The impact of the COVID-19 pandemic on abortion care utilization and disparities by age.

BACKGROUND: A variety of state-level restrictions were placed on abortion care in response to the COVID-19 pandemic, leading to drops in utilization and delays in time to abortion. Other pandemic-related factors also may have impacted receipt of abortion care, potentially exacerbating existing barriers to care. Massachusetts is an ideal setting to study the impact of these other pandemic-related factors on abortion care utilization because there was no wide-scale abortion policy change in response to the pandemic. OBJECTIVE: This study aimed to evaluate the impact of the COVID-19 pandemic on abortion care utilization and disparities in utilization by patient age in Massachusetts. STUDY DESIGN: Using the electronic medical records from all abortions that occurred at the Planned Parenthood League of Massachusetts from May 1, 2017 through December 31, 2020 (N=35,411), we performed time series modeling to estimate monthly changes in the number of abortions from the expected counts during the COVID-19 pandemic. We also assessed if legal minors (<18 years) experienced delays in time to abortion, based on gestational age at procedure, and whether minors were differentially impacted by the pandemic. RESULTS: There were 1725 less abortions than expected, corresponding to a 20% drop, from March 2020 to December 2020 (95% prediction interval, -2025 to -1394) with 888 less (20% reduction) abortions among adults, 792 (20% reduction) less among young adults, and 45 (27% reduction) among minors. Adults and young adults experienced significant reductions in the number of abortions beginning in March 2020, whereas decreases among minors did not begin until July 2020. The rate of abortions occurring ≥12 weeks gestational age was unchanged during the COVID-19 pandemic among minors (adjusted rate ratio, 0.92; 95% confidence interval, 0.55-1.51) and among adults (adjusted rate ratio, 0.92; 95% confidence interval, 0.78-1.09). Young adults had a lower rate of second trimester abortion during the pandemic (adjusted rate ratio, 0.79; 95% confidence interval, 0.66-0.95). CONCLUSION: Despite uninterrupted abortion service provision, abortion care utilization decreased markedly in Massachusetts during the pandemic. There was no evidence of an increase in second trimester abortions in any age group. Further research is needed to determine if a decline in the pregnancy rate or other factors, such as financial and travel barriers, fear of infection, or privacy concerns, may have contributed to this decline.

The Financial Burden of Antiquated Laws: The Case of Massachusetts' Parental Involvement Law for Abortion.

Background: A majority of U.S. states enforce parental involvement laws that require minors seeking abortion to obtain parental consent, or else obtain judicial bypass through the court system. Although such laws are widespread, the financial cost of their enforcement has yet to be documented. Methods: We used data from a retrospective observational cohort study among adolescents (aged ≤17 years old) who sought abortion services at Planned Parenthood League of Massachusetts (PPLM) between 2010 and 2016. We assessed the direct financial burden of judicial bypass among 449 minors accounting for direct public legal costs, private professional costs, cost of lost school, and cost to the young person. Results: The total added cost of judicial bypass in our cohort amounted to $374,982.04 (median cost of $705.14 per abortion). The direct out-of-pocket cost amounted to $84,370.23 ($179.89 per abortion). The majority of this cost was due to increased average procedure costs solely due to delays in care incurred by judicial bypass (range $0 to $5,200.50). In total, 74% of minors in our cohort were insured through Medicaid at the time of their abortion. Additional out-of-pocket costs for bypass were 20.2% of their household's maximum monthly income. Conclusions: These analyses show that judicial bypass as a function of parental involvement laws correlates with increased costs to individual minors and to the public, with the heaviest burden placed on minors of low socioeconomic status.

Expanding access to medication abortion through pharmacy dispensing of mifepristone: Primary care perspectives from Illinois.

OBJECTIVE: Medication abortion is safe and effective, yet access is limited by a strict Risk Evaluation and Mitigation Strategy (REMS) that prohibits pharmacy dispensing of mifepristone. Given the ability of primary care providers (PCPs) to expand medication abortion access, we assessed PCP perspectives on how lifting the mifepristone REMS would affect the provision of medication abortion in primary care. STUDY DESIGN: We conducted a qualitative study of PCPs and administrators in Illinois with experience or interest in providing medication abortion care at their practice. The final sample (N=19) consisted of seven family medicine physicians, three nurse practitioners, four certified nurse midwives, and five administrators. We queried participants on how removing the REMS to allow pharmacy dispensing of mifepristone would affect their ability to provide medication abortion. We conducted interviews via telephone and used ATLAS.ti to manage our transcripts; we analyzed these data for major themes regarding pharmacy dispensing. RESULTS: Primary care providers expressed support for pharmacy dispensing due to its ability to help normalize medication abortion, reduce implementation barriers in primary care, and expand abortion access. Further challenges to address if the REMS restrictions are lifted include federal funding restrictions on abortion, concerns about unsupervised mifepristone use, and pharmacy cooperation. CONCLUSION: Removing the mifepristone REMS to allow pharmacy dispensing could help normalize medication abortion care, facilitate provision in primary care, and address disparities in abortion access. IMPLICATIONS: Our findings illuminate novel benefits of removing the mifepristone REMS and highlight methods to promote successful implementation of pharmacy dispensing. Combined with prior literature, these results support prompt reevaluation and removal of the REMS to align medication abortion care with evidence-based practices.

Gender diversity among aspiration-abortion patients.

OBJECTIVE: Describe the array of gender identities among procedural abortion patients. STUDY DESIGN: Cross-sectional survey of abortion patients in three clinics in Massachusetts. Following aspiration abortion procedures and prior to discharge, patients self-administered a survey on a tablet. RESULTS: From November 2017 through July 2018, 1,553 aspiration abortion patients completed the survey (participation rate: 82%). Patients reported several gender identities. Non-binary (0.4%) and agender (0.4%) were the most common identities after female (91.1%) and woman (6.0%). Overall, 2.7% of patients identified as a gender other than female or woman. CONCLUSION: Aspiration abortion patients have a variety of gender identities. To promote quality of care for all patients, abortion providers can ensure their names, marketing materials, patient forms, and clinical environments are gender inclusive rather than focusing on women's health.

Mapping the scientific literature on reproductive health among transgender and gender diverse people: a scoping review.

We conducted a scoping review to map the extent, range and nature of the scientific research literature on the reproductive health (RH) of transgender and gender diverse assigned female at birth and assigned male at birth persons. A research librarian conducted literature searches in Ovid MEDLINE®, Ovid Embase, the Cochrane Library, PubMed, Google Scholar, Gender Studies Database, Gender Watch, and Web of Science Core Collection. The results were limited to peer-reviewed journal articles published between 2000 and 2018 involving human participants, written in English, pertaining to RH, and including disaggregated data for transgender and gender diverse people. A total of 2197 unique citations with abstracts were identified and entered into Covidence. Two independent screeners performed a title and abstract review and selected 75 records for full-text review. The two screeners independently extracted data from 37 eligible articles, which were reviewed, collated, summarised, and analysed using a numerical summary and thematic analysis approach. The existing scientific research literature was limited in terms of RH topics, geographic locations, study designs, sampling and analytical strategies, and populations studied. Research is needed that: focuses on the full range of RH issues; includes transgender and gender diverse people from the Global South and understudied and multiply marginalised subpopulations; is guided by intersectionality; and uses intervention, implementation science, and community-based participatory research approaches. Further, programmes, practices, and policies that address the multilevel barriers to RH among transgender and gender diverse people addressed in the existing scientific literature are warranted.

Time Trends in Massachusetts Adolescents' Postabortion Contraceptive Uptake.

PURPOSE: The purpose of the study was to assess uptake of postabortion contraception across changes in insurance regulations and insurance type used on the day of abortion, accounting for demographic characteristics and consent type (parental vs. judicial) for abortion among Massachusetts adolescents. METHODS: We conducted a retrospective record review of 1,375 minors (≤17 years) presenting for their first lifetime surgical abortion at a statewide network of abortion clinics between 2010 and 2016. Postabortion contraceptive method was defined as long-acting reversible contraception (LARC) placed onsite, short-acting reversible contraception (SARC) provided onsite, or no method received. RESULTS: The proportion of minors leaving with no method dropped from 38% in 2010 to 21% in 2016, while LARC placement increased from 19% to 45%. No difference was observed by consent type. Both LARC and SARC were more prevalent among minors with Medicaid or private insurance compared to those not using insurance on the day of abortion. In a multinomial regression model accounting for consent type and demographic characteristics, minors who received care during the final epoch of the study (relative risk ratio [RRR] = 3.30; 95% confidence interval [CI]: 2.23-4.88) or used private insurance (RRR = 3.91; 95% CI: 2.24-6.84) or Medicaid (RRR = 5.54; 95% CI: 3.37-9.11) on the day of service had significantly higher relative risk of receiving LARC versus no method (p < .001), with similar results for LARC versus SARC. CONCLUSIONS: Postabortion contraceptive uptake changed over time. Disparately low LARC uptake among minors not using insurance to pay for their abortions highlights a need to ensure equitable access to all methods, regardless of ability to pay.

Contraceptive Beliefs, Decision Making and Care Experiences Among Transmasculine Young Adults: A Qualitative Analysis.

CONTEXT: Transmasculine people-that is, individuals who were assigned female at birth and have a male or masculine gender identity-can experience unintended pregnancy. Yet research on contraception among transmasculine individuals is extremely limited. METHODS: Participants were recruited online; from community-based organizations, health centers and student groups; and by chain referral. From purposive sampling, 21 transmasculine individuals aged 18-29 who resided in the greater Boston area and had had, in the last five years, a sexual partner who was assigned male at birth were selected for in-depth interviews. All interviews were conducted in person between February and May 2018 in Boston, and transcripts were analyzed using a thematic analysis approach involving inductive and deductive coding to identify themes and subthemes. RESULTS: Most participants believed that contraceptive use was necessary to effectively prevent pregnancy among transmasculine individuals. Their beliefs and decisions regarding contraception occurred in the context of a lack of information about contraception among transmasculine people, especially those using testosterone. Many individuals chose a contraceptive method on the basis of whether it mitigated their gender dysphoria or stopped menstruation, and said they preferred condoms and implants because these methods provided fewer reminders of their natal anatomy and were not perceived as interfering with testosterone use. Gender bias, discrimination and stigma in patient-provider interactions and health care settings negatively influenced participants' contraceptive care experiences. CONCLUSIONS: Health care providers and facilities should provide transmasculine people with tailored contraceptive information and care that address their specific gender-affirmation needs and contraceptive preferences in safe, inclusive and supportive clinical settings.

Rapamycin-upregulated miR-29b promotes mTORC1-hyperactive cell growth in TSC2-deficient cells by downregulating tumor suppressor retinoic acid receptor ß (RARß).

miR-29b has been identified as a rapamycin-induced microRNA (miRNA) in Tsc2-deficient, mTORC1-hyperactive cells. The biological significance of this induction of miR-29b is unknown. We have found that miR-29b acts as an oncogenic miRNA in Tsc2-deficient cells: inhibition of miR-29b suppressed cell proliferation, anchorage-independent cell growth, cell migration, invasion, and the growth of Tsc2-deficient tumors in vivo. Importantly, the combination of miR-29b inhibition with rapamycin treatment further inhibited these tumor-associated cellular processes. To gain insight into the molecular mechanisms by which miR-29b promotes tumorigenesis, we used RNA sequencing to identify the tumor suppressor retinoid receptor beta (RARß) as a target gene of miR-29b. We found that miR-29b directly targeted the 3'UTR of RARß. Forced expression of RARß reversed the effects of miR-29b overexpression in proliferation, migration, and invasion, indicating that it is a critical target. miR-29b expression correlated with low RARß expression in renal clear cell carcinomas and bladder urothelial carcinomas, tumors associated with TSC gene mutations. We further identified growth family member 4 (ING4) as a novel interacting partner of RARß. Overexpression of ING4 inhibited the migration and invasion of Tsc2-deficient cells while silencing of ING4 reversed the RARß-mediated suppression of cell migration and invasion. Taken together, our findings reveal a novel miR-29b/RARß/ING4 pathway that regulates tumorigenic properties of Tsc2-deficient cells, and that may serve as a potential therapeutic target for TSC, lymphangioleiomyomatosis (LAM), and other mTORC1-hyperactive tumors.

Massachusetts' Parental Consent Law and Procedural Timing Among Adolescents Undergoing Abortion.

OBJECTIVE: To describe individual-level delay in obtaining abortion associated with use of the Massachusetts judicial bypass system, which legal minors (aged 17 years or younger) use to obtain abortion without consent of a parent or legal guardian in the setting of Massachusetts' parental consent law for abortion. METHODS: We conducted a retrospective cohort study of 2,026 abortions among minors at a large, statewide network of abortion clinics between 2010 and 2016. Delay was defined as the number of calendar days between the minor's first call to the clinic to schedule an abortion, and the day the abortion was received. RESULTS: In the study population, 1,559 (77%) abortions were obtained with parental consent and 467 (23%) using judicial bypass. Abortions after judicial bypass were more common among minors identifying as Hispanic, non-Hispanic black, or other race, those of low socioeconomic status (as indicated by having Medicaid insurance) and those with a prior birth or prior abortion (all P<.05). Minors with parental consent received their abortion a mean of 8.6 days after initial contact, compared with 14.8 days for minors with judicial bypass, for an unadjusted difference of 6.1 days. In multivariable linear regression modeling adjusting for demographic differences between groups, this difference persisted: minors who obtained abortions after judicial bypass had a significantly greater delay compared with those with parental consent (adjusted mean difference = 5.2 days; 95% CI 4.3 to 6.2). Using multivariable logistic regression modeling, minors with judicial bypass also had higher odds of becoming ineligible for medication abortion between the day of first call and the day of procedure (adjusted odds ratio 1.57; 95% CI 1.09 to 2.26). CONCLUSION: Massachusetts' parental consent law for abortion is associated with delay among minors and thereby may constrain the clinical options available to them.