Making a third-trimester abortion referral: Learning from patients.

OBJECTIVES: Research on abortion referral practices has focused on referral to first-trimester abortion care. Research has not examined whether and how these recommendations apply to referrals for abortion later in pregnancy. METHODS: We conducted a secondary analysis of semi-structured interviews with thirty third-trimester abortion patients of their experiences of referral from prenatal and/or pre-third-trimester abortion care. We used thematic coding to identify referral-related actions participants desired or wished providers would avoid. RESULTS: Participants reported needs in referral for information that third-trimester abortion was a possibility and about third-trimester providers and funding resources. Several also reported a need for emotional support from the prenatal or abortion care provider who denied them abortion care. CONCLUSIONS: Many factors important for first-trimester abortion referral are important in third-trimester abortion referral, but the specifics of third-trimester care (namely the paucity of clinics, need for travel, and possibility of strong emotional attachment to the pregnancy) require additional practice actions. PRACTICE IMPLICATIONS: Providers can support their patients in need of third-trimester abortion care by proactively providing: information that third-trimester abortion is available; information on third-trimester providers and funding support (e.g., an abortion referral hotline); and clear, non-judgmental emotional support.

Mifepristone-misoprostol versus misoprostol-alone regimen for medication abortion at ≥24 weeks' gestation.

OBJECTIVE: To compare time from misoprostol initiation to fetal expulsion for mifepristone-misoprostol versus misoprostol-alone regimens of medication abortion performed at ≥24 weeks' gestation. STUDY DESIGN: We conducted a retrospective study of medication abortion performed at ≥24 weeks' gestation between May 2016 and January 2018 at one site, comparing outcomes of patients receiving mifepristone-misoprostol versus misoprostol alone during two periods. All patients received feticidal injection and laminaria; the mifepristone-misoprostol group also received mifepristone 200 mg orally around the time of initial laminaria. Beginning 24-72 h later (depending on cervical assessment), both groups received misoprostol buccally every two hours. RESULTS: Analyses included 257 patients in the mifepristone-misoprostol group and 152 patients in the misoprostol-alone group. Median time from misoprostol initiation to fetal expulsion was similar between groups (4.8 h vs. 4.9 h; p = 0.43). Patients in the mifepristone-misoprostol group received less misoprostol overall (median [IQR]: 800 mcg [800-1200 mcg] vs. 1200 mcg [800-1600 mcg]; p < 0.01) and fewer patients received a second round of laminaria (n = 56, 22% vs. n = 58, 33%; p < 0.01) than the misoprostol-alone group. Seven patients (2%) were transferred to a hospital for complications; this proportion did not vary by regimen. CONCLUSIONS: Addition of mifepristone was not associated with a reduction in induction interval at ≥24 weeks. However, patients in the mifepristone-misoprostol group received a lower total dose of misoprostol and were less likely to require two days of laminaria. The clinical significance of these differences is unclear, but may have implications for patient experience. Both regimens had low rates of complications. IMPLICATIONS: A randomized controlled trial comparing the mifepristone-misoprostol and misoprostol-alone regimens at ≥24 weeks is needed, as is evidence on patient perspectives on these regimens. Given the existing evidence, either regimen is reasonable.