Telehealth Medication Abortion in Primary Care: A Comparison to Usual in-Clinic Care.

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.

The illusion of treatment choice in abortion care: A qualitative study of comparative care experiences in England and Wales.

Treatment choice is a key component of quality, person-centred care, but policies promoting choice often ignore how capacity to choose is unequally distributed and influenced by social structures. In abortion care, the choice of either medication or a procedure is limited in many countries, but the structuring of treatment choice from the perspective of people accessing abortion care is poorly understood. This qualitative study explored comparative experiences of abortion treatment choice in England and Wales, using in-depth interviews with 32 people who recently accessed abortion care and had one or more prior abortions. A codebook approach was used to analyse the data, informed by a multidisciplinary framework for understanding the relationship between choice and equity. Abortion treatment choice was structured by multiple intersecting mechanisms: limitations on the supply of abortion care, incomplete or unbalanced information from providers, and participants' socio-economic environments. Long waiting times or travel distances could reduce choice of both treatment options. In interactions with providers, participants described not being offered procedural abortions or receiving information that favoured medication abortion. Participants' socio-economic environments impacted the way they navigated decision-making and their ability to manage the experience of either treatment option. Individual preferences for care were shaped in part by the interplay between these structural barriers, creating an illusion of choice, as the health system bias towards medication abortion reinforced some participants' negative perceptions of procedural abortion. The erosion of choice, to the point it is rendered illusory, has unequal impacts on quality of care. People's needs for their abortion care are complex and diverse, and access to varied service models is required to meet these needs. Treatment choice could be expanded by integrating public and private non-profit sector provision, aligning time limits and workforce requirements for abortion care with international standards, addressing financial pressures on service delivery, and revising the language used to depict each treatment option.

"All hands on deck": a qualitative study of safeguarding and the transition to telemedical abortion care in England and Wales.

The COVID-19 pandemic raised significant challenges for in-person healthcare provision, leading healthcare providers to embrace digital health like never before. Whilst changes were made as part of a public health response, many have now become permanent fixtures of the healthcare landscape, significantly altering the way care is provided not only for patients, but also for the healthcare professionals that provide care. In abortion care in England and Wales, previously stringent regulations on in-person care provision were relaxed to permit the use of telemedicine and self-administration of medications at home. These changes have since been made permanent. However, there remains opposition to remote abortion care pathways on the basis of safeguarding. Opponents argue that it is not feasible to effectively safeguard patients accessing abortion care remotely. We conducted a qualitative study using semi-structured interviews with abortion care providers in England and Wales. Participants were asked about their views and experiences of the transition to remote care provision, with a particular focus on how they adapted their safeguarding practice. In this article, we present three themes that highlight the changing roles of healthcare professionals in abortion care: (1) a challenging backdrop and resulting apprehension, (2) adaptive practices, and (3) the continued importance of professional curiosity. Across all three themes, participants reflected significantly on how changes were made and what they experienced in the period of transition to telemedicine. In particular, they discussed the changing nature of their professional roles amidst digitalisation. Our findings provide a basis for reflection on the increasing introduction of digital approaches to healthcare provision, highlighting points for caution and emphasising the need to involve professionals in the transition process to ensure vital buy-in. Through this, we articulate two novel understandings of digitalisation: (1) the impact of speed-associated pressures on professional adaptation during digitalisation, and (2) off-proforma safeguarding through telemedicine as a form of invisible non-routine work.

Waiting to start abortion: A qualitative exploration of narratives of waiting shared in a Reddit community for abortion post-Dobbs leak in 2022.

With the Dobbs leak introducing uncertainty about access and the Dobbs v. Jackson Women's Health Organization decision in June of 2022 overturning the US constitutional right to abortion, delays in accessing desired abortion care are likely growing longer and more common. Timely research on people's experiences waiting to access abortion care is needed. Using data from an abortion subreddit (r/abortion), we analyzed posts that described waiting after having decided to terminate the pregnancy, either by having an in-clinic appointment or ordering medication(s) online for self-managed abortion. Our analysis explored described 1) wait time length, 2) factors contributing to waiting, and 3) impacts of waiting. We used a hybrid inductive and deductive thematic qualitative coding approach to analyze a month-stratified 10% random sample of posts to the r/abortion community in 2022 surrounding the Dobbs leak and decision (May-December, n = 523 posts). Among posts to r/abortion that described waiting to start an abortion (n = 80), wait times ranged from one day to more than a month. Lack of appointment availability and waiting for mailed medications were commonly described as causing delays in accessing in-clinic abortion care and self-managed abortion, respectively. People shared challenges with pregnancy symptoms and feelings of anxiety, fear, isolation, and uncertainty. Posters also commonly described needing additional support while waiting. Overall, waiting to start an abortion was extremely stressful and isolating., with people often waiting weeks between ordering medication or scheduling an appointment and initiating the abortion process. Experiences of waiting to start an abortion and their impacts are of increasing concern as abortion access is further restricted. Additional targeted information and support are needed to mitigate these challenges. Providing timely access is imperative to quality care and overall abortion experiences.

The FDA in the Crosshairs-Science, Politics, and Abortion.

In this Viewpoint, the Supreme Court case FDA v AHM is used to illustrate the tension the FDA faces between science and politics, and state authority over abortion vs federal authority over which drugs may be marketed nationwide.

Safety and effectiveness evaluation of a uterine direct visualization system in induced abortion. A multicenter clinical trial.

OBJECTIVES: While the decision of abortion is undeniably complex, there are situations where it becomes a necessary choice. In such circumstances, a secure abortion procedure is essential to safeguard the physical and mental well-being of women. A uterine direct visualization system was designed to fulfill the requirements and this study undertook an assessment of the system's safety and effectiveness within a medical facility setting. MATERIALS AND METHODS: Induced abortion requested women in 17 institutions across the country between December 2016 and February 2017 were enrolled. Subjects were separated to the study and control group randomly. Induced abortion was conducted by a uterine direct visualization system and an ultrasound-guided system in the study and control group, respectively. The clinical indexes collected during intra- and post-procedures were analyzed and compared between groups. RESULTS: Overall, 392 and 339 subjects were included in the study and control group, respectively. The baseline demographic and clinical characteristics were similar between two groups. Subjects in the study group had significant smaller number of uterine cavity entry (p < 0.001), less 2-h and 14-days postoperative bleeding (all p < 0.001), and less 14-days postoperative abdominal pain (p < 0.001). Significantly higher ratio of normal menstruation, in terms of incidence and duration after 60-days of operation, was observed in the study group (all p < 0.001). CONCLUSIONS: Induced abortion with uterine direct visualization system generate better outcome and less complication than the conventional ultrasound-guided abortion procedures.

Abortion pills on TV: An exploratory study of the associations between abortion plotline viewership and beliefs regarding in-clinic and self-managed medication abortion.

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.

Acces to abortion in the Grand Est region in 2023 / L'accès à l'interruption volontaire de grossesse dans la région Grand Est en 2023

Objectives: Although access to abortion is a national priority in France, there is little documented evidence that it is actually respected. In the Grand Est region, the 2021­2023 plan for access to abortion includes a review of family planning practices and health care provision, to update the 2019 report. It raises the question of access to abortion in all its dimensions, and aims to implement improvement actions best suited to the region's problems. Method: An online questionnaire was sent to hospitals, local perinatal centers, sexual health centers, and independent professionals with presumed family planning activity. Of those who responded, only those with actual family planning activity were included. Results: The five-day deadline for the first appointment recommended by the HAS can be met by 73% of those surveyed. During pre- or post-abortion consultations, a psychosocial interview is offered to 92% of patients, and the detection of violence to 97%. Although 14 hospitals (38%) have extended their abortion access time to 16 weeks of amenorrhea, the number of facilities handling abortions beyond 13 weeks of amenorrhea has fallen since 2019. In primary care, 70% of private practitioners and 61% of sexual health centers offer abortions up to 9 weeks of amenorrhea. Conclusions: Access to abortion has weakened in the Grand Est region between 2019 and 2023. New laws and regulations could be a lever for improvement, provided that the professionals involved are given the means.

Objectifs: Si l'accès à l'IVG est une priorité nationale en France, son respect effectif n'est que peu documenté. Dans le Grand Est, le plan d'accès à l'IVG 2021-2023 inclut la réalisation d'un état des lieux des pratiques et de l'offre de soins en orthogénie, pour actualiser celui de 2019. Il pose la question de l'accès à l'IVG dans toutes ses dimensions et vise la mise en place des actions d'amélioration les plus adaptées aux problématiques de la région. Méthodes: Un questionnaire en ligne a été envoyé aux centres hospitaliers, aux centres périnataux de proximité, aux centres de santé sexuelle et aux professionnels libéraux ayant une activité d'orthogénie supposée. Parmi ceux qui y ont répondu, seuls ceux qui avaient une activité d'orthogénie effective ont été inclus. Résultats: Le délai de premier rendez-vous de cinq jours recommandés par l'HAS peut être respecté par 73 % des enquêtés. Lors des consultations pré- ou post-IVG, un entretien psychosocial est proposé à 92 % et un repérage des violences à 97 %. Bien que 14 centres hospitaliers (38 %) aient allongé leur délai d'accès à l'IVG jusqu'à 16 SA, le nombre d'établissements prenant en charge les IVG au-delà de 13 semaines d'aménorrhée a baissé depuis 2019. En médecine de ville, 70 % des professionnels libéraux et 61 % des CSS ont une offre IVG allant jusqu'à 9 SA. Conclusions: L'accès à l'IVG s'est fragilisé dans le Grand Est entre 2019 et 2023. Les nouvelles lois et réglementations pourraient être un levier d'amélioration à condition que des moyens soient donnés aux professionnels impliqués.

Understanding medication abortion ineligibility due to gestational age among a cohort of patients in Southern California.

OBJECTIVE: Medication abortion (MAB) is safe and effective up to 77 days gestation. Limited data are available on how often patients are ineligible for MAB due to advanced gestational age and how many of those ineligible go on to receive procedural abortion. STUDY DESIGN: Retrospective analysis of electronic health records from Planned Parenthood of the Pacific Southwest (PPPSW) from January - December 2021. PPPSW has four procedural abortion sites and 15 MAB-only clinics that offered appointments only if last menstrual period-based GA was ≤70 days or unknown. Patients >70 days gestation by intake ultrasound at a MAB-only clinic were referred to a procedural center. RESULTS: Of 11,684 patients presenting for MAB at MAB-only sites 2224 (19%) did not receive a MAB; 3.8% (N = 444) presented past 70 days gestation and were thus ineligible due to gestational age limits. Of those ineligible (N = 444), 234 (53%) measured between 71-77 days of gestation. Three quarters (75.7%) of those ineligible went on to receive a procedural abortion at PPPSW after a mean wait time of 10 days. In multivariable analysis, no demographic factors were associated with higher odds of receiving a procedural abortion. CONCLUSIONS: Presenting for MAB past a gestational age limit was uncommon, supporting safety of no-test MAB protocols. A quarter of people ineligible for MAB due to gestational age did not receive a procedural abortion at PPPSW. If MAB were offered up to 77 days, half of patients who were denied MAB due to gestational age could have received MAB, expanding patient access. IMPLICATIONS: Being ineligible for MAB due to advanced gestational age was uncommon. Increasing MAB gestational age limits from 70 days to 77 days could further improve abortion access.

Has the introduction of increased genetic prenatal testing affected rates of termination of pregnancy due to fetal abnormality?

OBJECTIVE: Genetic high-resolution analyses and improved diagnostic imaging have impacted the ability to detect fetal disorders. It is unknown if this resulted in an alteration in the number of terminations of pregnancy due to fetal anomalies (TOPFA). The objective was to describe the incidence and indication of TOPFA. METHODS: A descriptive study based on records from the Regional Abortion Council in the Central Denmark Region from 2008 to 2021 consisting of 1895 TOPFA. RESULTS: A consistent incidence of TOPFA was observed, accounting for 0.96% of the total births during that period. When examining fetal indications, there was a small increase in the occurrence of genetic aberrations, primarily caused by deletions, duplications, and single nucleotide variations, whereas the number of chromosomal aberrations remained stable. Of 35.5% of the cases with malformations, the central nervous system was the most affected organ system, followed by malformations of the heart 29.6%. Overall, the total number of cases remained stable. DISCUSSION AND CONCLUSION: Unexpectedly, despite the development of new diagnostic tools, the incidence of TOPFA from 2008 to 2021 remained stable. However, the number of cases with genetic aberrations increased. This may be attributed to increased genetic testing for fetuses with identified malformations, resulting in more accurate diagnoses.

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.

Second-trimester dilatation and evacuation: Comparison of routine intraoperative ultrasonography versus problem-based intraoperative ultrasonography in reducing procedure-related complications: A pre-post study.

OBJECTIVE: To investigate whether routine intraoperative ultrasonographic guidance during second-trimester dilatation and evacuation (D&E) reduces procedure-related complications in an Ethiopian setting. METHODS: We conducted a pre-post study on routine ultrasonography during second-trimester D&E at St. Paul's Hospital Millennium Medical College (Ethiopia). Second-trimester D&E cases that were managed at the hospital between 2017 and 2022 were retrospectively analyzed by grouping them into an intervention group (using routine ultrasound intraoperatively for all cases) and a non-intervention group (problem-based intraoperative use of ultrasound, where ultrasound was used in problem cases only). SPSS version 23 was used for analysis and simple descriptive statistics, χ2 test, multivariate regression analysis, and Fisher exact test were performed as appropriate. P values less than 0.05 and odds ratio with 95% CI were used to present the results' significance. RESULTS: A total of 242 second-trimester D&E cases were analyzed (84 cases managed under routine intraoperative ultrasound guidance and 158 cases managed with a problem-based intraoperative use of ultrasound). Compared with problem-based intraoperative use of ultrasound (using it only in selected cases), routine intraoperative ultrasound use was not associated with a decrease in D&E complications (adjusted odds ratio [aOR] 0.22, 95% confidence interval [CI] 0.04-1.16). The two factors associated with increased D&E procedure complications were advanced gestational age (aOR 13.52, 95% CI 1.86-98.52), and need for additional mechanical cervical dilatation during the D&E procedure (aOR 9.53, 95% CI 1.32-69.07). Provider experience, cervical preparation methods (laminaria vs Foley), and maternal age were not associated with occurrence of D&E complications. CONCLUSION: Our study does not support the preference of routine intraoperative ultrasound guidance over problem-based (in selected cases) intraoperative ultrasound use during the second-trimester D&E procedure. More research is needed to make a strong clinical recommendation on using routine intraoperative ultrasound guidance during all second-trimester D&E procedures.

Can mid-level providers manage medical abortion after 12 weeks' gestation as safely and effectively as physicians? A non-inferiority, randomized controlled trial in Addis Ababa, Ethiopia.

OBJECTIVE: To determine whether clinical outcomes among clients undergoing medical abortion after 12 weeks' gestation differ by provider cadre. METHODS: Randomized controlled trial conducted among eligible clients seeking abortion between 13 and 20 weeks' gestation. Participants seeking in-facility abortion were randomized to receive care from a mid-level provider (nurse/midwife) or physician. The primary outcome was median time to expulsion with non-inferiority margin of -1.5 h between provider groups. Quantile median regression models assessed non-inferiority. Secondary outcomes included retained placenta, complications, and patient acceptability. RESULTS: After randomization and eligibility assessment by the provider, 171 women participated in the study: 81 in the physician group and 90 in the mid-level provider group. Their average age was 24 years, the mean gestational age was 16 weeks, and 65% were nulliparous in both groups. The median time to expulsion did not differ significantly, being 8.1 h for the mid-level group and 6.6 h for the physician group. The adjusted median difference was 0.8 h (95% confidence interval [CI] -1.15 to 2.66), within the non-inferiority margin. Retained placenta occurred similarly: 30.0% (n = 24) of the physician group and 20.5% (n = 18) of the mid-level provider group (adjusted risk difference [ARD] 7.6%, 95% CI -2.81 to 18.06). Complications occurred in 7% of cases, including 5.0% (n = 4) of patients in the physician group and 8.9% (n = 8) in the mid-level provider group (ARD -4.7%, 95% CI -12.43 to 3.12). Patient acceptability did not differ by group. CONCLUSIONS: Training mid-level providers to provide abortion services after 12 weeks' gestation independently of physicians is feasible and may result in comparable clinical outcomes.

Outcomes After Induction of Labor Compared With Dilation and Evacuation for the Management of Rupture of Membranes in the Second Trimester.

Previable and periviable rupture of membranes is associated with significant morbidity for the pregnant patient. For those who have a choice of options and undergo active management, it is not known how the risks of induction of labor compare with those for dilation and evacuation (D&E). We performed a retrospective cohort study of patients with rupture of membranes between 14 0/7 and 23 6/7 weeks of gestation who opted for active management. Adverse events (52.2% vs 16.9%, P <.01) and time to uterine evacuation greater than 24 hours (26.7% vs 9.6%, P =.01) were more common among patients undergoing induction of labor. In a multivariable regression, induction of labor was an independent risk factor for complications (odds ratio 5.70, 95% CI, 2.35-13.82) compared with D&E. Severe complications were rare across both groups (4.4% for patients undergoing induction vs 2.6% for D&E, P =.63). Given the differing risks by termination method, access to D&E is an important treatment option for this patient population.

Supported at-home abortion: An exploratory study of methods, outcomes, and motivations of community-led abortion care in the United States and Canada.

OBJECTIVES: This an exploratory study aimed to describe methods and outcomes of comprehensive community-led abortion care in the United States and Canada. STUDY DESIGN: This community-based participatory research study recruited community abortion providers from the United States and Canada through existing confidential networks. They participated through in-person and online collaboration to design and implement a data collection tool for abortion methods, outcomes, and motivations from clients. We implemented significant security measures to protect participant confidentiality. RESULTS: Thirty community providers were recruited, five withdrew, and 12 provided data for 167 at-home abortions. Most abortions occurred between 6 and 10 weeks (104 [62%]). Abortions between 13 and 21 weeks represent 39 cases (23%). Misoprostol only was the most common method (n = 125 [75%]), followed by herbs alone (n = 12 [7%]) and aspiration (n = 12 [7%]). Complications were rare (n = 3 [1.8%]), with 163 complete abortions (98%). The primary motivation for seeking community-led abortion care was avoiding a clinic. CONCLUSIONS: Community providers employed various abortion methods with safety and effectiveness profiles comparable to those reported for clinical and community-based abortion care. Clients wanting a different model of abortion care seek out community-led abortions, regardless of whether clinics are legal and accessible. IMPLICATIONS: Community-led abortion is a viable choice for patients. Community providers should be recognized for their contributions to abortion access and high-quality, person-centered care. This study demonstrates a broader range of abortion providers and diverse options meeting the need for individualized abortion care.