgical abortions.