“We just need to create as many avenues for access as we possibly can”: Clinician and administrator attitudes toward telehealth medication abortion in the U.S. South

Medical abortion is fundamental to women's health care. It provides a safe and effective alternative to early surgical abortion and can occur in the privacy of a woman's home. Compared to European countries and the United States (US), access to medical abortion in Australia has been a recent development, as prior to 2013 use of mifepristone was severely restricted and only available under the Authorised Prescriber provisions of the Therapeutic Goods Act 1989 to the few clinicians who applied for it.1 In 2015 a composite pack of mifepristone and misoprostol, sponsored by MS Health, a subsidiary of Marie Stopes International (MSI), became available for use up to 63 days gestation. The study by Goldstone et al.2 in this issue of ANZJOG, documents the recent clinical experience of 15 008 Australian women who sought abortion up to a gestation of 63 days and received the regimen of 200 mg of oral mifepristone followed 24–48 h later by 800 μg misoprostol self-administered buccally at home. This followed a previous study by the same lead author which detailed the outcomes of 13 345 early medical abortions between 2009 and 2011.3 The combined regimen of mifepristone, followed 36–48 h later by the prostaglandin E1 analogue misoprostol, is now well established as both safe and effective for gestations up to 63 days and the Goldstone paper adds to the extensive international evidence. Studies on the use of mifepristone in over 400 000 women have reported that the rates of serious adverse events, including hospital admission, blood transfusion, or significant infection, range from 0.01 to 0.7%, and that these events are almost always treatable without long-term sequelae.4, 5 Common side effects such as bleeding, cramping, fever and chills are generally minor and transitory.5 There have been a small number of deaths worldwide attributable to the use of mifepristone related to post-abortion sepsis with a rare organism, Clostridium sordellii.6 While not diminishing the significance of these deaths, the mortality risk for both medical and surgical abortion is substantially lower than continuing a pregnancy to term.7 The Goldstone study is one of the largest published cohorts and confirms previous findings with high method success (95.16%), low rates of infection (0.11%) or haemorrhage requiring transfusion (0.13%). No link could be confirmed between the one death that occurred as a result of Streptococcal pyogenes-related necrotising pneumonia and mifepristone administration. In countries where mifepristone has been available for some time, around half of all women choose medical over surgical abortion and the few randomised trials that have been undertaken show comparable acceptability of both methods.8 Irrespective of whether misoprostol (following mifespristone administration) is administered in a public hospital/clinic or in a private setting,9 most international studies report that around 90% of women who undergo medical abortion would, if required, choose the method again or would recommend it to a friend.10 Overall acceptability varies with parity (lower in nulliparous than in parous women), gestational age (reduces as gestational age increases) and according to the amount of pain and bleeding experienced.11, 12 Despite the fact that abortion is one of the most commonly performed gynaecological procedures in Australia and that approximately one in four women will have an abortion in their lifetime,13 the availability of medical abortion in Australia, however positive a development, has not reduced some of the barriers to access faced by many women. As a result of law reform in six of eight Australian jurisdictions, abortion can be performed lawfully subject to various conditions in these jurisdictions but it has been fully decriminalised only in the Australian Capital Territory. Abortion remains a crime in New South Wales (NSW) and Queensland and can only be performed lawfully at all as a result of case law permitting abortion where it is necessary to prevent serious risk to the life or health of the woman. Australian research has consistently indicated that 70–80% of the public support a woman's right to access abortion and believe it should be lawful.14, 15 Practitioners report that the current complex and varied legal status of abortion across Australia has a significant impact on service provision and compromises patient care.16, 17 Regardless of legal status and public opinion, access in most states and territories is complicated by the costs of largely private provision and lack of access for women in rural regions where few private services operate. Women are often required to pay for the costs of an abortion ‘upfront’ and if they live at a distance which necessitates extensive travel and an overnight stay near the abortion clinic, costs can be prohibitive.18 Of the 80 000 estimated abortions in Australia each year, most occur in the private sector.18-20 In several states, including the most populous state of NSW, public access to abortion is extremely limited. Public hospitals have abrogated responsibility for abortion service provision, leaving the private sector, including independent abortion clinics and a small number of motivated general practitioners (GPs), to fill the need. Although private services provide high-quality medical care, they can be costly and out of financial reach for some women. While costs vary, particularly with the introduction of newer services, a recent study of women attending a service provider reported the median out of pocket cost for a medical abortion as $560 and more than two-thirds (68.1%) of women had to rely on financial assistance from two or more sources.18 Compared to women from urban areas, women who had to travel for four or more hours to a city-based clinic were significantly more likely to present later than nine weeks gestation which made them more often ineligible to choose medical abortion. This group of women were also more likely to identify as Aboriginal and/or Torres Strait Islander, report less knowledge of medical abortion and have greater difficulty paying for the procedure. These results indicate that the potential for medical abortion to improve equitable access to abortion services will remain limited unless geographical, knowledge and financial impediments to obtaining early care are reduced.18 Many of these barriers that leave some women without the means to terminate an unwanted pregnancy could be addressed through medicare funded access to both medical and surgical abortion through the public hospital system. Nevertheless, other service delivery models within the Australian setting need consideration. Private provision through dedicated clinics can remain an option, but primary care services delivered through general practice, family planning clinics and sexual health services ought to be enhanced. It was hoped that with subsidy of mifepristone and misoprostol through the Pharmaceutical Benefits Scheme in 2013, coupled with the provision of accredited online training for GPs in the delivery of medical abortion, that improvements in access, especially for women in rural areas, would occur through GP provision. However, uptake in general practice appears to be low with a recent NSW-based qualitative study suggesting reasons for this ranging from from the belief that medical abortion is beyond the scope of general practice, to fears of community stigma and the perception that provision is complicated.21 While medical abortion will not be within the scope of all GP practices, support by local gynaecologists and hospital services for those who do want to provide this service is imperative in the event that specialist back-up is required. Other innovations include the availability in most states and territories of telemedicine medical abortion services. One of the first, The Tabbot Foundation, underwent a recent independent review. The results presented at the 15th World Congress on Public Health in Melbourne found it to be a safe and effective service.22 Since its establishment in 2015, mifepristone and misoprostol have been sent through the post to over 1800 women following a referral for an ultrasound and blood tests and a telephone assessment consultation. Follow-up to confirm abortion completion involves a blood test but, as mentioned in the paper by Goldstone et al., the use of a home-based semi-quantitative urine pregnancy test shows promise in reducing the need for women to return to the clinic to confirm successful treatment. This, together with the use of remote access communication technologies, is ideally suited to the Australian context where repeat clinic visits can be challenging but follow-up is required. While implementation of evidence-based clinical and service delivery innovations are imperative, promoting a workforce that is competent and willing to provide abortion is even more fundamental.23 Early exposure to each component necessary to support women in controlling their fertility should begin in medical school and continue through to specialist gynaecology training, as well as general practice and other relevant disciplines. All gynaecologists and GPs, regardless of whether they personally choose to provide abortion services, should have skills in supporting informed decision-making about pregnancy options, knowledge about medical and surgical abortion and skills or rapid referral pathways for the provision of effective contraception, including post-abortion long acting reversible contraception (LARC) to prevent repeat unwanted conceptions. Only then will abortion service provision become normalised as an essential component of women's health care in Australia.24 Globally, many would be aware that the Trump administration in the United States has issued an executive order that restricts funding to international organisations that provide women in low and middle income countries with information about their reproductive health rights and options. The policy requires non-governmental organisations receiving federal funding to agree to ‘neither perform nor actively promote abortion as a method of family planning in other nations’. This will potentially see many organisations forfeiting federal funding from the US, the largest contributor to global health funds, for crucial reproductive health care as well as non-abortion-related health initiatives.25 Within the US, the Trump government is also planning to defund Planned Parenthood which provides contraceptive advice and abortion to millions of women across the country. In Australia threats to severely restrict access to abortion are unlikely in the current climate, but as a nation we continue to fail to address the issue of equity of access to one of the most common procedures women will require in their lifetime. The public health system in a number of states has neglected management of unintended pregnancy and provision of abortion procedures. In countries where women can elect either medical or surgical abortion, around 50% choose the former, whereas currently only a third of Australian women take up this option. This may be due to several reasons, including the relative recency of its introduction, a lack of community or even medical practitioner awareness and knowledge about medical abortion and current clinical guidelines for follow-up care requiring a repeat clinic visit. Studies such as the one by Goldstone et al. have been essential in documenting the uptake, safety and efficacy of medical abortion in Australia and are crucial in helping women make informed choices when faced with an unintended pregnancy, and in equipping healthcare providers to support women in their choice. But more needs to be done to ensure that our health system does not fail to provide the basic services which every woman has a right to access, regardless of her financial circumstances or where she lives.

The road to equity: A scoping review of the evidence and practices on abortion policies and services in Sweden.

Centring sexual and reproductive health and justice in the global COVID-19 response

Federal, state, and institutional barriers to the expansion of medication and telemedicine abortion services in Ohio, Kentucky, and West Virginia during the COVID-19 pandemic

BackgroundImproving access to safe abortion is an essential strategy in the provision of universal access to reproductive health care. Australians are largely supportive of the provision of abortion and its decriminalization. However, the lack of data and the complex legal and service delivery situation impacts upon access for women seeking an early termination of pregnancy. There are no systematic reviews from a health services perspective to help direct health planners and policy makers to improve access comprehensive medical and early surgical abortion in high income countries. This review therefore aims to identify quality studies of abortion services to provide insight into how access to services can be improved in Australia.MethodsWe undertook a structured search of six bibliographic databases and hand-searching to ascertain peer reviewed primary research in English between 2005 and 2015. Qualitative and quantitative study designs were deemed suitable for inclusion. A deductive content analysis methodology was employed to analyse selected manuscripts based upon a framework we developed to examine access to early abortion services.ResultsThis review identified the dimensions of access to surgical and medical abortion at clinic or hospital-outpatient based abortion services, as well as new service delivery approaches utilising a remote telemedicine approach. A range of factors, mostly from studies in the United Kingdom and United States of America were found to facilitate improved access to abortion, in particular, flexible service delivery approaches that provide women with cost effective options and technology based services. Standards, recommendations and targets were also identified that provided services and providers with guidance regarding the quality of abortion care.ConclusionsKey insights for service delivery in Australia include the: establishment of standards, provision of choice of procedure, improved provider education and training and the expansion of telemedicine for medical abortion. However, to implement such directives leadership is required from Australian medical, nursing, midwifery and pharmacy practitioners, academic faculties and their associated professional associations. In addition, political will is needed to nationally decriminalise abortion and ensure dedicated public provision that is based on comprehensive models tailored for all populations.

ObjectivesNationally representative evidence on abortion service provision is scarce in South Asia. To inform improvements in service provision, this paper assesses the availability of facility-based postabortion services in Nepal, India (six states), Bangladesh and Pakistan, and legal abortion services in India and Nepal and Bangladesh (where the official term used is menstrual regulation or MR). Study designThe paper presents comparable indicators on three aspects of abortion service provision from representative surveys of public and private sector facilities, conducted over 2012–2015. Indicators cover three areas: (a) need for abortion-related care (total number of abortions and percent of abortions that are legal and the postabortion treatment rate); (b) availability and accessibility of facility-based abortion-related services (percent of facilities offering only one of the two services, percent which are public and percent located in rural areas); (c) quality of facility-based abortion care (percent of legal abortions using procedures not recommended by WHO and percent of women turned away when seeking abortion or MR services). ResultsThe proportion of all abortions that are illegal ranges from 58% to almost 78% in the three countries where abortion is permitted under broad criteria. The annual treatment rate for abortion complications ranges from about 4 to 26 per 1000 women ages 15–49 across the countries and states covered. In India and Nepal, less than 40% of public sector facilities that are permitted to provide abortion services do so; in Bangladesh, the situation is somewhat better, at 53% providing MR. Across the six Indian states, 4–43% of facilities that offer abortion care are located in rural areas, disproportionately lower than the proportion of women living in rural areas (49–87%). About 30–60% of facilities offered only postabortion care and did not offer legal services in the three countries where legal services are permitted (with the sole exception of Tamil Nadu where this proportion was only 11%); of the remaining facilities, the large majority offered both services. Medication abortion is offered by the large majority of facilities that provide induced abortion and accounts for 40–45%, of facility-based abortions in Nepal and four of the states of India; in Assam and Bihar, this proportion was much lower (13% and 27% respectively). Invasive procedures that are not recommended by WHO are more widely used in India (up to 25–37% of facility-based abortions are D&C procedures; the large majority of this group are D&C, and a small proportion may be D&E, a WHO-recommended abortion procedure, that could not be separated out in this study because providers use the two labels interchangeably); by comparison, the proportion is much smaller in Nepal (5%). Between 22% to a little over half of facilities turned away some women who would otherwise be eligible for an abortion or MR procedure in Nepal, the six Indian states, and Bangladesh. ConclusionsThere is an urgent need to increase access to abortion, MR and postabortion services, especially for rural women. Greater access to legal abortion/MR services in the three countries that permit these procedures would increase the proportion of abortions that are legal and safe, reduce morbidity and the need for facility-based treatment for complications. Broadening the legal criteria under which abortion is permitted in Pakistan, and implementing access under such broader criteria, is needed to achieve the same improvements in Pakistan. Ensuring that these services are of high quality and comprehensive—meeting WHO-recommended standards—is essential to protect women’s reproductive health and rights. ImplicationsTo improve access to abortion, MR and postabortion care in South Asia, all facilities (public and private) permitted to provide these services should do so, and should include medication abortion. Improvements in quality of care are critical: invasive procedures (D&C) should be eliminated through adherence to WHO’s standards of safe abortion care and women seeking abortions should not be turned away because of providers’ biases.

P043Southern health providers’ perspectives on policy considerations for implementation of telehealth medication abortion services

Background: Access to safe and effective abortion services plays a vital role in safeguarding women's reproductive health, ultimately contributing to their overall well-being. This is particularly relevant in Bangladesh, where the legality of abortion is contingent upon specific circumstances. Therefore, ensuring women have the autonomy to choose between safe and effective termination methods becomes crucial. Objective: The study aims to see explore the efficacy, safety, and accessibility of mifepristone-misoprostol regimen and surgical abortion methods within the context of Bangladesh. Methods: This investigation employed a cross-sectional observational design, conducted within the Department of Obstetrics and Gynecology at Dhaka National Medical College in Bangladesh. The study spanned one year, commencing in March 2023 and concluding in February 2024. To ensure a representative sample of the patient population seeking abortion services, consecutive sampling was utilized. This approach involved recruiting all patients admitted during the designated timeframe who fulfilled the pre-established inclusion and exclusion criteria. Ultimately, the study enrolled 104 participants, a sample size determined by the number of admissions fitting the criteria within the one year. Results: The study found no significant difference in age distribution between women choosing medical or surgical abortion, with both groups mainly consisting of women aged 18-25. Overall complication rates were similar, but medical abortion had a higher need for additional procedures and longer stays, while surgical abortion required more bleeding observation. Pain experiences differed significantly, with no women in the medical group reporting no pain and a higher prevalence of moderate pain compared to surgical abortion. Women undergoing medical abortion were slightly more likely to experience complications overall, and primigravid women (first pregnancy) were significantly more likely to experience complications than multigravid women. Conclusion: Our findings suggest comparable safety profiles for both surgical and medical abortion procedures within the studied population. This indicates that surgical abortion can be a safe and effective option alongside medical abortion, potentially expanding the range of choices offered to women.

What about access to birth control and emergency contraception now that abortion rights are overturned?

BackgroundDespite a liberal abortion law, access to safe abortion services in South Africa is challenging for many women. Medication abortion was introduced in 2013, but its reach remains limited. We aimed to estimate the costs and cost effectiveness of providing first-trimester medication abortion and manual vacuum aspiration (MVA) services to inform planning for first-trimester service provision in South Africa and similar settings.MethodsWe obtained data on service provision and outcomes from an operations research study where medication abortion was introduced alongside existing MVA services in public hospitals in KwaZulu-Natal province. Clinical data were collected through interviews with first-trimester abortion clients and summaries completed by nurses performing the procedures. In parallel, we performed micro-costing at three of the study hospitals. Using a model built in Excel, we estimated the average cost per medical and surgical procedure and determined the cost per complete abortion performed. Results are presented in 2015 US dollars.ResultsA total of 1,129 women were eligible for a first trimester abortion at the three study sites. The majority (886, 78.5%) were eligible to choose their abortion procedure; 94.1% (n = 834) chose medication abortion. The total average cost per medication abortion was $63.91 (52.32–75.51). The total average cost per MVA was higher at $69.60 (52.62–86.57); though the cost ranges for the two procedures overlapped. Given average costs, the cost per complete medication abortion was lower than the cost per complete MVA despite three (0.4%) medication abortion women being hospitalized and two (0.3%) having ongoing pregnancies at study exit. Personnel costs were the largest component of the total average cost of both abortion methods.ConclusionThis analysis supports the scale-up of medication abortion alongside existing MVA services in South Africa. Women can be offered a choice of methods, including medication abortion with MVA as a back-up, without increasing costs.

BackgroundIncreasing access to safe abortion services is the most effective way of preventing the burden of unsafe abortion, which is achieved by increasing safe choices for pregnancy termination. Medical abortion for termination of early abortion is said to safe, effective, and acceptable to women in several countries. In Ethiopia, however, medical methods have, until recently, never been used. For this reason it is important to assess women's preferences and the acceptability of medical abortion and manual vacuum aspiration (MVA) in the early first trimester pregnancy termination and factors affecting acceptability of medical and MVA abortion services.MethodsA prospective study was conducted in two hospitals and two clinics from March 2009 to November 2009. The study population consisted of 414 subjects over the age of 18 with intrauterine pregnancies of up to 63 days' estimated gestation. Of these 251 subjects received mifepristone and misoprostol and 159 subjects received MVA. Questionnaires regarding expectations and experiences were administered before the abortion and at the 2-week follow-up visit.ResultsThe study groups were similar with respect to age, marital status, educational status, religion and ethnicity. Their mean age was about 23, majority in both group completed secondary education and about half were married. Place of residence and duration of pregnancy were associated with method choice. Subjects undergoing medical abortions reported significantly greater satisfaction than those undergoing surgical abortions (91.2% vs 82.4%; P < .001). Of those women who had medical abortion, (83.3%) would choose the method again if needed, and (77.4%) of those who had MVA would also choose the method again. Ninety four percent of women who had medical abortion and 86.8% of those who had MVA would recommend the method to their friends.ConclusionsWomen receiving medical abortion were more satisfied with their method and more likely to choose the same method again than were subjects undergoing surgical abortion. We conclude that medical abortion can be used widely as an alternative method for early pregnancy termination.

ObjectiveTo explore the perspectives of abortion service users regarding termination methods and abortion service delivery in Vietnam.Materials and methodsStructured exit interviews were conducted between August and November 2011 with women who underwent termination of pregnancy at 62 public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City in Vietnam. All women presenting for termination during the study period were recruited to participate in the study. Following their abortion, women were asked about their perspectives on abortion service delivery and attributes of medical abortion (MA) versus manual vacuum aspiration (MVA). Multiple logistic regression was used to assess the association between current method uptake and each attribute.ResultsA total of 1,233 women were included in the survey: 541 (43.9%) from Hanoi, 163 (13.2%) from Khanh Hoa, and 529 (42.9%) from Ho Chi Minh: 23.1% underwent MA; 78.9% reported that women should be given a choice between MA and MVA; and 77.6% thought that abortion services were accessible. Among the 48% who responded, 30.1% thought that MA should be made available at primary/secondary health care facilities. Among women who had previously undergone both methods, women who reported that MA “feels more natural” (like a menstrual regulation/period) were more likely to choose MA for their current abortion (odds ratio 2.15, 95% confidence interval 1.26–3.69).ConclusionMA uptake is significantly lower than MVA uptake. Further insights to women’s perceptions of MA in Vietnam could help improve abortion service delivery in the country.

Provision of abortion and other reproductive health services among former Midwest Access Project trainees

Half of all pregnancies in the United States are unintended, and half of these pregnancies end in elective termination [1]. At current abortion rates, a woman has a 43% chance of having an abortion by the age of 45 [2]. Despite the demand for abortion services, 87% of all counties in the United States have no abortion provider [3]. Furthermore, the majority of women seek abortion services at nonprimary care sites, disrupting continuity of care for those who would prefer to access abortion service from their primary care provider. Almost 90% of all abortions occur in the first trimester, when safe, simple, and highly effective abortion services can be provided in the primary care setting [3]. If primary care clinicians were to offer abortion care, they could greatly improve timely access to safe abortion and relevant reproductive health services, particularly in rural and underserved settings.

Half of all pregnancies in the United States are unintended, and 40% of these pregnancies end in elective termination. At current abortion rates, one in four women will have an abortion by the age of 45. Despite the demand for abortion services, 90% of all counties in the United States have no abortion provider. Furthermore, the majority of women seek abortion services at nonprimary care sites, disrupting continuity of care for those who might prefer to access abortion service from their primary care provider. Over 90% of all abortions occur in the first trimester, when safe, simple, and highly effective abortion services can be provided in the primary care setting. Further, 75% of abortion patients are eligible to receive medication abortion with mifepristone and misoprostol, which can be provided in the primary care setting utilizing skills already elements of family medicine training and practice, specifically pregnancy diagnosis and patient-centered counseling skills. If primary care clinicians were to offer abortion care, they could greatly improve timely access to safe abortion and relevant reproductive health services, particularly in rural and underserved settings.