Strengthening regional commitment to ensuring access to medical abortion medicines in WHO's South-East Asia region: report of a participatory assessment and workshop.

BACKGROUND: In 2019, the World Health Organization identified improving access to safe abortion as an important priority toward improving sexual and reproductive health and rights and achieving Sustainable Development Goals. One strategy for addressing this priority is strengthening access to medicines for medical abortion. All 11 countries in the South-East Asia Region have some indications for legal abortion and permit post-abortion care. Therefore, strengthening access to medical abortion medicines is a reasonable strategy for improving access to safe abortion for the Region. METHODOLOGY: We applied an adapted version of an existing World Health Organization landscape assessment protocol for the availability of medical abortion medicines at the country-level in the South-East Asia Region. We collected publicly available data on the existence of national health laws, policies, and standard treatment guidelines; inclusion of medical abortion medicines in the national essential medicines list; and marketing authorization status for medical abortion medicines for each country and verified by Ministries of health. The findings were once more presented, discussed and recommendations were formulated during regional technical consultation workshop. Each country teams participated in the process, and subsequently, the suggestions were validated by representatives from Ministries of Health.. RESULTS: Few countries in the Region currently have national policies and guidelines for comprehensive safe abortion. However, either mifepristone-misoprostol in combination or misoprostol alone (for other indications) is included in national essential medicines lists in all countries except Indonesia and Sri Lanka. Few countries earmark specific public funds for procuring and distributing medical abortion commodities. In countries where abortion is legal, the private sector and NGOs support access to medical abortion information and medicines. Several countries only allow registered medical practitioners or specialists to administer medical abortion. CONCLUSION: Following this rapid participatory assessment and technical consultation workshop, the World Health Organization South-East Asia Regional Technical Advisory and Sexual and Reproductive Health and Rights technical committee recommended priority actions for policy and advocacy, service delivery, and monitoring and evaluation, and indicated areas for support.

Telehealth Medication Abortion in Primary Care: A Comparison to Usual in-Clinic Care.

INTRODUCTION: Providing abortion in primary care expands access and alleviates delays. The 2020 COVID-19 public health emergency (PHE) led to the expansion of telehealth, including medication abortion (MAB). This study evaluates the accessibility of novel telehealth MAB (teleMAB) initiated during the PHE, with the lifting of mifepristone restrictions, compared with traditional in-clinic MAB offered before the PHE at a Massachusetts safety-net primary care organization. METHODS: We conducted a retrospective electronic medical record review of 267 MABs. We describe sociodemographic, care access, and complete abortion characteristics and compare differences between teleMAB and in-clinic MABs using Chi-squared test, fisher's exact test, independent t test, and Wilcoxon rank sum. We conducted logistic regression to examine differences in time to care (6 days or less vs 7 days or more). RESULTS: 184 MABs were eligible for analysis (137 in-clinic, 47 teleMAB). Patients were not significantly more likely to receive teleMAB versus in-clinic MAB based on race, ethnicity, language, or payment. Completed abortion did not significantly differ between groups (P = .187). Patients received care more quickly when accessing teleMAB compared with usual in-clinic MAB (median 3 days, range 0 to 20 vs median 6 days, range 0 to 32; P < . 001). TeleMAB patients had 2.29 times the odds of having their abortion appointment within 6 days compared with in-clinic (95% CI: 1.13, 4.86). CONCLUSION: TeleMAB in primary care is as effective, timelier, and potentially more accessible than in-clinic MAB when in-person mifepristone regulations were enforced. TeleMAB is feasible and can promote patient-centered and timely access to abortion care.

Abortion pills on TV: An exploratory study of the associations between abortion plotline viewership and beliefs regarding in-clinic and self-managed medication abortion.

OBJECTIVES: Entertainment television is an influential source of health information, including about reproductive health. We investigated the association between exposure to television plotlines about medication abortion on audience awareness and beliefs about medication abortion. STUDY DESIGN: We administered a national cross-sectional online survey from December 2021 to January 2022 with a probability-based sample of people assigned female at birth. We asked respondents to select plotlines they had seen from a list of seven that portrayed medication abortion. Among the 3425 people who responded to plotline items, 3340 responded to our outcome measures. Using weighed multivariable analyses, we examined adjusted relationships between exposure to specific types of abortion plotlines and awareness of and beliefs about medication abortion medical safety. RESULTS: We found that audience exposure to medication abortion plotlines in which the medication abortion was obtained from a clinic and portrayed as safe was associated with greater awareness of medication abortion compared to nonexposure (RR: 1.68; 95% CI: 1.17, 2.40). Exposure to plotlines that portrayed MA or self-managed MA as safe was associated with audience beliefs that medication abortion is safe. CONCLUSIONS: This study demonstrates that the content of abortion plotlines and exposure to accurate information may be connected to audience awareness of and beliefs about abortion. IMPLICATIONS: In a climate of misinformation about abortion, audience exposure to medically accurate television plotlines about medication abortion may be an effective way to increase awareness of medication abortion and influence beliefs about medication abortion safety.

Deception by obfuscation: Studnicki et al.'s retracted longitudinal cohort study of emergency room utilization following abortion.

OBJECTIVES: In November 2022, the anti-abortion advocacy group Alliance for Hippocratic Medicine filed a lawsuit against the U.S. Food and Drug Administration challenging the initial 2000 approval of mifepristone and its subsequent approvals, which removed unnecessary restrictions on its use, by disputing the medication's safety record. Such challenges relied on a study examining the incidence of emergency room visits following medication abortion with mifepristone and procedural abortion using Medicaid claims data from 1999-2015. In February 2024 that study was retracted by its publisher. In this paper, we analyzed the methods and presentations of the data used in the study. STUDY DESIGN: We drew upon commonly accepted principles in responsible epidemiologic and scientific research to evaluate the methods and presentations of the data and organized our findings into themes. RESULTS: We found multiple instances of methodological flaws, mischaracterizations, and obfuscations of data in this study, including use of a misleading research question and framing, analytic flaws, inappropriate use of an unvalidated proxy measure for outcomes of interest, and inappropriate and deceptive visualizations of data. In each instance, the resulting effect obfuscated and misrepresented the safety of medication abortion with mifepristone. CONCLUSIONS: The misrepresentation and exaggeration of data promoted and exacerbated misinterpretations about the study's findings, resulting in substantial harm before it was retracted. Recognizing that ongoing judicial proceedings threaten access to conventional reproductive health care in the United States, public health policies must be informed by scientific and medical literature that is comprehensive, methodologically sound, and absent any obfuscations or misrepresentations. IMPLICATIONS: Studnicki et al.'s study of emergency room visits after abortion misrepresented the safety of mifepristone with multiple instances of methodological flaws and obfuscations of data. While the study has now been retracted, it led to irrevocable harm, threatening access to medication abortion, which has an established safety record.

The FDA in the Crosshairs-Science, Politics, and Abortion.

In this Viewpoint, the Supreme Court case FDA v AHM is used to illustrate the tension the FDA faces between science and politics, and state authority over abortion vs federal authority over which drugs may be marketed nationwide.

Provision of Medications for Self-Managed Abortion Before and After the Dobbs v Jackson Women's Health Organization Decision.

Importance: The Supreme Court decision in Dobbs v Jackson Women's Health Organization overturned the right to choose abortion in the US, with at least 16 states subsequently implementing abortion bans or 6-week gestational limits. Prior research indicates that in the 6 months following Dobbs, approximately 32 360 fewer abortions were provided within the US formal health care setting. However, trends in the provision of medications for self-managed abortion outside the formal health care setting have not been studied. Objective: To determine whether the provision of medications for self-managed abortion outside the formal health care setting increased in the 6 months after Dobbs. Design, Setting, and Participants: Cross-sectional study using data from sources that provided abortion medications outside the formal health care setting to people in the US between March 1 and December 31, 2022, including online telemedicine organizations, community networks, and online vendors. Using a hierarchical bayesian model, we imputed missing values from sources not providing data. We estimated the change in provision of medications for self-managed abortion after the Dobbs decision. We then estimated actual use of these medications by accounting for the possibility that not all provided medications are used by recipients. Exposure: Abortion restrictions following the Dobbs decision. Main Outcomes and Measures: Provision and use of medications for a self-managed abortion. Results: In the 6-month post-Dobbs period (July 1 to December 31, 2022), the total number of provisions of medications for self-managed abortion increased by 27 838 (95% credible interval [CrI], 26 374-29 175) vs what would have been expected based on pre-Dobbs levels. Excluding imputed data changes the results only slightly (27 145; 95% CrI, 25 747-28 246). Accounting for nonuse of medications, actual self-managed medication abortions increased by an estimated 26 055 (95% CrI, 24 739-27 245) vs what would have been expected had the Dobbs decision not occurred. Conclusions and Relevance: Provision of medications for self-managed abortions increased in the 6 months following the Dobbs decision. Results suggest that a substantial number of abortion seekers accessed services despite the implementation of state-level bans and restrictions.

Understanding the Impacts of the Supreme Court Case FDA v Alliance for Hippocratic Medicine.

This Viewpoint outlines the potential effects of the Supreme Court case regarding mifepristone restrictions: a decision for the FDA would allow current dispensing, while ruling against the FDA would severely curtail access to reproductive health options.

Why are plants named after witches and devils in north-western Europe?

ETHNOPHARMACOLOGICAL RELEVANCE: Witches in Western Europe are associated with the use of medicinal, abortifacient, hallucinogenic, and toxic plants. Curiously, these associations are not backed up by first-hand evidence and historians are unconvinced that people convicted as witches were herbalists. Local plant names provide an untapped source for analysing witchcraft-plant relationships. AIM OF THE STUDY: We analysed vernacular plant names indicating an association with witches and devils to find out why these species and witchcraft were linked. MATERIALS AND METHODS: We constructed a database with vernacular names containing the terms witch and devil in related north-west European languages. The devil was added because of its association with witchcraft. The plant species' characteristics (e.g., medicinal use, toxicity) were assessed to determine if there were non-random associations between these traits and their names. RESULTS: We encountered 1263 unique vernacular name-taxa combinations (425 plant taxa; 97 families). Most species named after witches and/or devils were found within the Asteraceae, Ranunculaceae, and Rosaceae. For Dutch, German and English we confirmed associations between witchcraft names and toxicity. Hallucinogenic plants do not appear to be associated with witch-names. For Dutch, we found significant associations between plant names and medicinal and apotropaic uses, although we did not find any association with abortifacient qualities. CONCLUSIONS: This study demonstrates that there is a wide variety of plants associated with witches and the devil in north-western Europe. Plant names with the terms witch and devil were likely used in a pejorative manner to name toxic and weedy plants, and functioned as a warning for their harmful properties. Our study provides novel insights for research into the history of witchcraft and its associated plant species.

Enhancing bovine abortion surveillance: A learning experience.

Abortions and perinatal mortalities (APM) substantially affect cattle industry efficiency. Various infectious and noninfectious factors have been associated with bovine APM worldwide. Infections are often considered pivotal due to their abortifacient potential, leading laboratories to primarily investigate relevant infectious agents for APM cases. Some infectious causes, such as Brucella abortus, have also a zoonotic impact, necessitating monitoring for both animal and human health. However, underreporting of bovine APM is a global issue, affecting early detection of infectious and zoonotic causes. Previous studies identified factors influencing case submission, but regional characteristics may affect results. In Belgium, farmers are obliged to report cases of APM within the context of a national brucellosis monitoring program. The inclusion criteria for this monitoring program cover abortions (gestation length of 42-260 d) and perinatal mortalities of (pre)mature calves following a gestation length of more than 260 d, which were stillborn or died within 48 h after birth. The objective of the present study was to describe the evolution in submission of APM cases within a mandatory abortion monitoring program in relation to subsidized initiatives in the northern part of Belgium. Based on the proportion of APM submissions versus the proportion of bovine reproductive females, an APM proportion (APMPR) was calculated, and factors at both animal and herd level that may influence this APMPR were explored by using linear models. This evaluation revealed that the APMPR increased with the introduction of an extensive analytical panel of abortifacient agents and a free on-farm sample collection from 0.44% to 0.94%. Additionally, an increase of the APMPR was associated with an outbreak of an emerging abortifacient pathogen (Schmallenberg virus; 1.23%), and the introduction of a mandatory eradication program for bovine viral diarrhea virus (BVDv; 1.20%). The APMPR was higher in beef compared with dairy cattle, and it was higher in winter compared with fall, spring, and summer. Smaller herds categorized in the first quartile had a higher APMPR compared with larger herds. Herds that submitted an APM in the previous year had a higher APMPR in the next year compared with herds without an APM submission. Finally, herds for which there was evidence of the presence of BVDv had a higher APMPR compared with herds without evidence of the presence of BVDv. In conclusion, the number of APM submissions increased after the introduction of a free on-farm sample collection and an extensive pathogen screening panel. Production type (beef), season (winter), smaller herd size, previous APM, and presence of BVDv seemed to have a positive effect on APMPR. However, even under mandatory circumstances, APM still seems to be underreported, since the APMPR was lower than the expected minimal rate of 2%. Therefore, further research is necessary to identify the drivers that convince farmers to submit APM cases to improve submission rates and ensure an efficient monitoring program for APM and eventually associated zoonotic pathogens.

Explaining the Fifth Circuit Court of Appeals Ruling on Mifepristone Access.

This Viewpoint summarizes the Fifth Circuit Court of Appeals ruling on access to mifepristone, the first of 2 pills used in medication abortion.

Effectiveness and safety of misoprostol-only for first-trimester medication abortion: An updated systematic review and meta-analysis.

OBJECTIVES: This study aimed to update our 2019 systematic review of data on the effectiveness and safety of misoprostol-only for first-trimester abortion. STUDY DESIGN: We searched PubMed on December 18, 2022, to find published articles describing the outcomes of treatment with misoprostol-only for abortion of viable intrauterine pregnancy at ≤91 days of gestation. From each article identified, two authors independently abstracted relevant data about each group of patients treated with a distinct regimen. We assessed the risk of bias using four defined indicators. We estimated the proportion of patients with treatment failure using meta-analytic methods as well as the proportion hospitalized or transfused after treatment. We examined associations between treatment failure and selected characteristics of the groups. RESULTS: We identified 49 papers with 66 groups that collectively included 16,354 evaluable patients, of whom 2960 (meta-analytic estimate 15%, 95% CI 12%, 19%) had treatment failures. Of 9228 patients assessed for ongoing pregnancy after treatment, 521 (meta-analytic estimate 6%, 95% CI 5%, 8%) had that condition. Failure risk was significantly associated with misoprostol dose, the total allowed number of doses, the maximum duration of dosing, and certain indicators of risk of bias. Among 11,007 patients allowed to take at least three misoprostol doses, the first consisting of misoprostol 800 mcg administered vaginally, sublingually, or buccally, the meta-analytic estimate of the failure risk was 11% (95% CI 8%, 14%). At most, 0.2% of 15,679 evaluable patients were hospitalized or received transfusions. CONCLUSIONS: Although some studies in this updated review were adjudicated to have a high risk of bias, the results continue to support the key conclusion of our 2019 analysis: misoprostol-only is effective and safe for the termination of first-trimester intrauterine pregnancy. IMPLICATIONS: Misoprostol-only is a safe and effective option for medication abortion in the first trimester if mifepristone is unavailable or inaccessible.

A novel multiplex qPCR­HRM assay for the simultaneous detection of four abortive zoonotic agents in cattle, sheep, and goats.

Abortifacient pathogens induce substantial economic losses in the livestock industry worldwide, and many of these pathogens are zoonotic, impacting human health. As Brucella spp., Coxiella burnetii, Leptospira spp., and Listeria monocytogenes cause abortion, rapid differential molecular diagnostic tests are needed to facilitate early and accurate detection of abortion to establish effective control measures. However, the available molecular methods are laborious, time-consuming, or costly. Therefore, we developed and validated a novel multiplex real-time polymerase chain reaction (qPCR) method based on high-resolution melting (HRM) curve analysis to simultaneously detect and differentiate four zoonotic abortifacient agents in cattle, goats, and sheep. Our HRM assay generated four well-separated melting peaks allowing the differentiation between the four zoonotic abortifacients. Out of 216 DNA samples tested, Brucella spp. was detected in 45 samples, Coxiella burnetii in 57 samples, Leptospira spp. in 12 samples, and Listeria monocytogenes in 19 samples, co-infection with Brucella spp. and Coxiella burnetii in 41 samples, and 42 samples were negative. This assay demonstrated good analytical sensitivity, specificity, and reproducibility. This is a valuable rapid, cost-saving, and reliable diagnostic tool for detecting individual and co-infections for zoonotic abortifacient agents in ruminants.

Survey of colleges and schools of pharmacy to determine restrictions for teaching, research, and advocacy related to contraception.

INTRODUCTION: The pharmacist's role in reproductive health is evolving. Since 46 states allow providers to refuse to provide reproductive health services, it is important to consider whether learning is impacted by institution restrictions on contraception teaching, advocacy, and research. METHODS: An electronic survey was emailed to deans of all pharmacy schools on the American Association of Colleges of Pharmacy Institutional Membership list with a request to share with faculty teaching women's health content within their curriculum. The survey collected information about contraception teaching, research, and advocacy. RESULTS: Of 145 schools contacted, 39 (27%) provided complete responses. Of these, 22 (56%) were public, not religiously-affiliated, seven (18%) were private, not religiously-affiliated, six (15%) were private, currently religiously-affiliated, and four were (10%) private, historically religiously-affiliated. All respondents taught hormonal contraception in the required curriculum and 15 (39%) taught miscarriage management/abortifacients. None reported restrictions on contraception teaching or research. One respondent cited an advocacy restriction for contraception methods due to violation of the school's beliefs, and another cited an advocacy restriction for miscarriage management/abortifacients. Respondents noted students expressed ethical questions/concerns about refusing to dispense contraception (59%), dispensing certain contraceptives (54%), dispensing to minors (46%), and dispensing all contraceptives (21%). Additionally, respondents reported pharmacists/faculty expressed ethical questions/concerns about refusing to dispense contraception (31%), dispensing to minors (21%), dispensing certain contraceptives (15%), and all contraceptives (13%). CONCLUSIONS: Overall, respondents reported no restrictions in contraception teaching and scholarship and minimal advocacy restrictions. Faculty should consider ethical questions/concerns from students, faculty, and pharmacists when teaching this material.

Causes of pregnancy arrest in the canine species.

In the canine species, early pregnancy arrest before 30-40 days of pregnancy will induce intra-uterine embryonic or foetal resorption, with very few clinical signs. If no genital examination by ultrasound is performed at that time, it will often remain unnoticed and the bitch will be qualified as infertile. It is only when pregnancy stops at a later stage, mostly after 40 days, that clinical signs will be seen. Expulsion of aborted foetuses or placentas may be observed, although the dam frequently eats the expelled tissues. Intra-uterine mummification may also occur. This article reviews the causes of pregnancy termination in the bitch, both at the embryonic and the foetal stages, reported in the literature. Canine brucellosis is by far the most important disease concerned in this aspect. There is an important current concern about this disease, due to the fact that several outbreaks have been observed recently in Europe, and that it is a very contagious disease; it may be an underestimated zoonosis. Other bacterial causes of pregnancy arrest are sporadic. There is, however, a growing attention towards the microbiological content of raw food diets which are more and more popular among dog breeders and may-if badly prepared-contain abortifacient bacteria such as Campylobacter jejuni or Listeria monocytogenes. The abortifacient role of endogenous vaginal bacteria and mycoplasms remains unclear and may be related to an imbalanced vaginal flora with subsequent ascending bacterial contamination of the uterus. The role of Canine Herpesvirus on abortion is controversial and probably not frequent. Other viruses have been shown experimentally to induce abortion but their natural occurrence in this respect remains unknown. The same applies to the parasite Neospora caninum which is suspected, but not proven, potentially to induce pregnancy arrest in bitches. Among non-infectious causes, uterine pathology such as cystic endometrial hyperplasia (CEH) or sub-clinical post-mating endometritis which can cause infertility and may also induce embryonic resorption. The role of luteal insufficiency in pregnancy arrest is probably overestimated.