hCG trends after mifepristone and misoprostol for undesired pregnancy of unknown location.

OBJECTIVES: To describe human chorionic gonadotropin (hCG) trends for patients with a pregnancy of unknown location (PUL) presenting for medication abortion by management strategy and outcome. STUDY DESIGN: This retrospective cohort study included patients presenting for medication abortion with a PUL at ≤42 days gestation managed with either (1) immediate mifepristone with serial hCG follow-up (same-day-start) or (2) hCG testing every 48 to 72 hours ± ultrasonography to confirm pregnancy location followed by treatment (delay-for-diagnosis). The primary outcome was percent hCG change over time between presentation and diagnosis, summarized using a multivariate regression model. RESULTS: Of the 55 same-day-start patients, none were treated for ectopic. The eight who eventually required suction curettage had median hCG percent changes (interquartile range) on days 3, 4, and 5 of +57% (-14 to 127; n = 2), +292% (226-353; n = 4), and +392% (n = 1), while the 41 successful medication abortions had declines of -64% (n = 1), -65% (-75 to -27; n = 17), and -77% (-85 to -68; n = 13). Of the 380 delay-for-diagnosis patients, the 30 ectopic pregnancies had day 3, 4, and 5 changes of +38% (-17 to 56; n = 14), +50% (17-71; n = 7), and +115% (87-177; n = 4). None of the ectopic pregnancies declined ≥50% by days 3 to 5. The hCG trend for ectopic pregnancies differed from successful medication abortions (p < 0.01), but not medication abortions with retained intrauterine pregnancies (p = 0.41). CONCLUSIONS: Serum hCG trends can help differentiate ectopic pregnancy from successful medication abortion, but cannot distinguish between ectopic and retained intrauterine pregnancy. IMPLICATIONS: Serial serum hCG testing is effective for confirming successful medication abortion and identifying patients requiring further follow-up among patients undergoing medication abortion for an undesired PUL.

Helping patients choose between pain control options for outpatient procedural abortion at less than 12 weeks' gestation.

OBJECTIVES: This study aimed to identify predictors of patient satisfaction with their chosen pain control regimen for procedural abortion at <12 weeks' gestation in the outpatient setting. STUDY DESIGN: In this prospective cohort study, we developed an instrument to evaluate predictors of satisfaction with pain control regimens among patients choosing local anesthesia alone (paracervical block with 20 mL of 1% buffered lidocaine) or local anesthesia plus intravenous (IV) moderate sedation with 100 mcg of fentanyl and 2 mg of midazolam. Our primary outcome was to identify predictors of satisfaction with both anesthesia cohorts as measured on a 4-point Likert scale, but due to high satisfaction levels in the IV group, we focused our analysis on the local anesthesia group. RESULTS: We enrolled 149 patients in the local anesthesia group and 155 in the moderate IV sedation group. The mean procedure pain scores were 6.9 (±2.1) out of 10 in the local group and 4.0 (±2.7) in the IV group (p < 0.0001). More women in the IV group (92%) were satisfied or very satisfied with the amount of pain relief they experienced compared to the local group (66%; p < 0.0001). In the univariable model, only being afraid of a minor medical procedure was predictive of less satisfaction with local anesthesia for pain control (relative risk 0.8 [95% CI, 0.6-0.9]). Age, gestational age, anticipated pain, self-reported pain tolerance, self-reported anxiety, discomfort with the abortion decision, and history of prior vaginal or cesarean delivery or induced abortion did not predict satisfaction levels. CONCLUSIONS: Fear of minor medical procedures was the only variable that predicted decreased satisfaction with local anesthesia alone for procedural abortion under 12 weeks. IMPLICATIONS: Reliable predictors for satisfaction with local anesthesia alone for procedural abortion in the outpatient setting remain elusive. Fear of minor medical procedures may serve as an indicator of decreased satisfaction and could be incorporated into patient counseling. Moderate IV sedation is associated with high satisfaction levels.

Mifepristone Use Among Obstetrician-Gynecologists in Massachusetts: Prevalence and Predictors of Use.

OBJECTIVES: We estimated the prevalence of mifepristone use for evidence-based indications among obstetrician-gynecologists in independent practice in Massachusetts and explored the demographic and practice-related factors associated with use. METHODS: We used data from a cross-sectional survey administered to Massachusetts obstetrician-gynecologists identified from the American Medical Association Physician Masterfile. We measured the prevalence of mifepristone use for four clinical scenarios: early pregnancy loss, medication abortion, cervical preparation before dilation and evacuation procedures, and cervical preparation before induction of labor. Multivariate regression was used to calculate the odds of mifepristone use for these scenarios based on practice type, years in practice, physician sex, and history of medication abortion training. RESULTS: A total of 198 obstetrician-gynecologists responded to the survey (response rate = 29.0%); this analysis was limited to 158 respondents who were not in residency or fellowship. Overall, 46.0% used mifepristone for early pregnancy loss and 38.6% for medication abortion. Fewer used mifepristone for cervical preparation before dilation and evacuation (26.0%) or before induction of labor (26.4%). Respondents in academic practice settings, with more years in practice, of female sex, and with sufficient medication abortion training were significantly more likely to use mifepristone for one or more evidence-based clinical indications. CONCLUSIONS: Sufficient medication abortion training during residency significantly predicts whether obstetrician-gynecologists use mifepristone in practice. The U.S. Supreme Court's overturning of Roe v. Wade will allow state-level abortion bans and restrictions to be in effect, which will reduce exposure to abortion training during residency. Increasing training in and utilization of mifepristone are critical for equitable access to reproductive health services. Further interventions may need to be developed to increase mifepristone use in nonacademic practice settings.

Induced Abortion and the Risk of Rh Sensitization.

Importance: While population-level data suggest Rh immunoglobulin is unnecessary before 12 weeks' gestation, clinical evidence is limited. Thus, guidelines vary, creating confusion surrounding risks and benefits of Rh testing and treatment. As abortion care in traditional clinical settings becomes harder to access, many people are choosing to self-manage and need to know if ancillary blood type testing is necessary. Objective: To determine how frequently maternal exposure to fetal red blood cells (fRBCs) exceeds the most conservative published threshold for Rh sensitization in induced first-trimester abortion. Design, Setting, and Participants: Multicenter, observational, prospective cohort study using high-throughput flow cytometry to detect circulating fRBCs in paired maternal blood samples before and after induced first-trimester abortion (medication or procedural). Individuals undergoing induced first-trimester abortion before 12 weeks 0 days' gestation were included. Paired blood samples were available from 506 participants who underwent either medical (n = 319 [63.0%]) or procedural (n = 187 [37.0%]) abortion. Exposure: Induced first-trimester abortion. Main Outcomes and Measures: The primary outcome was the proportion of participants with fRBC counts above the sensitization threshold (125 fRBCs/5 million total RBCs) after induced first-trimester abortion. Results: Among the 506 participants, the mean (SD) age was 27.4 (5.5) years, 313 (61.9%) were Black, and 123 (24.3%) were White. Three of the 506 participants had elevated fRBC counts at baseline; 1 of these patients had an elevated fRBC count following the abortion (0.2% [95% CI, 0%-0.93%]). No other participants had elevated fRBC counts above the sensitization threshold after induced first-trimester abortion. The median change from baseline was 0 fRBCs, with upper 95th and 99th percentiles of 24 and 35.6 fRBCs, respectively. Although there was a strong association between the preabortion and postabortion fRBC counts, no other baseline characteristic was significantly associated with postabortion fRBC count. Conclusions and Relevance: Induced first-trimester abortion is not a risk factor for Rh sensitization, indicating that Rh testing and treatment are unnecessary before 12 weeks' gestation. This evidence may be used to inform international guidelines for Rh immunoglobulin administration following first-trimester induced abortion.

Use of Abortion Services in Massachusetts After the Dobbs Decision Among In-State vs Out-of-State Residents.

This cohort study compares observed vs expected abortion counts after Dobbs in Massachusetts among in-state vs out-of-state residents.

Second-Trimester Dilation and Evacuation: A Simulation-Based Team Training Curriculum.

Introduction: Despite the need for providers skilled in second-trimester dilation and evacuation (D&E) procedures, there are few second-trimester abortion training opportunities for OB/GYN residents and other health care trainees. Barriers to such training include restrictive state laws and institutional policies, lack of trained faculty, and limited procedural volume. Simulation-based D&E training is, therefore, a critical tool for OB/GYN residents and other medical professionals to achieve clinical competency. Methods: This simulation for OB/GYN residents centers on a 29-year-old woman at 18 weeks gestation with intrauterine fetal demise, requiring learners to perform a second-trimester D&E and manage an unexpected postprocedural hemorrhage. We designed the simulation to be used with a high-fidelity mannequin. Personnel roles required for the simulation included an anesthesiologist, medical assistant, OR nurse, and two OB/GYN faculty. Learner performance was assessed using a pre- and postsimulation learner evaluation, a critical action checklist, and a focus group with simulation facilitators. Results: Forty-nine residents participated over an 8-year period. Learners demonstrated improved competency performing a second-trimester D&E and increased confidence managing postprocedural hemorrhage after participating in this simulation. In addition, focus group participants reported that a majority of learners demonstrated confidence and effective communication with team members while performing in a decision-making role. Discussion: In addition to improving learners' clinical competency and surgical confidence for second-trimester D&E procedures, this simulation serves as a valuable instrument for the standardized assessment of learners' performance, as well as an opportunity for all participants to practice teamwork and communication in a high-acuity setting.

Management of early pregnancy loss among obstetrician-gynecologists in Massachusetts and barriers to mifepristone use.

OBJECTIVES: To measure the prevalence of early pregnancy loss management types among obstetrician-gynecologists in Massachusetts, and delineate barriers, facilitators, demographic and practice-related factors associated with mifepristone use for early pregnancy loss. STUDY DESIGN: We surveyed a census of obstetrician-gynecologists in Massachusetts. Descriptive statistics measured the prevalence of offering expectant, misoprostol-alone, mifepristone and misoprostol, dilation and curettage in the office and operating room, and multivariate logistic regression analysis evaluated barriers and facilitators to mifepristone use. Data were weighted to account for nonresponders. RESULTS: 198 obstetrician-gynecologists responded to the survey (response rate=29%). Participants most commonly offered expectant management (98%), dilation and curettage in the operating room (94%), and misoprostol-only medication management (80%). Fewer offered mifepristone-misoprostol (51%) or dilation and curettage in an office setting (45%). Those in private practice or other practice types had lower odds of offering mifepristone-misoprostol than those in academic practice (private practice: aOR 0.34, 95% confidence interval [CI] [0.19, 0.61]). Female physicians had higher odds of offering mifepristone-misoprostol (aOR 1.97, 95% CI [1.11, 3.49]). Obstetrician-gynecologists who included medication abortion in their practice had much higher odds of using mifepristone for early pregnancy loss (aOR 25.06, 95% CI [14.52, 43.24]). The Food and Drug Administration Risk and Evaluation Management Strategies Program was a primary barrier among those not using mifepristone (54%). CONCLUSIONS: Many obstetrician-gynecologists do not offer mifepristone-based regimens for early pregnancy loss, which are more efficacious than misoprostol-only regimens. The Food and Drug Administration Risk Evaluation and Mitigation Strategies Program is a major barrier to mifepristone use. IMPLICATIONS: Half of obstetrician-gynecologists in Massachusetts do not use mifepristone for early pregnancy loss management. Major barriers include lack of experience with mifepristone and the Food and Drug Administration Risk Evaluation and Mitigation Strategies Program regulations. Removing medically unnecessary regulations and increasing education on mifepristone via access to abortion care experts may increase uptake of this practice.

At-home urine pregnancy test assessment after mifepristone and misoprostol for undesired pregnancy of unknown location.

OBJECTIVES: The ideal assessment after mifepristone and misoprostol for undesired pregnancy of unknown location (PUL) is unknown. STUDY DESIGN: We prospectively followed patients at Planned Parenthood League of Massachusetts (2019-2021) with PUL who received immediate mifepristone and misoprostol with serial at-home urine pregnancy tests (UPT) and in-office serum HCGs. RESULTS: Of 13 patients, 10 had a successful medication abortion. For those who completed UPTs (N = 9), all were negative by Day 14. Two abnormal pregnancies had positive UPTs on Day 14. CONCLUSION: A negative UPT on Day 14 may help determine complete abortion after medication abortion for undesired PUL. A positive UPT on Day 14 warrants further evaluation. IMPLICATION: Patients taking mifepristone and misoprostol in the setting of undesired PUL who cannot access serum testing may consider an at-home UPT to confirm complete abortion.

Acute complications with same-day versus overnight cervical preparation before dilation and evacuation at 14 to 16 weeks.

OBJECTIVE: Evaluate if same-day cervical preparation is associated with a clinically acceptable complication rate compared with overnight osmotic dilators for dilation and evacuation (D&E). STUDY DESIGN: This retrospective, noninferiority, cohort study compared complication rates for same-day versus overnight cervical preparation with D&E between 14 and 16 weeks gestation. Cervical preparation was achieved with misoprostol, osmotic dilators, or both. Our primary outcome was the acute complication rate, defined as: hemorrhage (≥500 mL); hospitalization or hospital transfer; transfusion; or unplanned procedure occurring within 24 hours of the index procedure. Secondarily we evaluated nonmajor (re-aspiration, suture repair of cervical laceration, uterine tamponade, or emergency department only transfer) and major (transfusion, uterine artery embolization, abdominal surgery, or hospital admission) complications separately. Inverse probability of treatment weighting using the propensity score was used to perform an adjusted analysis, taking into account age, ethnicity, clinic location, insurance, gestational age, gravidity, and prior pregnancy outcomes. RESULTS: We analyzed 1,319 subjects (n = 864 same-day, n = 455 overnight). Same-day cervical preparation patients were more likely to have Medicaid and a prior vaginal delivery. In both unadjusted and adjusted analyses, acute complication rates for same-day were noninferior to overnight preparation (unadjusted 0.93% vs 1.98%, difference of -1.05%, CI: -2.48% to 0.38%; adjusted difference -0.50%, CI: -1.45 to 0.44%). Only one major complication in the same-day group, a cervical laceration resulting in hemorrhage requiring transfusion, occurred in the entire sample. CONCLUSIONS: In this retrospective review, same-day cervical preparation was noninferior to overnight preparation for D&E between 14 and 16 weeks gestation, both with low complication rates. IMPLICATIONS: For early second trimester dilation and evacuation, same-day cervical preparation should be considered a safe alternative to overnight cervical preparation.

Continuation rates of two different-sized copper intrauterine devices among nulliparous women: Interim 12-month results of a single-blind, randomised, multicentre trial.

Background: The most widely used copper intrauterine device (IUD) in the world (the TCu380A), and the only product available in many countries, causes side effects and early removals for many users. These problems are exacerbated in nulliparous women, who have smaller uterine cavities compared to parous women. We compared first-year continuation rates and reasons/probabilities for early removal of the TCu380A versus a smaller Belgian copper IUD among nulliparous users. Methods: This 12-month interim report is derived from a pre-planned interim analysis of a sub population and focused on key secondary comparative endpoints. In this participant-blinded trial at 16 centres in the USA, we randomised participants aged 17-40 in a 4:1 ratio to the NT380-Mini or the TCu380A. In the first year, participants had follow-up visits at 6-weeks and 3, 6, and 12-months, and a phone contact at 9 months; we documented continued use, expulsions, and reasons for removal. Among participants with successful IUD placement, we compared probabilities of IUD continuation and specific reasons for discontinuation using log-rank tests. This trial is registered with ClinicalTrials.gov number NCT03124160 and is closed to recruitment. Findings: Between June 1, 2017, and February 25, 2019, we assigned 927 nulliparous women to either the NT380-Mini (n = 744) or the TCu380A (n = 183); the analysis population was 732 (NT380-Mini) and 176 (TCu380A). Participants using the NT380-Mini, compared to the TCu380A, had higher 12-month continuation rates (78·7% [95% CI: 72·9-84·5%] vs. 70·2% [95% CI: 59·7-80·7], p = 0·014), lower rates of removal for bleeding and/or pain (8·1% vs. 16·2%, p = 0·003) and lower IUD expulsion rates (4·8% vs. 8·9%, p = 0·023), respectively. Interpretation: The NT380-Mini offers important benefits for a nulliparous population compared to the TCu380A in the first twelve months, when pivotal experiences typically occur. Higher continuation rates with the NT380-Mini may avert disruptions in contraceptive use and help users avoid unintended pregnancy. Funding: Bill & Melinda Gates Foundation, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Mona Lisa, N.V. (Belgium).

Mifepristone and Misoprostol for Undesired Pregnancy of Unknown Location.

OBJECTIVE: To compare immediate initiation with delayed initiation of medication abortion among patients with an undesired pregnancy of unknown location. METHODS: This retrospective cohort study used electronic medical record data from the Planned Parenthood League of Massachusetts (2014-2019) for patients who requested medication abortion with a last menstrual period (LMP) of 42 days or less and pregnancy of unknown location (no gestational sac) on initial ultrasonogram. Clinicians could initiate medication abortion with mifepristone followed by misoprostol while simultaneously excluding ectopic pregnancy with serial serum human chorionic gonadotropin (hCG) testing (same-day-start group) or establish a diagnosis with serial hCG tests and repeat ultrasonogram before initiating treatment (delay-for-diagnosis group). We compared primary safety outcomes (time to diagnosis of pregnancy location [rule out ectopic], emergency department visits, adverse events, and nonadherence with follow-up) between groups. We also reported secondary efficacy outcomes: time to complete abortion, successful medication abortion (no uterine aspiration), and ongoing pregnancy. RESULTS: Of 5,619 medication abortion visits for patients with an LMP of 42 days or less, 452 patients had pregnancy of unknown location (8.0%). Three patients underwent immediate uterine aspiration, 55 had same-day start, and 394 had delay for diagnosis. Thirty-one patients (7.9%), all in the delay-for-diagnosis group, were treated for ectopic pregnancy, including four that were ruptured. Among patients with no major ectopic pregnancy risk factors (n=432), same-day start had shorter time to diagnosis (median 5.0 days vs 9.0 days; P=.005), with no significant difference in emergency department visits (adjusted odds ratio [aOR] 0.90, 95% CI 0.43-1.88) or nonadherence with follow-up (aOR 0.92, 95% CI 0.39-2.15). Among patients who proceeded with abortion (n=270), same-day start had shorter time to complete abortion (median 5.0 days vs 19.0 days; P<.001). Of those who had medication abortion with known outcome (n=170), the rate of successful medication abortion was lower (85.4% vs 96.7%; P=.013) and the rate of ongoing pregnancy was higher (10.4% vs 2.5%; P=.041) among patients in the same-day-start group. CONCLUSION: In patients with undesired pregnancy of unknown location, immediate initiation of medication abortion is associated with more rapid exclusion of ectopic pregnancy and pregnancy termination but lower abortion efficacy.

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.

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.

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.

Contraception After Surgical Abortion in Patients With Opioid Use Disorder.

OBJECTIVES: This study describes the prevalence of medications for opioid use disorder (MOUD) among surgical abortion patients, evaluates long-acting reversible contraception (LARC) uptake after surgical abortion among patients on MOUD, and identifies predictors of immediate postabortion LARC uptake among individuals on MOUD. METHODS: We performed a secondary analysis of data from a retrospective observational cohort study of LARC uptake immediately after surgical abortion up to 210/7 weeks gestation at Planned Parenthood League of Massachusetts between October 2012 and April 2017. We estimated proportions and analyzed predictors of LARC uptake among women on MOUD using logistic regression analysis to control for possible confounders. RESULTS: During the study period, 26,858 patients had an abortion procedure; 768 (2.9%; 95% confidence interval, 2.7%-3.1%) used MOUD. In the primary study, controlling for demographic factors, MOUD was not an independent predictor of LARC uptake. In this analysis, patients on MOUD differed demographically from non-MOUD users and were significantly more likely to initiate a LARC method immediately after their procedure: 30.1% versus 25.3% (p = .002), including 22.7% who obtained an intrauterine device and 7.4% who obtained an implant. Among patients on MOUD, a prior live birth and public insurance predicted LARC uptake at the time of abortion. CONCLUSION: Women on MOUD had higher postabortion LARC uptake compared with those not on MOUD in a setting with easy access to postabortion LARC. Public insurance coverage for abortion was associated with LARC uptake among women on MOUD.

State and federal abortion restrictions increase risk of COVID-19 exposure by mandating unnecessary clinic visits.

OBJECTIVE: To quantify the number of medically unnecessary clinical visits and in-clinic contacts monthly caused by US abortion regulations. STUDY DESIGN: We estimated the number of clinical visits and clinical contacts (any worker a patient may come into physical contact with during their visit) under the current policy landscape, compared to the number of visits and contacts if the following regulations were repealed: (1) State mandatory in-person counseling visit laws that necessitate two visits for abortion, (2) State mandatory-ultrasound laws, (3) State mandates requiring the prescribing clinician be present during mifepristone administration, (4) Federal Food and Drug Administration Risk Evaluation and Mitigation Strategy for mifepristone. If these laws were repealed, "no-test" telemedicine abortion would be possible for some patients. We modeled the number of visits averted if a minimum of 15 percent or a maximum of 70 percent of medication abortion patients had a "no-test" telemedicine abortion. RESULTS: We estimate that 12,742 in-person clinic visits (50,978 clinical contacts) would be averted each month if counseling visit laws alone were repealed, and 31,132 visits (142,910 clinical contacts) would be averted if all four policies were repealed and 70 percent of medication abortion patients received no-test telemedicine abortions. Over 2 million clinical contacts could be averted over the projected 18-month COVID-19 pandemic. CONCLUSION: Medically unnecessary abortion regulations result in a large number of excess clinical visits and contacts. POLICY IMPLICATIONS: Repeal of medically unnecessary state and federal abortion restrictions in the United States would allow for evidence-based telemedicine abortion care, thereby lowering risk of SARS-CoV-2 transmission.

Prevalence and predictors of initiation of intrauterine devices and subdermal implants immediately after surgical abortion.

OBJECTIVES: To estimate uptake of long-acting reversible contraception (LARC) methods immediately after surgical abortion in a system that makes these methods readily available, and to determine demographic, medical, social, and visit-specific predictors of immediate post-abortion intrauterine device (IUD) and implant initiation. STUDY DESIGN: We performed a retrospective cohort study of LARC (levonorgestrel intrauterine system [IUS], copper IUD, and subdermal implant) initiation at the time of surgical abortion up to 21w0d gestation at Planned Parenthood League of Massachusetts from 2012 through 2017. We calculated proportions of IUD and implant initiation and used mixed effect logistic regression to estimate predictors of each outcome. RESULTS: Among 26,858 surgical abortion patients, 25.4% received immediate post-abortion LARC: 14.2%, 4.2%, and 7.0% received a levonorgestrel IUS, copper IUD, and implant, respectively. Compared to White women, Black women had lower odds of initiating an IUD (aOR 0.81, 95% CI 0.74-0.89). Multiparous women had greater odds than nulliparous women of initiating an IUD (aOR 1.69, 95% CI 1.57-1.82) or implant (aOR 1.36, 95% 1.20-1.53). We found age was the strongest predictor of implant initiation (<18 versus≥35: aOR 3.26, 95% CI 2.26-4.71), but was not associated with IUD uptake. Gestational age was not associated with IUD or implant uptake. Implant uptake increased from 2.4% (2012) to 8.7% (2017) (aOR 3.65, 95% CI 2.36-5.65) while IUD uptake remained fairly constant. CONCLUSION: About 25% of women chose to initiate intrauterine or implantable contraception immediately after surgical abortion when these methods are readily available. Implant uptake has increased significantly in recent years. Women who initiated IUDs and implants differed in their demographic and social profiles. IMPLICATIONS: Women seeking surgical abortion should have same-day access to IUDs and implants. Clinicians and researchers should analyze IUD and implant initiation separately.

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.

"Without any indication": stigma and a hidden curriculum within medical students' discussion of elective abortion.

Pregnancy termination is a common, beneficial medical procedure, but abortion care in the United States is stigmatized. Language, including categorization of some abortions as elective, may both reflect and convey stigma. We present a history of the term "elective" in reference to abortion, followed by data demonstrating its use by a sample of contemporary medical trainees and an analysis of the term's relationship to abortion stigma, medical training, and patient access to abortion care. We analyzed interviews with 41 U.S. medical students who had applied to residency programs in obstetrics and gynecology. Participants discussed experiences with, and attitudes toward, abortion before and during medical school, and plans to perform abortions in future practice. We inductively coded participants' use of "elective" in reference to abortion and analyzed their meanings. Participants did not use "elective" according to its medical definition, which conveys an absence of urgency for surgery. Instead, "elective" identified a subset of abortions that lacked maternal or fetal medical indications. "Elective" negatively marked and isolated some abortions, and participants used the term to convey judgment about patients' social and reproductive histories. Participants saw medical and psychosocial indications as mutually exclusive, and became confused when interrelated factors influenced patients' abortion decisions. They ignored the voluntary nature of abortion in the setting of medical illness, sexual violence, or fetal complications, and accepted discrimination against women seeking abortion for psychosocial indications as normal and ethical. The term "elective" enables the creation and perpetuation of abortion stigma, and contributes to a hidden curriculum for abortion training in medical education that distracts from core content, incorporates social judgment of patients into medical practice, and promotes normative gender concepts. Our findings support calls to improve the language of abortion care to ensure policies and training environments are consistent with professional standards.