Prior knowledge and experience with self-managed abortion among people seeking abortion care in US Midwestern states.

OBJECTIVES: This study seeks to understand what methods people use and/or have heard of others using for self-managed abortion (SMA) prior to coming to a health facility for abortion care. STUDY DESIGN: We collected survey data on sociodemographics, gestational stage, and SMA awareness and methods from patients seeking care in 17 abortion facilities in Ohio, West Virginia, Kentucky, Pennsylvania, and Illinois from April 2020 to April 2022. We used descriptive statistics to examine the proportion of participants who had attempted SMA and, separately, who had heard of people attempting SMA. RESULTS: In total, 71 respondents (4.2%) had attempted SMA, and 416 (25.5%) had heard of others attempting SMA. The most frequently attempted methods for self-management were taking herbs and/or vitamins (31% each) or hitting oneself/being hit (22.5%). About a third of those who tried SMA reported trying more than one method (30%). CONCLUSIONS: Our findings suggest that people who attempt SMA are committed to self-managing their abortion. More research is needed to better understand sociodemographic characteristics of people who have attempted or heard of people attempting SMA research.

Permanent Sterilization in Nulliparous Patients: Is Legislative Anxiety an Indication for Surgery?

AbstractThe Supreme Court's Dobbs v. Jackson Women's Health Organization decision, first leaked to the public on 2 May 2022 and officially released on 24 June 2022, overturned Roe v. Wade and thereby determined that abortion is no longer a federally protected right under the Constitution. Instead, the decision gives individual states the right to regulate abortion. Since the Dobbs decision first leaked, our institution has received numerous requests for permanent contraception from individuals stating that their motivation to pursue permanent contraception was influenced by the Dobbs decision and concerns about their reproductive autonomy. Discussions with patients seeking permanent contraception since the Supreme Court's leaked decision have led us to ask ourselves, is legislative anxiety an indication for surgery? This article presents a case series consisting of a convenience sample of 17 young, nulliparous individuals who sought out permanent contraception in the six months following the leak of the Dobbs decision. Healthcare professionals often feel discomfort in offering permanent contraception to young and nulliparous individuals. Accordingly, we discuss pertinent legal issues, review relevant ethical considerations, and offer a framework for these discussions intended to empower the consulting healthcare professional to center the bodily autonomy of every patient regardless of age, parity, or indication for permanent contraception.

Satisfaction With Abortion Training in an Abortion-Restrictive State.

Background With increasingly disparate patient access to abortion care and resident access to abortion training opportunities following the Dobbs v Jackson Women's Health Organization decision, educators must better understand how legal restrictions affect obstetrics and gynecology (OB/GYN) resident training experiences and residents' desire to provide abortions. Objective To characterize how resident perceptions of abortion restrictions affect satisfaction with training and intent to provide abortion. Methods We recruited OB/GYN residents training in Ohio, a state restrictive to abortion, to complete surveys capturing training experiences between 2019 and 2020. Logistic regression models were used to estimate associations between perception of the legal climate on training and satisfaction with training and intent to provide abortions. To provide additional context to survey responses, we reviewed open-ended responses to the effect of the legal climate on training. Results Of 343 eligible residents, 88 (26%) responded from 13 of 15 programs (87% of programs). Most (73%) felt that the legal climate affected their training, and these respondents were more likely to be unsatisfied with their training (adjusted odds ratio [aOR] 16.6; 95% CI 2.83-97.22). We found no association between perception of legal climate on training and intent to provide abortions. In open-ended responses, most residents described a desire for more abortion training and barriers to patient care. Some highlighted the positives of training in a restrictive environment, which allowed for an improved understanding of the skills required for patient advocacy. Conclusions Many residents felt that the legal climate in Ohio affected their abortion training, a perception that was associated with decreased satisfaction with training.

The Power of Language in Hospital Care for Pregnant and Birthing People: A Vision for Change.

Language is commonly defined as the principal method of human communication made up of words and conveyed by writing, speech, or nonverbal expression. In the context of clinical care, language has power and meaning and reflects priorities, beliefs, values, and culture. Stigmatizing language can communicate unintended meanings that perpetuate socially constructed power dynamics and result in bias. This bias may harm pregnant and birthing people by centering positions of power and privilege and by reflecting cultural priorities in the United States, including judgments of demographic and reproductive health characteristics. This commentary builds on relationship-centered care and reproductive justice frameworks to analyze the role and use of language in pregnancy and birth care in the United States, particularly regarding people with marginalized identities. We describe the use of language in written documentation, verbal communication, and behaviors associated with caring for pregnant people. We also present recommendations for change, including alternative language at the individual, clinician, hospital, health systems, and policy levels. We define birth as the emergence of a new individual from the body of its parent, no matter what intervention or pathology may be involved. Thus, we propose a cultural shift in hospital-based care for birthing people that centers the birthing person and reconceptualizes all births as physiologic events, approached with a spirit of care, partnership, and support.

A Rubric to Center Equity in Obstetrics and Gynecology Research.

The Steering Committee for the Obstetrics & Gynecology special edition titled "Racism in Reproductive Health: Lighting a Path to Health Equity" formed a working group to create an equity rubric. The goal was to provide a tool to help researchers systematically center health equity as they conceptualize, design, analyze, interpret, and evaluate research in obstetrics and gynecology. This commentary reviews the rationale, iterative process, and literature guiding the creation of the equity rubric.

Provider Mistrust and Telemedicine Abortion Care Preferences Among Patients in Ohio, West Virginia, and Kentucky.

Objectives: The convenience and privacy provided by telemedicine medication abortion may make this service preferable to patients who mistrust their abortion provider. We assessed associations between mistrust in the abortion provider and preferences for telemedicine abortion. Study Design: From April 2020 to April 2021, we surveyed patients seeking abortion in Ohio, West Virginia, and Kentucky. Using unconditional logistic regression models, we examined unadjusted and adjusted associations between mistrust in the abortion provider and preferences for telemedicine abortion among all participants, and among only participants undergoing medication abortion. Results: Of 1,218 patients who met inclusion criteria, 546 used medication abortion services. Just more than half (56%) of all participants and many (64%) of medication abortion participants preferred telemedicine services. Only 6% of medication abortion participants received telemedicine medication dispensing services. Only 1.4% of all participants and 1% of medication abortion participants mistrusted the abortion provider. Participants who mistrusted the abortion provider were somewhat more likely to prefer telemedicine abortion (unadjusted odds ratio [OR]: 2.5, 95% CI: 0.8-7.9; adjusted OR: 2.9, 95% CI: 0.9-9), and medication abortion participants who mistrusted the abortion provider were also somewhat more likely to prefer telemedicine abortion (unadjusted OR: 3.5, 95% CI: 0.4-28.9; adjusted OR: 5.0, 95% CI: 0.6-43), although these associations were not statistically significant. Conclusions: In three abortion-restrictive states, most patients expressed preferences for telemedicine abortion, but few accessed them. Provider mistrust was rare, but those experiencing mistrust trended toward preferring telemedicine services. Telemedicine may improve access to abortion services for patients experiencing medical mistrust.

"They were there because they were pregnant. Which is a really apolitical thing"-Medical student discussions of politics in abortion care in the United States.

OBJECTIVES: State abortion policies can vary widely. Geographic location and political climate could influence a medical student's abortion education experience. We compared how medical students training in one permissive and one restrictive state discussed politics in abortion care. STUDY DESIGN: From 2018 to 2019, we interviewed US medical students during their Obstetrics and Gynecology rotation from two Midwestern academic centers with differing state abortion policies-one in Ohio (restrictive) and one in Illinois (permissive). In-depth interviews occurred following an abortion shadowing experience and included questions about politics in abortion care. We sorted data using flexible coding, with index codes around "politics," followed by specific analytic coding. We compared codes by medical school using NVIVO software. RESULTS: We interviewed 28 students (50% in Ohio). Students in Ohio discussed specific barriers to patient care and how politics infringed upon the quality of medical care, describing abortion as stigmatized care. Students in Illinois described abortion as high-quality medical care, delivered without the infringement of restrictive laws. Students at both schools described their medical school climates as supportive to abortion, yet in Ohio, students described exposure to more diverse abortion views than Illinois students. Ohio students also described engaging in abortion advocacy work, while Illinois students felt more politically disconnected. CONCLUSIONS: Even as clinical training opportunities decline, restrictive states may hold unique advocacy opportunities. Educators should tailor abortion curricula to address state level differences, as disparities in abortion access and student learning opportunities widen. IMPLICATIONS: Students training in permissive states see abortion as routine health care, occurring without political interference. Students in restrictive states see abortion as hindered by politics and stigmatized, which may encourage advocacy. Educators should tailor curricula to address state level differences as disparities in abortion access and student learning opportunities widen.

Assessing psychosocial costs: Ohio patients' experiences seeking abortion care.

OBJECTIVES: Existing research has not thoroughly characterized the psychosocial costs associated with seeking abortion care in restrictive states. Our study seeks to fill this gap by analyzing the accounts of Ohio abortion patients from 2018 to 2019. STUDY DESIGN: Using inductive and deductive approaches, we analyzed semi-structured in-depth qualitative interviews with 41 Ohio residents who obtained abortion care from one of three clinics in Ohio or Pennsylvania. RESULTS: Ohioans seeking abortion care often experienced fear of judgment, interpersonal strain, and stress as a result of efforts to overcome pre-Dobbs financial, geographic, and timing challenges. Those who needed financial assistance or traveled more than an hour generally reported greater exposure to psychosocial costs. CONCLUSIONS: Participants in this study incurred a complex set of psychosocial costs. Psychosocial costs often resulted from, or were exacerbated by, the financial, geographic, and time-sensitive burdens that patients experienced seeking care. IMPLICATIONS: The psychosocial costs incurred by patients seeking abortion care may be exacerbated in restrictive contexts, especially those who do not have access to insurance coverage for care. Psychosocial costs associated with care seeking are likely to increase as states implement more severe restrictions post-Dobbs. To fully understand abortion costs, researchers must examine costs comprehensively, including both financial and psychosocial costs.

Delivery at Catholic hospitals and postpartum contraception use, five US states, 2015-2018.

OBJECTIVES: To evaluate whether the prevalence of postpartum contraceptive use was lower among people who delivered at a Catholic hospital compared to a non-Catholic hospital. METHODS: We linked 2015-2018 Pregnancy Risk Assessment Monitoring System (PRAMS) survey data from five states to hospital information from the corresponding birth certificate file. People with a live birth self-reported their use of contraception methods on the PRAMS survey at 2-6 months postpartum, which we coded into two dichotomous (yes vs. no) outcomes for use of female sterilization and highly-effective contraception (female/male sterilization, intrauterine device, implant, injectable, oral contraception, patch, or ring). We conducted multilevel log-binomial regression to examine the relationship between birth hospital type and postpartum contraception use adjusting for confounders. RESULTS: Prevalence of female sterilization for people who delivered at a Catholic hospital was 51% lower than that of their counterparts delivering at a non-Catholic hospital (adjusted prevalence ratio: 0.49; 95% confidence interval: 0.37-0.65). CONCLUSION: We found lower use of postpartum female sterilization, but no difference in highly effective contraception overall, for people who delivered at a Catholic hospital compared to a non-Catholic hospital.

Federal, state, and institutional barriers to the expansion of medication and telemedicine abortion services in Ohio, Kentucky, and West Virginia during the COVID-19 pandemic.

OBJECTIVES: We aimed to characterize the combined impact of federal, state, and institutional policies on barriers to expanding medication and telemedicine abortion care delivery during the COVID-19 pandemic in the abortion-restrictive states of Ohio, Kentucky, and West Virginia. STUDY DESIGN: We analyzed 4 state policies, 2 COVID-related state executive orders, and clinic-level survey data on medication abortion provision from fourteen abortion facilities in Ohio, Kentucky, and West Virginia from December 2019 to December 2020. We calculated the percent of medication abortions provided at these facilities during the study period by state, to assess changes in medication abortion use during the pandemic. RESULTS: We ascertained that COVID-19-executive orders in Ohio and West Virginia that limited procedural abortion in Spring 2020 coincided with an increase in the overall number and proportion of medication abortions in this region, peaking at 1613 medication abortions (70%) in April 2020. Ohio and West Virginia, which had executive orders limiting procedural abortion, saw relatively greater increases in April compared to Kentucky. Despite temporary lifting of the mifepristone REMS, prepandemic regulations banning telemedicine abortion in Kentucky and West Virginia and requiring in-person clinic visits for medication abortion distribution in Ohio limited clinics' ability to adapt to offer medication abortion by mail. CONCLUSIONS: Our findings illustrate how restrictive medication and telemedicine abortion policies in Ohio, Kentucky, and West Virginia created additional obstacles for patients seeking medication abortion during the pandemic. Permanently lifting federal regulations on in-clinic distribution of mifepristone would only advantage abortion seekers in states without restrictive telehealth and medication abortion policies. State policies that limit access to comprehensive abortion services should be central in larger efforts toward dismantling barriers that impinge upon reproductive autonomy. IMPLICATION STATEMENT: We find that abolishing the REMS on mifepristone would not be enough to expand access to patients in abortion-restrictive states with telemedicine and medication abortion laws. While the REMS is a barrier, it represents one of several hindrances to the expansion of telemedicine abortion distribution across the United States.

"It Allows You to Challenge Your Beliefs": Examining Medical Students' Reactions to First Trimester Abortion.

BACKGROUND: Abortion is a common medical procedure, integral to women's health, and a core educational topic for medical students. Medical schools often rely on brief clinical exposure to abortion during the obstetrics and gynecology clerkship to provide this learning. Abortion is also a highly politicized and stigmatized procedure. Given this potential conflict, we examine medical student reactions to their observation of abortion care. STUDY DESIGN: Medical students in their second and third years at an academic medical center who observed in a first trimester abortion clinic completed open-ended, written questionnaires. Questionnaires explored student reactions to participating in the abortion clinic. We used applied thematic analysis to code and qualitatively analyze 78 questionnaires. RESULTS: We identified the following five themes: (1) students found participating in abortion care deeply worthwhile, (2) some were challenged by their reactions, particularly when reactions conflicted with prior beliefs, (3) some demonstrated empathy for the patient, but (4) some expressed judgment of both the patient and the abortion provider, and (5) students reported a desire for curricular change around abortion education, requesting more time for reflection, and some felt that their abortion observation might better prepare them to serve future patients. CONCLUSIONS: Observing in an abortion clinic is a valued experience that allows students to challenge their existing beliefs and may build empathy. Educators should provide students with adequate time for preparation and reflection around this topic and address areas of misunderstanding that may perpetuate abortion stigma. These findings may inform medical student curriculum changes around abortion.

Navigating uncertainty: Narrative medicine in pregnancy options counseling education.

OBJECTIVES: Pregnancy options counseling, or nondirective counseling of patients with unintended pregnancy, is a "necessary competency" for medical students according the Association of Professors of Gynecology and Obstetrics. Narrative Medicine (NM) utilizes stories of illness to inform clinical practice and promotes self-reflection in medical education. The authors analyzed the effect of a NM workshop on medical students' ability to provide pregnancy options counseling. METHODS: The authors randomized students in the major clinical year at Columbia University Medical Center (CUMC) to either a 2-hour NM workshop or to a control intervention. The NM group participated in reading and reflective writing exercises addressing varying perspectives on pregnancy. Students then completed a video-taped and numerically-scored OSCE (Objective Structured Clinical Examination) regarding pregnancy options counseling. The authors compared mean OSCE scores between the groups. RESULTS: The study analyzed 103 participants. Overall mean OSCE scores were higher in the NM group (11.9 ± 1.5, n = 51) than the control group (11.3 ± 1.6, n = 52) (p = 0.049). CONCLUSIONS: Students undergoing a NM workshop had higher scores on a pregnancy options counseling OSCE. PRACTICE IMPLICATIONS: This brief intervention may aid future physicians in providing nondirective pregnancy options. This novel approach to teaching is an easily shared learning tool.

Patient-centered Contraceptive Counseling and Prescribing.

Learning how to best meet a patient's contraceptive needs improves her chances of using her birth control consistently and is crucial to providing patient-centered care. The best contraceptive method for an individual patient is the one that is safe and that she is most comfortable using. Women's health care providers must be equipped to talk to each patient about her needs and options. The shared decision-making model in contraceptive counseling allows the patient and provider to work together in order to meet a patient's needs while remaining medically safe.