"Who is driving you home today?" Escort policies as a barrier to abortion access.

Post-sedation escort policies are not evidence-based but traditional consensus recommendations made by professional societies. As people travel further for abortion care, escort policies are increasingly difficult to navigate and force people to delay care, compromise privacy, or undergo procedures without sedation. At worst, clinics may turn away people who present without an escort. Recent research shows that patients can be discharged safely after sedation using rideshare or transport services without a known escort. Updating escort policies lowers barriers to abortion and preserves autonomy, comfort, and choice.

The future of abortion is now: Mifepristone by mail and in-clinic abortion access in the United States.

The COVID-19 pandemic disrupted health care delivery in all aspects of medicine, including abortion care. For 6 months, the mifepristone Risk Evaluation and Mitigation Strategy (REMS) was temporarily blocked, allowing for the remote provision of medication abortion. Remote medication abortion may become a dominant model of care in the future, either through the formal health system or through self-sourced, self-managed abortion. Clinics already face pressure from falling abortion rates and excessive regulation and with a transition to remote abortion, may not be able to sustain services. Although remote medication abortion improves access for many, those who need or want in-clinic care such as people later in pregnancy, people for whom abortion at home is not safe or feasible, or people who are not eligible for medication abortion, will need comprehensive support to access safe and appropriate care. To understand how we may adapt to remote abortion without leaving people behind, we can look outside of the U.S. to become familiar with emerging and alternative models of abortion care.

Trends in medication abortion provision before and after the introduction of mifepristone: A study of the National Abortion Federation's Canadian member services.

OBJECTIVE: We analyzed trends in medication abortion provision before and after the 2017 introduction of mifepristone in Canada. METHODS: We reviewed 2016-2018 abortion services data from Canadian members of the National Abortion Federation (NAF) to determine the overall proportion of medication abortions in each calendar year as well as temporal and geographic trends in provision. RESULTS: In 2016, NAF's Canadian members reported on 33,857 abortions of which 2,844 (8.4%) were with medications and used a methotrexate/misoprostol regimen. In 2018, 8,534 (25.6%) of the 33,320 reported abortions were with mifepristone/misoprostol. DISCUSSION: Mifepristone/misoprostol has been rapidly incorporated into abortion services in Canada.

Abortion through telemedicine.

PURPOSE OF REVIEW: Medical abortion offers a well tolerated and effective method to terminate early pregnancy, but remains underutilized in the United States. Over the last decade, 'telemedicine' has been studied as an option for medical abortion to improve access when patients and providers are not together. A number of studies have explored various practice models and their feasibility as an alternative to in-person service provision. RECENT FINDINGS: A direct-to-clinic model of telemedicine medical abortion has similar efficacy with no increased risk of significant adverse events when compared with in-person abortion. A direct-to-consumer model is currently being studied in the United States. International models of direct-to-consumer medical abortion have shown promising results. SUMMARY: The introduction of telemedicine into abortion care has been met with early success. Currently, there are limitations to the reach of telemedicine because of specific restrictions on mifepristone in the United States as well as laws that specifically prohibit telemedicine for abortion. If these barriers are removed, telemedicine can potentially increase abortion access.

What contraception do women use after abortion? An analysis of 319,385 cases from eight countries.

Contraception is an essential element of high-quality abortion care. However, women seeking abortion often leave health facilities without receiving contraceptive counselling or methods, increasing their risk of unintended pregnancy. This paper describes contraceptive uptake in 319,385 women seeking abortion in 2326 public-sector health facilities in eight African and Asian countries from 2011 to 2013. Ministries of Health integrated contraceptive and abortion services, with technical assistance from Ipas, an international non-governmental organisation. Interventions included updating national guidelines, upgrading facilities, supplying contraceptive methods, and training providers. We conducted unadjusted and adjusted associations between facility level, client age, and gestational age and receipt of contraception at the time of abortion. Overall, postabortion contraceptive uptake was 73%. Factors contributing to uptake included care at a primary-level facility, having an induced abortion, first-trimester gestation, age ≥25, and use of vacuum aspiration for uterine evacuation. Uptake of long-acting, reversible contraception was low in most countries. These findings demonstrate high contraceptive uptake when it is delivered at the time of the abortion, a wide range of contraceptive commodities is available, and ongoing monitoring of services occurs. Improving availability of long-acting contraception, strengthening services in hospitals, and increasing access for young women are areas for improvement.

What can obstetrician/gynecologists do to support abortion access?

Unsafe abortion causes approximately 13% of all maternal deaths worldwide, with higher rates in areas where abortion access is restricted. Because safe abortion is so low risk, if all women who needed an abortion could access safe care, this rate would drop dramatically. As women's health providers and advocates, obstetrician/gynecologists can support abortion access. By delivering high-quality, evidence-based care ourselves, supporting other providers who perform abortion, helping women who access abortion in the community, providing second-trimester care, and improving contraceptive uptake, we can decrease morbidity and mortality from unsafe abortion.

Does the type of abortion provider influence contraceptive uptake after abortion? An analysis of longitudinal data from 64 health facilities in Ghana.

BACKGROUND: Understanding what factors influence the receipt of postabortion contraception can help improve comprehensive abortion care services. The abortion visit is an ideal time to reach women at the highest risk of unintended pregnancy with the most effective contraceptive methods. The objectives of this study were to estimate the relationship between the type of abortion provider (consultant physician, house officer, or midwife) and two separate outcomes: (1) the likelihood of adopting postabortion contraception; (2) postabortion contraceptors' likelihood of receiving a long-acting and permanent versus a short-acting contraceptive method. METHODS: We used retrospective cohort data collected from 64 health facilities in three regions of Ghana. The dataset includes information on all abortion procedures conducted between 1 January 2008 and 31 December 2010 at each health facility. We used fixed effect Poisson regression to model the associations of interest. RESULTS: More than half (65 %) of the 29,056 abortion clients received some form of contraception. When midwives performed the abortion, women were more likely to receive postabortion contraception compared to house officers (RR: 1.18; 95 % CI: 1.13, 1.24) or physicians (RR: 1.21; 95 % CI: 1.18, 1.25), after controlling for facility-level variation and client-level factors. Compared to women seen by house officers, abortion clients seen by midwives and physicians were more likely to receive a long-acting and permanent rather than a short-acting contraceptive method (RR: 1.46; 95 % CI: 1.23, 1.73; RR: 1.58; 95 % CI: 1.37, 1.83, respectively). Younger women were less likely to receive contraception than older women irrespective of provider type and indication for the abortion (induced or PAC). CONCLUSIONS: When comparing consultant physicians, house officers, and midwives, the type of abortion provider is associated with whether women receive postabortion contraception and with whether abortion clients receive a long-acting and permanent or a short-acting method. New strategies are needed to ensure that women seen by physicians and house officers can access postabortion contraception and to ensure that women seen by house officers have access to long-acting and permanent contraceptive methods.

Second-trimester postabortion care for ruptured membranes, fetal demise, and incomplete abortion.

BACKGROUND: Guidance for postabortion care (PAC) is established for the first trimester but limited in the second trimester. OBJECTIVES: To establish evidence-based recommendations for PAC in the second trimester. SEARCH STRATEGY: Medline, POPLINE, and the Cochrane Central Register of Controlled Trials were searched with terms related to second-trimester PAC, including fetal demise, ruptured membranes, and incomplete abortion. The reference lists of retrieved articles were also searched. SELECTION CRITERIA: Clinical trials and comparative studies of women presenting in the second trimester (12-28weeks) were included if more than 50% of participants met PAC criteria or if outcomes for PAC were analyzed separately. DATA COLLECTION AND ANALYSIS: Data were extracted from included studies. When interventions in at least two articles were comparable, a meta-analysis was performed. MAIN RESULTS: Overall, 17 studies of 1419 women met inclusion criteria. Misoprostol given vaginally, sublingually, or buccally was associated with shorter expulsion times than was oral misoprostol. Additionally, 200µg of misoprostol was more effective than lower doses. Pretreatment with mifepristone decreased expulsion time. Misoprostol was more effective than oxytocin. CONCLUSION: Misoprostol with or without mifepristone is an effective treatment for second-trimester PAC. The minimum misoprostol dose is 200µg vaginally, sublingually, or buccally every 6-12hours.

One-year continuation of the etonogestrel contraceptive implant in women with postabortion or interval placement.

BACKGROUND: Our study investigated whether women with etonogestrel implant placement in the immediate postabortion period have similar continuation rates to women with interval placement. STUDY DESIGN: This is a prospective cohort study of women at Boston Medical Center. We compared 1-year continuation rates in women who had immediate postabortion placement to interval placement using Cox proportional hazard models. RESULTS: One hundred five women were enrolled, 53 in the abortion and 52 in the interval group. There were two losses to follow-up leaving 103 women for analysis. The overall 1-year continuation rate was 74.8%, with 68.6% postabortion continuation and 80.8% interval continuation. The risk of discontinuation in women with postabortion placement was higher but not statistically different than women with interval placement (unadjusted hazard ratio: 1.79, 95% confidence interval: 0.81-3.96). CONCLUSION: Overall etonogestrel implant continuation was acceptable with similar rates for postabortion and interval placement. For women who want a contraceptive implant after an abortion, immediate placement should be available.