Travel for abortion care: implications for clinical practice.

PURPOSE OF REVIEW: Traveling long distances to obtain abortion care due to restrictions and scarce availability is associated with significant obstacles. We review clinical strategies that can facilitate abortion access and outline considerations to ensure person-centered and equitable care. RECENT FINDINGS: Establishing a patient's gestational duration prior to travel may be beneficial to ensure they are eligible for their desired abortion method at the preferred facility or to determine if a multiday procedure is required. If a local ultrasound cannot be obtained prior to travel, evidence demonstrates people can generally estimate their gestational duration accurately. If unable to provide care, clinicians should make timely referrals for abortion. Integration of telemedicine into abortion care is safe and well regarded by patients and should be implemented into service delivery where possible to reduce obstacles to care. Routine in-person follow-up care is not necessary. However, for those who want reassurance, formalized pathways to care should be established to ensure people have access to care in their community. To further minimize travel-related burdens, facilities should routinely offer information about funding and practical support, emotional support, and legal resources. SUMMARY: There are many opportunities to optimize clinical practice to support those traveling for abortion care.

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.

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.

Abortion With Pills: Review of Current Options in The United States.

Interest in self-management approaches to abortion with pills in the United States preceded the coronavirus disease 2019 (COVID-19) pandemic and has accelerated during this global health crisis. Coupled with the unclear future of legal abortion in the United States, clinical care providers need to be aware of the range of self-managed abortion approaches and of the varying levels of engagement with the formal health care system they entail. This article is intended to serve as a resource to inform providers of the current landscape of abortion with pills in the United States, while also describing possible shifts in the future that may result due to the ongoing pandemic and the continuing erosion of access to abortion care and services.

Clinical and service delivery implications of omitting ultrasound before medication abortion provided via direct-to-patient telemedicine and mail in the U.S.

OBJECTIVES: To compare outcomes among patients who did or did not have pre-abortion ultrasound or pelvic exam before obtaining medication abortion (MA) via direct-to-patient telemedicine and mail. STUDY DESIGN: We analyzed data from participants screened for enrollment into the TelAbortion study at five sites from March 25 to September 15, 2020. We compared participants who had preabortion ultrasound or pelvic exam ("test-MA") to those who did not ("no-test MA"). Outcomes were: abortion not complete with pills alone (i.e., had procedure intervention or ongoing pregnancy), ongoing pregnancy separately, ectopic pregnancy, hospitalization and/or blood transfusion, and unplanned clinical encounters. We used propensity score weighting and multivariable logistic regression to adjust for baseline characteristics. RESULTS: Our analysis included 287 participants who had no-test MA and 125 who had test-MA. Abortion was not complete with pills alone in 16of 287 (5.6%) no-test MA patients compared to 2of 123 (1.9%) test-MA patients (adjusted risk difference [aRD] = 4.3%, 95% confidence interval [CI]: 1.4%-7.1%). No ectopic pregnancies were detected. Groups did not differ regarding hospitalization and/or blood transfusion (p = 0.76) or ongoing pregnancy diagnosis (p = 0.59). Unplanned clinical encounters were more common in no-test MA patients (35of 287, 12.5%) than test-MA patients (10of 125, 8.0%, aRD = 6.7%, 95% CI: 0.5%-13.1%). CONCLUSIONS: Compared to patients who had pre-abortion ultrasound, patients who had no-test MA via telemedicine were more likely to have abortions that were not complete with pills alone and/or unplanned clinical encounters. However, both no-test and test-MA patients had similar and very low rates of ongoing pregnancy and hospitalization or blood transfusion. IMPLICATIONS: Omitting pre-abortion ultrasound before provision of medication abortion via telemedicine does not appear to compromise safety or result in more ongoing pregnancies. However, compared to patients who have preabortion ultrasound, patients who do not have pre-abortion tests may be more likely to seek post-treatment care and have procedural interventions.

Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic.

OBJECTIVE: To present updated evidence on the safety, efficacy and acceptability of a direct-to-patient telemedicine abortion service and describe how the service functioned during the COVID-19 pandemic. STUDY DESIGN: We offered the study at 10 sites that provided the service in 13 states and Washington DC. Interested individuals obtained any needed preabortion tests locally and had a videoconference with a study clinician. Sites sent study packages containing mifepristone and misoprostol by mail and had remote follow-up consultations within one month by telephone (or by online survey, if the participant could not be reached) to evaluate abortion completeness. The analysis was descriptive. RESULTS: We mailed 1390 packages between May 2016 and September 2020. Of the 83% (1157/1390) of abortions for which we obtained outcome information, 95% (1103/1157) were completed without a procedure. Participants made 70 unplanned visits to emergency rooms or urgent care centers for reasons related to the abortion (6%), and 10 serious adverse events occurred, including 5 transfusions (0.4%). Enrollment increased substantially with the onset of COVID-19. Although a screening ultrasound was required, sites determined in 52% (346/669) of abortions that occurred during COVID that those participants should not get the test to protect their health. Use of urine pregnancy test to confirm abortion completion increased from 67% (144/214) in the 6 months prior to COVID to 90% (602/669) in the 6 months during COVID. Nearly all satisfaction questionnaires (99%, 1013/1022) recorded that participants were satisfied with the service. CONCLUSIONS: This direct-to-patient telemedicine service was safe, effective, and acceptable, and supports the claim that there is no medical reason for mifepristone to be dispensed in clinics as required by the Food and Drug Administration. In some cases, participants did not need to visit any facilities to obtain the service, which was critical to protecting patient safety during the COVID-19 pandemic. IMPLICATIONS: Medical abortion using telemedicine and mail is effective and can be safely provided without a pretreatment ultrasound. This method of service delivery has the potential to greatly improve access to abortion care in the United States.

"False positive" urine pregnancy test results after successful medication abortion.

OBJECTIVE: To examine the proportion of high-sensitivity urine pregnancy test (HSPT) results that were positive by time after successful medication abortion. STUDY DESIGN: We used data from an ongoing study that provides mifepristone and misoprostol for medication abortion by direct-to-patient telemedicine and mail. Providers evaluated abortion outcomes by patient interview and clinical tests per clinical judgment and participant preference. We identified all participants enrolled July 2016 to September, 2020 who had an HSPT result and no indication of viable pregnancy after treatment. We used logistic regression to examine the association between the timing of the initial post-treatment HSPT, gestational age, and the proportion of HSPTs that gave a positive result. RESULTS: Of the 472 participants in our analysis, 88 (19%) had positive initial HSPTs. The proportions that were positive at ≤20 days, 21 to 27 days, 28 to 34 days, and ≥35 days after mifepristone ingestion was 14 of 29 (48%), 15 of 58 (26%), 49 of 258 (19%), and 10 of 127 (8%), respectively (p < 0.001). Gestational age at mifepristone ingestion was not significantly related to positive HSPT results (p = 0.28). Multivariable logistic regression confirmed both findings and did not identify a statistically significant interaction between these variables. In the 67 participants who relied solely on further HSPTs to confirm abortion outcome, the median interval between the initial positive test and first negative test was 14 days. CONCLUSIONS: The proportion of participants with positive HSPTs declined with time after successful medication abortion. However, nearly one-fifth of participants with complete abortion had positive tests 4 weeks after treatment. IMPLICATIONS: HSPTs provide an inexpensive, convenient option for confirming success of medication abortion at home. However, a substantial minority of patients without ongoing pregnancy have positive HSPT results. Development of a symptom-based strategy for medication abortion outcome assessment without any confirmatory tests should be a priority.

Virtually possible: using telehealth to bring reproductive health care to women with opioid use disorder in rural Maine.

BACKGROUND: Maternal opioid use disorder (OUD) has increased more sharply in recent years among rural residents in the United States than among urban residents. In 2018, the prevalence of maternal OUD accounted for 3.5% of all hospital deliveries in Maine. Opioid use during pregnancy is associated with negative health effects for both the woman and infant. While many women with OUD use contraception, few report using a highly reliable method. METHODS: A family planning clinic in Maine piloted a program to increase reproductive health access for women with OUD through the use of telehealth. In this model, a community outreach educator travelled to a community organization that serves this population to provide reproductive health information and an opportunity to connect with a nurse practitioner via telehealth to receive the following reproductive health services: HIV counseling and testing, contraception, or pregnancy testing and counseling. We assessed the feasibility of this program through the following outcome measures: number of women who engaged with the community outreach educator, number of women who used telehealth services, and number of women who received services at a referred clinic during the six-month pilot. RESULTS: During the pilot program, the community outreach educator held eighteen educational sessions and engaged fifty-one women; providing condoms and/or answers to various reproductive health questions. Fifteen women used telehealth services. The majority used the service to receive testing for sexually transmitted infections (STI) such as HIV. Four women used telehealth for contraceptive services and received either birth control or the Depo-Provera injectable on-site. A third of the women received more than one reproductive health service via telehealth. Of the women who were referred to a family planning clinic for additional services, only 2 attended their appointment. No challenges with hearing or seeing the practitioner through the video platform were recorded. CONCLUSIONS: Improving women's access to effective contraceptive methods and preventive reproductive health services is critical to ensuring women with OUD are able to seek effective treatment and to ensure the health of future pregnancies. Findings from this pilot program suggest that innovative health care models such as on-site provision of reproductive health care through telehealth have the potential to increase access to reproductive care for this hard-to-reach population.

TelAbortion: evaluation of a direct to patient telemedicine abortion service in the United States.

OBJECTIVES: To evaluate the safety, feasibility, and acceptability of a direct-to-patient telemedicine service that enabled people to obtain medical abortion without visiting an abortion provider in person. STUDY DESIGN: We offered the service in five states. Each participant had a videoconference with a study clinician and had pre-treatment laboratory tests and ultrasound at facilities of her choice. If the participant was eligible for medical abortion, the clinician sent a package containing mifepristone, misoprostol, and instructions to her by mail. After taking the medications, the participant obtained follow-up tests and had a follow-up consultation with the clinician by telephone or videoconference to evaluate abortion completeness. The analysis was descriptive. RESULTS: Over 32 months, we conducted 433 study screenings and shipped 248 packages. The median interval between screening and mailing was 7 days (91st percentile 17 days), and no participant took the mifepristone at ≫71 days of gestation. We ascertained abortion outcomes of 190/248 package recipients (77%): 177/190 (93%) had complete abortion without a procedure. Of the 217/248 package recipients who provided meaningful follow-up data (88%), one was hospitalized for postoperative seizure and another for excessive bleeding, and 27 had other unscheduled clinical encounters, 12 of which resulted in no treatment. A total of 159/248 participants who received packages (64%) completed satisfaction questionnaires at study exit; all were satisfied with the service. CONCLUSIONS: This direct-to-patient telemedicine abortion service was safe, effective, efficient, and satisfactory. The model has the potential to increase abortion access by enhancing the reach of providers and by offering people a new option for obtaining care conveniently and privately. IMPLICATIONS: Provision of medical abortion by direct-to-patient telemedicine and mail has the potential to increase abortion access by increasing the reach of providers and by offering people the option of obtaining abortion care without an in-person visit to an abortion provider.

Systematic Review of Sexual and Reproductive Health Care Content in Nursing Curricula.

OBJECTIVE: To examine whether and to what extent pre-licensure nursing programs include sexual and reproductive health (SRH) content in their curricula. DATA SOURCES: Electronic databases, including CINAHL, MEDLINE, PubMed, Web of Science, Science Direct, Google Scholar, ProQuest, and CAB Direct were searched for relevant literature. We also reviewed the reference lists of all studies, nursing organization Web sites, and the personal files of the authors. STUDY SELECTION: Inclusion criteria were studies focused on SRH content in pre-licensure nursing education, written in English, and published between January 1990 and November 2016. We identified 632 articles, and of these, 22 met the inclusion criteria. Duplicates were discarded, and 13 articles were reviewed (9 quantitative descriptive, 2 modified Delphi, 2 mixed methods). DATA EXTRACTION: Data extraction and subsequent analysis were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted and organized under the following headings: author and year to establish a historical timeline, study purpose and design, sample size, data collection methods, main study findings, and limitations. DATA SYNTHESIS: We found the following: (a) most studies focused on baccalaureate education; if associated degree programs were reviewed, findings were not reported separately; (b) definitions were not consistent, which affected the scope of study results; (c) the SRH topics taught were similar; (d) there is a recent interest in sexual orientation and gender identity curriculum; (e) barriers to including content were time constraints, competing demands with other curriculum priorities, and a need for creative curriculum tools. CONCLUSION: Documentation of SRH content in pre-licensure nursing education is limited. Faculty should conduct ongoing evaluation of their curricular strategies and clinical experiences and publish results in the literature.