Effectiveness and safety of telehealth medication abortion in the USA.

Telehealth abortion has become critical to addressing surges in demand in states where abortion remains legal but evidence on its effectiveness and safety is limited. California Home Abortion by Telehealth (CHAT) is a prospective study that follows pregnant people who obtained medication abortion via telehealth from three virtual clinics operating in 20 states and Washington, DC between April 2021 and January 2022. Individuals were screened using a standardized no-test protocol, primarily relying on their medical history to assess medical eligibility. We assessed effectiveness, defined as complete abortion after 200 mg mifepristone and 1,600 µg misoprostol (or lower) without additional intervention; safety was measured by the absence of serious adverse events. We estimated rates using multivariable logistic regression and multiple imputation to account for missing data. Among 6,034 abortions, 97.7% (95% confidence interval (CI) = 97.2-98.1%) were complete without subsequent known intervention or ongoing pregnancy after the initial treatment. Overall, 99.8% (99.6-99.9%) of abortions were not followed by serious adverse events. In total, 0.25% of patients experienced a serious abortion-related adverse event, 0.16% were treated for an ectopic pregnancy and 1.3% abortions were followed by emergency department visits. There were no differences in effectiveness or safety between synchronous and asynchronous models of care. Telehealth medication abortion is effective, safe and comparable to published rates of in-person medication abortion care.

Patient Acceptability of Telehealth Medication Abortion Care in the United States, 2021‒2022: A Cohort Study.

Objectives. Despite the recent expansion of direct-to-patient telehealth abortion care in the United States, patient experiences with the service are not well understood. Methods. We described care experiences of 1600 telehealth abortion patients in 2021 to 2022 and used logistic regression to explore differences by race or ethnicity and between synchronous (phone or video) and asynchronous (secure messaging) telehealth abortion care. Results. Most patients trusted the provider (98%), felt telehealth was the right decision (96%), felt cared for (92%), and were very satisfied (89%). Patients most commonly cited privacy (76%), timeliness (74%), and staying at home (71%) as benefits. The most commonly reported drawback was initial uncertainty about whether the service was legitimate (38%). Asian patients were less likely to be very satisfied than White patients (79% vs 90%; P = .008). Acceptability was high for both synchronous and asynchronous care. Conclusions. Telehealth abortion care is highly acceptable, and benefits include privacy and expediency. Public Health Implications. Telehealth abortion can expand abortion access in an increasingly restricted landscape while maintaining patient-centered care. (Am J Public Health. 2024;114(2):241-250. https://doi.org/10.2105/AJPH.2023.307437).

The Role of Telehealth in Promoting Equitable Abortion Access in the United States: Spatial Analysis.

BACKGROUND: Even preceding the Supreme Court's 2022 Dobbs v. Jackson Women's Health Organization decision, patients in the United States faced exceptional barriers to reach abortion providers. Abortion restrictions disproportionately limited abortion access among people of color, young people, and those living on low incomes. Presently, clinics in states where abortion remains legal are experiencing an influx of out-of-state patients and wait times for in-person appointments are increasing. Direct-to-patient telehealth for abortion care has expanded since its introduction in the United States in 2020. However, the role of this telehealth model in addressing geographic barriers to and inequities in abortion access remains unclear. OBJECTIVE: We sought to examine the amount of travel that patients averted by using telehealth for abortion care, and the role of telehealth in mitigating inequities in abortion access by race or ethnicity, age, pregnancy duration, socioeconomic status, rural residence, and distance to a facility. METHODS: We used geospatial analyses and data from patients in the California Home Abortion by Telehealth Study, residing in 31 states and Washington DC, who obtained telehealth abortion care at 1 of 3 virtual abortion clinics. We used patients' residential ZIP code data and data from US abortion facility locations to document the round-trip driving distance in miles, driving time, and public transit time to the nearest abortion facility that patients averted by using telehealth abortion services from April 2021 to January 2022, before the Dobbs decision. We used binomial regression to assess whether patients reported that telehealth was more likely to make it possible to access a timely abortion among patients of color, those experiencing food insecurity, younger patients, those with longer pregnancy durations, rural patients, and those residing further from their closest abortion facility. RESULTS: The 6027 patients averted a median of 10 (IQR 5-26) miles and 25 (IQR 14-46) minutes of round-trip driving, and 1 hour 25 minutes (IQR 46 minutes to 2 hours 30 minutes) of round-trip public transit time. Among a subsample of 1586 patients surveyed, 43% (n=683) reported that telehealth made it possible to obtain timely abortion care. Telehealth was most likely to make it possible to have a timely abortion for younger patients (prevalence ratio [PR] 1.4, 95% CI 1.2-1.6) for patients younger than 25 years of age compared to those 35 years of age or older), rural patients (PR 1.4, 95% CI 1.2-1.6), those experiencing food insecurity (PR 1.3, 95% CI 1.1-1.4), and those who averted over 100 miles of driving to their closest abortion facility (PR 1.6, 95% CI 1.3-1.9). CONCLUSIONS: These findings support the role of telehealth in reducing abortion-related travel barriers in states where abortion remains legal, especially among patient populations who already face structural barriers to abortion care. Restrictions on telehealth abortion threaten health equity.

Clinical outcomes of medication abortion using misoprostol-only: A retrospective chart review at an abortion provider organization in the United States.

OBJECTIVES: This study aimed to evaluate the effectiveness and safety of medication abortion with misoprostol-only among patients treated by an abortion provider organization in the United States during the COVID-19 pandemic. STUDY DESIGN: We abstracted data from patients receiving misoprostol-only for abortion from December 2020 to December 2021. Two regimens were used, both allowing three to four doses of misoprostol 800 mcg every 3 hours but differing in the recommended administration routes (vaginal, buccal, or sublingual). We estimated the proportions of patients who had complete abortion and ongoing pregnancy in the two regimen groups in complete case analyses and after imputing missing outcomes based on pretreatment characteristics. We also estimated maximum effectiveness, assuming that all patients without known treatment failures had complete abortions. We tabulated serious adverse events. RESULTS: We ascertained abortion outcomes for 476 (52%) of the total 911 treated patients. Of the 476 patients, 389 (82%) had complete abortion confirmed by test or history, and 45 (9%) had ongoing pregnancies detected after the provision of treatment. These proportions did not differ significantly between the two regimen groups in adjusted complete case analyses (p > 0.44). The results of imputed analyses were similar. Of the total 911 patients, at most 90% (95% confidence interval 88%, 92%) had complete abortion, and at least 5% (95% confidence interval 4%, 7%) had ongoing pregnancy. Serious adverse events were reported in three patients (0.6% of 487 patients with data for this outcome). CONCLUSIONS: Our analysis suggests that the misoprostol-only regimens studied were safe and effective for most patients. Due to high loss to follow-up, observations from patients contacted after treatment likely somewhat underestimate true effectiveness. IMPLICATIONS: Medication abortion with misoprostol-only was safe and produced complete abortion in most patients with follow-up. If loss to follow-up is high, effectiveness observed by clinics may misestimate true treatment efficacy.

Mailing abortion pills does not delay care: A cohort study comparing mailed to in-person dispensing of abortion medications in the United States.

OBJECTIVE: Given the substantial barriers to abortion access in the United States, many clinics now mail patients abortion medications. We examined whether dispensing the medications by mail prolonged time to medication use. STUDY DESIGN: We analyzed data from no-test medication abortions with medication provided either by mail or in a clinic from 11 United States clinics from February 2020 to January 2021. We examined mean number of days from patients' first contact with the clinic to mifepristone ingestion, its two-component intervals (first contact to medication dispensing and dispensing to mifepristone ingestion), and pregnancy duration at mifepristone ingestion. We used Poisson regression to compare mean outcomes across three dispensing methods: in-person, mailed from the clinic, and mailed from a mail-order pharmacy. RESULTS: Among the 2600 records, patients took mifepristone on average at 49 days of gestation (95% CI, 47-51) and 7 days (95% CI, 4-10) after first contact. Mean time from first contact to mifepristone ingestion was 6 days when medications were dispensed in-person and 9 days when mailed (p = 0.38). While time from first contact to dispensing was similar across methods (6 days in-person, 5 days mailed, p = 0.77), more time elapsed from dispensing to mifepristone ingestion when medications were mailed (4 days from clinic, 5 days from mail-order pharmacy) versus dispensed in-person (0.3 days, p < 0.001). Time to mifepristone ingestion was shorter with higher pregnancy duration. Pregnancy duration at ingestion was similar across methods (48 days in-person, 50 days mailed). CONCLUSIONS: Mailing medications did not significantly prolong time from patients' first contact with the clinic to mifepristone ingestion or increase pregnancy duration at mifepristone ingestion. IMPLICATIONS: Abortion providers should offer a range of medication abortion dispensing options, prioritizing patient preference.

Unequal impacts of the COVID-19 pandemic on women's fertility preferences: Evidence from a longitudinal cohort in the United States.

•The COVID-19 pandemic suppressed fertility desires among US women.•Impacts on fertility preferences persisted from summer 2020 to early 2021.•The fertility preferences of younger women, women of color and those facing financial stress were most impacted.

Outcomes and Safety of History-Based Screening for Medication Abortion: A Retrospective Multicenter Cohort Study.

Importance: Screening for medication abortion eligibility typically includes ultrasonography or pelvic examination. To reduce physical contact during the COVID-19 pandemic, many clinicians stopped requiring tests before medication abortion and instead screened patients for pregnancy duration and ectopic pregnancy risk by history alone. However, few US-based studies have been conducted on the outcomes and safety of this novel model of care. Objective: To evaluate the outcomes and safety of a history-based screening, no-test approach to medication abortion care. Design, Setting, and Participants: This retrospective cohort study included patients obtaining a medication abortion without preabortion ultrasonography or pelvic examination between February 1, 2020, and January 31, 2021, at 14 independent, Planned Parenthood, academic-affiliated, and online-only clinics throughout the US. Exposures: Medications for abortion provided without preabortion ultrasonography or pelvic examination and dispensed to patients in person or by mail. Main Outcomes and Measures: Effectiveness, defined as complete abortion after 200 µg of mifepristone and up to 1600 µg of misoprostol without additional intervention, and major abortion-related adverse events, defined as hospital admission, major surgery, or blood transfusion. Results: The study included data on 3779 patients with eligible abortions. The study participants were racially and ethnically diverse and included 870 (23.0%) Black patients, 533 (14.1%) Latinx/Hispanic patients, 1623 (42.9%) White patients, and 327 (8.7%) who identified as multiracial or with other racial or ethnic groups. For most (2626 [69.5%]), it was their first medication abortion. Patients lived in 34 states, and 2785 (73.7%) lived in urban areas. In 2511 (66.4%) abortions, the medications were dispensed in person; in the other 1268 (33.6%), they were mailed to the patient. Follow-up data were obtained for 2825 abortions (74.8%), and multiple imputation was used to account for missing data. Across the sample, 12 abortions (0.54%; 95% CI, 0.18%-0.90%) were followed by major abortion-related adverse events, and 4 patients (0.22%; 95% CI, 0.00%-0.45%) were treated for ectopic pregnancies. Follow-up identified 9 (0.40%; 95% CI, 0.00%-0.84%) patients who had pregnancy durations of greater than 70 days on the date the mifepristone was dispensed that were not identified at screening. The adjusted effectiveness rate was 94.8% (95% CI, 93.6%-95.9%). Effectiveness was similar when medications were dispensed in person (95.4%; 95% CI, 94.1%-96.7%) or mailed (93.3%; 95% CI, 90.7%-95.9%). Conclusions and Relevance: In this cohort study, screening for medication abortion eligibility by history alone was effective and safe with either in-person dispensing or mailing of medications, resulting in outcomes similar to published rates of models involving ultrasonography or pelvic examination. This approach may facilitate more equitable access to this essential service by increasing the types of clinicians and locations offering abortion care.

Unequal Gender Norms Are Related to Symptoms of Depression Among Young Adolescents: A Cross-Sectional, Cross-Cultural Study.

PURPOSE: This study was undertaken among 10- to 14-year-old girls and boys in disadvantaged areas of Shanghai, China; Cuenca, Ecuador; Flanders, Belgium; and Denpasar and Semarang, Indonesia. It aimed to assess whether gender norms are related to depressive symptomatology, and to examine whether sex differences in depressive symptoms can be explained by differences in gender norm perceptions. METHODS: We examined the distributions of depressive symptoms and two gender norms scales, gender stereotypical traits (GST), and sexual double standard (SDS), across sites and by sex. We next assessed crude and adjusted associations between each of the gender norms scales and depressive symptoms. Finally, we conducted path analysis to examine the mediating role of gender perceptions in sex differences in depressive symptoms. RESULTS: Girls reported more depressive symptoms than boys in all sites except Denpasar. SDS perceptions were more unequal among girls in most sites, while GST perceptions were more unequal among boys in all sites except Semarang. Gender-equal SDS and GST perceptions were associated with fewer depressive symptoms, while unequal perceptions were related to more symptoms. Gendered perceptions about traits and relationships appeared to partially mediate relationships between sex and depressive symptoms in Shanghai, Cuenca, and Semarang. CONCLUSIONS: Unequal gender norm perceptions were linked to poor mental health among boys and girls, suggesting that gender norms may play a role in psychological wellbeing for adolescents of both sexes. Gender norm perceptions appear to play a role in mental health sex disparities we observed across sites.

The Intersection of Power and Gender: Examining the Relationship of Empowerment and Gender-Unequal Norms Among Young Adolescents in Kinshasa, DRC.

PURPOSE: To examine how perceptions of gender norms and expressions of empowerment are related among disadvantaged young adolescent boys and girls in Kinshasa, DRC. METHODS: We included data from 2,610 adolescent boys and girls between 10 and 14 years old. We examined correlations between three dimensions of perceived gender norms (a sexual double standard, gender stereotypical roles, and gender stereotypical traits) and two domains of agency (voice and decision-making), overall and by sex. We conducted sex-stratified simple and multivariable linear regression models to assess these associations, adjusting for sociodemographic factors. We also tested for differences in the association between gender norm perceptions and agency by sex. RESULTS: Correlations between gender norm perceptions and agency scores were low (under 0.15). Among boys, greater perception of a sexual double standard was related to more voice (p=0.001) and more decision-making power (p=0.008). Similar patterns were observed among girls for the relationship between sexual double standard and voice (p≤.001), but not for decision-making. Increased perceptions of gender stereotypical traits were related to more voice among girls (p≤.001), while conversely girls who perceived greater gender stereotypical roles had less decision-making power (p=0.010). CONCLUSIONS: This study demonstrated that gender norm perceptions and agency are distinct but related constructs. Interventions aimed to promote gender equality must consider gender unequal norms and gender-unequal divisions of power as important but different dynamics.

Associations Between Agency and Sexual and Reproductive Health Communication in Early Adolescence: A Cross-cultural, Cross-sectional Study.

PURPOSE: To assess the extent to which adolescents aged 10-14 have communicated about sexual relationships, pregnancy, and contraception and how agency in the form of voice and decision-making along with an enabling socioecological environment are associated with sexual and reproductive health (SRH) communication. METHODS: Using data from the Global Early Adolescent Study, we included 1,367, 697, and 1,424 adolescents in Kinshasa, Cuenca, and Shanghai, respectively. Patterns of SRH communication and agency levels were described by site and sex. Multivariable logistic regressions assessed odds of SRH communication first in relation to socioecological characteristics and second with levels of agency, after adjustment for social environmental factors. Interaction terms tested sex differences in associations. RESULTS: Experiences of SRH communication ranged from one in ten in Kinshasa to about half in Cuenca. Pregnancy was the most discussed SRH topic. Socioecological factors consistently related to SRH communication included older age and pubertal onset, while others varied by context. In multivariable analyses, voice was linked to all forms of SRH communication in Kinshasa and Cuenca with adjusted odds ratios ranging from 1.6 to 2.2, but not in Shanghai. In Cuenca, decision-making was associated with a 50% and 60% increase in odds of communication about pregnancy and contraception, respectively. In Kinshasa, a stronger association between voice and pregnancy discussions was observed for girls than boys. CONCLUSIONS: Developmental characteristics and voice were linked to communication about SRH among young adolescents across two contexts. Results suggest agency may play a role in shaping antecedents, like communication, to sexual behaviors.