First-trimester Aspiration Abortion Research Articles

Transcutaneous Electrical Nerve Stimulation for Pain Management of Aspiration Abortion up to 83 Days of Gestation: A Randomized Controlled Trial.

To evaluate high-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) as an inexpensive, noninvasive pain management approach for first-trimester aspiration abortion. We conducted a noninferiority, single-blind, randomized controlled trial of patients seeking aspiration abortion at up to 83 days of gestation. Participants received TENS (placed posteriorly, T10-L1 and S2-S4) or intravenous (IV) sedation (fentanyl, midazolam). The primary outcome was pain with aspiration, as self-reported by visual analog scale (VAS, 100 mm). To detect at least a 15 mm mean difference on the 100 mm VAS with 90% power and a significance level of .05, a total of 90 participants were required. Between January 2018 and October 2019, we enrolled 109 participants (55 TENS, 54 IV). Participant median gestation was 53 days (range 36-82) in the TENS group and 58 days (range 35-82) in the IV group (P=.65). Group demographics and clinical histories were similar. Intention-to-treat analysis (n=109) yielded noninferior results for the primary outcome (mean difference 4.8 mm, 95% CI -5.9 to 13.5 mm). In the per-protocol analysis, 9 (16%) in the TENS group were excluded after receiving IV sedation; 100 participants were included (46 TENS, 54 IV). Median (range) reported VAS for aspiration was 73 mm (13-97) and 66 mm (0-99) in the TENS and IV groups, respectively (P=.40). With a mean difference of 4.4 mm (95% CI -5.6 to 14.5 mm), we found TENS to be noninferior to IV. Physicians underestimated participant pain, perceiving pain to be 34 mm (6-91) in the TENS group and 25 mm (0-83) in the IV group (P=.003). We found TENS to be a noninferior alternative to IV sedation for aspiration pain during first-trimester abortion. Expanding pain management options can improve quality of and access to abortion. Transcutaneous electrical nerve stimulation could be a standalone or adjunct approach for abortion pain management for those without access to or are ineligible to receive IV sedation due to the lack of sedation practitioner, designated driver, or local restrictions. ClinicalTrials.gov, NCT03187002.

Changes to medication abortion clinical practices in response to the COVID-19 pandemic

ObjectivesTo document medication abortion clinical practice changes adopted by providers in response to the COVID-19 pandemic. Study designLongitudinal descriptive study, comprised of three online surveys conducted between April to December, 2020. We recruited sites from email lists of national abortion and family planning organizations. ResultsSeventy-four sites opted to participate. We analyzed 55/74 sites (74%) that provided medication abortion and completed all three surveys. The total number of abortion encounters reported by the sites remained consistent throughout the study period, though medication abortion encounters increased while first-trimester aspiration abortion encounters decreased. In response to the COVID-19 pandemic, sites reduced the number of in-person visits associated with medication abortion and confirmation of successful termination. In February 2020, considered prepandemic, 39/55 sites (71%) required 2 or more patient visits for a medication abortion. By April 2020, 19/55 sites (35%) reported reducing the total number of in-person visits associated with a medication abortion. As of October 2020, 37 sites indicated newly adopting a practice of offering medication abortion follow-up with no in-person visits. ConclusionsSites quickly adopted protocols incorporating practices that are well-supported in the literature, including forgoing Rh-testing and pre-abortion ultrasound in some circumstances and relying on patient report of symptoms or home pregnancy tests to confirm successful completion of medication abortion. Importantly, these practices reduce face-to-face interactions and the opportunity for virus transmission. Sustaining these changes even after the public health crisis is over may increase patient access to abortion, and these impacts should be evaluated in future research. Implications statementMedication abortion serves a critical function in maintaining access to abortion when there are limitations to in-person clinic visits. Sites throughout the country successfully and quickly adopted protocols that reduced visits associated with the abortion, reducing in-person screenings, relying on telehealth, and implementing remote follow-up.

SOCIAL SCIENCE ORAL ABSTRACTS: Trends in self-pay costs and insurance acceptance for abortion across the United States, 2017 to 2020

<h3>Introduction</h3> Abortion cost can be a significant financial burden and a barrier to care. The Hyde Amendment prevents Federal funding from being used for abortion care, forcing many low-income people to pay for abortion out of pocket rather than using their Medicaid coverage. Current data on self-pay abortion costs are limited to national estimates or small sample sizes. We provide data on trends in self-pay abortion costs by region for medication abortion and first and second trimester procedures using a national database of abortion clinics in the United States. We also examine the proportion of clinics that accept any type of insurance. <h3>Method</h3> We used data from University of California San Francisco (UCSF)/Advancing New Standards in Reproductive Health (ANSIRH's) abortion facility database which includes data on publicly advertising abortion clinics and is updated each year. We used Chrome browser's incognito mode to search for clinics by State and City using the key words: "Abortion clinic in [State]", "Abortion clinic in [City]" for all cities with a population of 100,000 or larger in each state, and the 3 largest cities for states that did not have a city of that size. We examined links to clinics from the first 3 pages of results for states and first 2 pages for cities. We then conducted mystery shopper phone calls to clinics to supplement any missing data not found on facility web pages. Mystery callers did not make clinic appointments. Clinics were only included if they reported being open and providing abortions for a given year. Abortion training sites such as teaching hospitals were only included if they publicly advertised abortion services. To estimate mean costs of abortion for clinics that gave a range of prices for a certain abortion type (e.g., second trimester) we first averaged the prices for that procedure type per clinic. Then, clinic mean prices were averaged by region to develop regional means. We reported the number and percentage of clinics in each region that reported accepting any insurance. <h3>Results</h3> We identified 751 to 776 publicly advertising abortion clinics per year in the United States: 776 in 2017, 751 in 2018, 758 in 2019, and 765 in 2020. The national mean self-pay price for medication abortion increased from $511 in 2017 to $644 in 2020. Mean price for medication abortion varied greatly by region, the lowest cost in 2020 being $489 in the South Atlantic and the highest being $873 in the Pacific. Nationally, mean first-trimester aspiration abortion costs also increased over time, from $489 to $715 between 2017 and 2020. Mean price for first-trimester aspiration abortion varied greatly by region, with the lowest cost in 2020 being $493 in the South Atlantic and the highest cost being $1191 in New England. In contrast, mean second trimester abortion costs decreased nationally, from $1180 in 2017 to $1068 in 2020. This decrease was mostly concentrated in the Pacific, East North Central, and New England regions, while other regions saw an increase in the same period. There was a sharp national decline in the proportion of clinics that accepted insurance from 88% to 80% between 2018 and 2019, which was sustained in 2020. This decline was observed in all regions. <h3>Conclusions</h3> An improved understanding of patient costs for an abortion and how that varies by region and state is a crucial first step to reducing financial barriers and to inform public and private insurance coverage policy. Abortion costs are increasing over time, while the proportion of clinics that accept insurance is decreasing. This may be because public and private insurance reimbursement rates do not cover the full costs of providing abortion care. Insurance reimbursement rates must be increased to reflect actual clinic costs. Additionally, repealing the Hyde Amendment would have profound impacts on people who have abortions in the United States.

First-Trimester Abortion Complications: Simulation Cases for OB/GYN Residents in Sepsis and Hemorrhage

IntroductionSerious complications associated with first-trimester abortions are rare. The US mortality rate for these procedures is 0.7 per 100,000, primarily due to infection and hemorrhage. While complications are unlikely to arise during training, residents must be prepared to manage them in practice. To address this, we developed a 2-hour simulation-based abortion complication curriculum for OB/GYN resident learners.MethodsOB/GYN residents participated in three sessions: a case-based didactic reviewing institutional aspiration abortion practice and preop preparation; an in-vivo aspiration abortion hemorrhage simulation; and an interdepartmental postabortal sepsis simulation. Participants completed surveys before and after their participation that evaluated clinical knowledge, and self-rated competence in, and preparedness for, managing first-trimester abortion complications.ResultsResident learners (N = 26) represented all four classes of OB/GYN residents. Residents initially showed stronger clinical knowledge in managing postabortal hemorrhage than sepsis (90% vs. 62%, p < .001). Clinical knowledge improved following the sepsis simulation (62% to 91%, p < .001), and remained strong but unchanged after the hemorrhage simulation (90% to 87%, p = .3). Resident self-assessments of competence and preparedness were significantly improved after both the hemorrhage (p = .006) and sepsis (p = .002) simulations. Learners reported that the simulation increased their level of comfort in managing these complications in their future practice.DiscussionPostabortal hemorrhage and sepsis simulations increased OB/GYN residents' knowledge, comfort, and preparedness for managing rare complications of first-trimester abortions. In-vivo simulation and interdepartmental collaboration were novel aspects of these simulations that may facilitate increased preparedness and management skills.

First-trimester aspiration abortion practices: a survey of United States abortion providers

ObjectivesTo assess whether first-trimester aspiration abortion practices of US providers agree with evidence-based policy guidelines. Study designWe sent surveys by mail or electronically to all abortion facilities in the United States identified via professional networks and websites from June through December 2013. Administrators reported on the volume of procedures performed at their site(s) through 13 weeks 6 days' gestation and on clinic services. Clinicians reported on personal demographic characteristics and abortion practices. We reviewed guidelines from key US professional organizations to determine how well reported practices aligned with available recommendations and the extent to which guidelines have changed since the time of the survey. ResultsWe identified 703 clinical sites in the United States; 383 (54%) sites responded, 256 of which offer first-trimester aspiration abortions. Most providers identified as obstetrician-gynecologists (74%) and female (64%); 52% were less than 50 years old compared to 36% in 2002. Overall, reported practices follow evidence-based guidelines, including routine administration of periprocedure antibiotics (85%), use of misoprostol for cervical ripening in the late first trimester (94%), pain management practices, and same-day contraception provision (98%) including long-acting devices (76%). Less evidence-based practices include routine preprocedure ultrasound (99%), not providing abortion before 5 weeks' gestation (66%), restrictive fasting policies, and prolonged and postprocedure antibiotic provision. ConclusionOverall, the first-trimester aspiration abortion practices revealed in our survey agree with professional evidence-based policy guidelines, though some related to preprocedure ultrasound use, very early abortion provision, preanesthesia fasting protocols, and antibiotic regimens deserve attention. ImplicationsIn this third cross-sectional survey of US abortion practices (prior surveys 1997 and 2002), first-trimester aspiration abortion providers are younger than before, reflecting an improvement in the “graying” of the abortion provider workforce. Research and education are needed to further improve evidence-based practice in abortion care.

Training in aspiration abortion care: An observational cohort study of achieving procedural competence

BackgroundStudies in multiple countries have found that the provision of aspiration abortion care by trained nurses, midwives, and other front-line health care workers is safe and acceptable to women. In the United States, most state abortion laws restrict the provision of abortion to physicians; nurse practitioners, nurse-midwives, and physician assistants, can legally perform medication abortion in only twelve states and aspiration abortion in five. Expansion of abortion care by these providers, consistent with their scopes of practice, could help alleviate the increasing difficulty of accessing abortion care in many states. ObjectivesThis study used a competency-based training model to teach advanced practice clinicians to perform vacuum aspiration for the abortion care. Previous research reporting on the training of providers other than physicians primarily focused on numbers of procedures performed, without assessment of skill competency or clinician confidence. DesignIn this prospective, observational cohort study, advanced practice clinician trainees were recruited from 23 clinical sites across six partner organizations. Trainees participated in a standardized, competency-based didactic and clinical training program in uterine aspiration for first-trimester abortion. SettingsTrainee clinicians needed to be employed by one of the six partner organizations and have an intention to remain in clinical practice following training. ParticipantsCalifornia-licensed advanced practice clinicians were eligible to participate in the training if they had at least 12 months of clinical experience, including at least three months of medication abortion provision, and certification in Basic Life Support. MethodsA standardized, competency-based training program consisting of both didactic and clinical training in uterine aspiration for first-trimester abortion was completed by 46 advanced practice clinician participants. Outcomes related to procedural safety and to the learning process were measured between August 2007 and December 2013, and compared to those of resident physician trainees. ResultsEssentially identical odds of complications occurring from advanced practice clinician-performed procedures were not significantly different than the odds of complications occurring from resident-performed procedures (OR: 0.99; CI: 0.46–2.02; p > 0.05) after controlling for patient sociodemographic and medical history. The number of training days to foundational competence ranged from six to 10, and the number of procedures to competence for those who completed training ranged from 40 to 56 (median = 42.5). ConclusionsA standardized, competency-based trainingprogram can prepare advanced practice clinicians to safely provide first-trimester aspiration abortions. Access to safe abortion care can be enhanced by increasing the number of providers from cadres of clinicians other than physicians.

Patient choice of adjunctive nonpharmacologic pain management during first-trimester abortion: a randomized controlled trial

ObjectiveTo determine if offering patients a choice of adjunctive nonpharmacologic pain management during first-trimester aspiration abortion results in lower pain scores when compared with standard care. Study designWe enrolled women receiving first-trimester aspiration abortion at the University of Hawaii. We randomized patients to standard care (control) or standard care plus a choice of nonpharmacologic pain management options (intervention). Standard care was ibuprofen 800 mg orally at least 30 min preprocedure, lidocaine paracervical block and anticipatory guidance from the provider. We measured pain on a 100-mm visual analog scale immediately postprocedure with adequate sample size to detect a 20-mm difference in pain scores. ResultsSeventy-four women participated in the trial and reported an overall mean pain score of 61.9±27.0. Participants in the control and intervention groups reported similar overall mean pain scores (control 60.6±28.8, intervention 63.3±28.5). We found procedure time, complications, provider-perceived case difficulty and patient satisfaction with pain management to be similar between groups. Providers underestimated participant pain compared to participants' own scores (mean physician estimate of participant pain: 46.3±18.5, mean participant pain score: 61.9±27.0, p<.01). Intervention group participants most frequently selected ambient music (59%) as the nonpharmacologic intervention. Forty-one percent (15/37) of participants in the intervention group chose more than one nonpharmacologic intervention. ConclusionsParticipants in the control group reported similar pain scores to participants in the intervention group. Procedure time and difficulty were similar between the two groups. ImplicationsIncorporating patient choice into a nonpharmacologic pain management model did not result in lower pain scores. This approach did increase the patient's visit time. Abortion providers frequently use nonpharmacologic pain management in the United States, and these techniques did not negatively impact patient pain scores in our study.

Expanding the Abortion Provider Workforce: A Qualitative Study of Organizations Implementing a New California Policy.

Access to abortion care in the United States varies according to multiple factors, including location, state regulation and provider availability. In 2013, California enacted a law that authorized nurse practitioners (NPs), certified nurse-midwives (CNMs) and physician assistants (PAs) to provide first-trimester aspiration abortions; little is known about organizations' experiences in implementing this policy change. Beginning 10 and 24 months after implementation of the new law, semistructured interviews were conducted with 20 administrators whose five organizations trained and employed NPs, CNMs and PAs as providers of aspiration abortions. Interview data on the organizations' experiences were analyzed thematically, and facilitators of and barriers to implementation were identified. Administrators were committed to the provision of aspiration abortions by NPs, CNMs and PAs, and nearly all identified improved access to care and complication management as clear benefits of the policy change. However, integration of the new providers was uneven and depended on a variety of circumstances. Organizational disincentives included financial and logistical costs incurred in trying to deploy and integrate the different types of providers. Some administrators found that increased costs were outweighed by improved patient care, whereas others did not. In general, having a strong administrative champion within the organization made a critical difference. California's expansion of the abortion-providing workforce had a positive impact on patient care in the sampled organizations. However, various organizational obstacles must be addressed to more fully realize the benefits of having NPs, CNMs and PAs provide aspiration abortions.

Integrating Doulas Into First-Trimester Abortion Care: Physician, Clinic Staff, and Doula Experiences.

Balancing the need to provide individual support for patients and the need for an efficient clinic can be challenging in the abortion setting. This study explores physician, staff, and specially trained abortion doula perspectives on doula support, one approach to patient support. We conducted separate focus groups with physicians, staff members, and doulas from a high-volume, first-trimester aspiration abortion clinic with a newly established volunteer abortion doula program. Focus groups explored 1) abortion doula training, 2) program implementation, 3) program benefits, and 4) opportunities for improvement. Interviews were transcribed and computer-assisted content analysis was performed; salient findings are presented. Five physicians, 5 staff members, and 4 abortion doulas participated in separate focus group discussions. Doulas drew on both their prior personal skills and experiences in addition to their abortion doula training to provide women with support at the time of abortion. Having doulas in the clinic to assist with women's emotional needs allowed physicians and staff to focus on technical aspects of the procedure. In turn, both physicians and staff believed that introducing doulas resulted in more patient-centered care. Although staff did not experience challenges to integrating doulas, physicians and doulas experienced initial challenges in incorporating doula support into the clinical flow. Staff and doulas reported exchanging skills and techniques that they subsequently used in their interactions with patients. Physicians, clinic staff, and doulas perceive abortion doula support as an approach to provide more patient-centered care in a high-volume aspiration abortion clinic.

Role of Insurance Coverage in Contraceptive Use After Abortion.

To assess postaspiration abortion contraceptive use and the role of insurance coverage for abortion in a state that covers abortion and contraception for low-income women. This is a secondary analysis of a previously published prospective study to assess the safety of abortion provision. From 2007 through 2013, women seeking first-trimester aspiration abortion were recruited at 25 clinical facilities within four Planned Parenthood affiliates and Kaiser Permanente of Northern California. Patients' medical charts were reviewed to assess the contraceptive methods received on the day of the abortion. A 4-week follow-up survey assessed contraceptive use and contraceptive-related incidents. Primary outcomes included leaving with any method on the day of the abortion and use of any method at the 4-week assessment. Secondary outcomes included intrauterine device or implant use on the day of the procedure and at 4 weeks and switching to a less effective method at 4 weeks. A total of 19,673 women agreed to participate, and 13,904 (71%) completed the 4-week follow-up survey. Ninety-four percent (18,486/19,673) left their abortion visit with a contraceptive method: 21% (4,111/19,673) with an intrauterine device, implant, or permanent method. By the 4-week survey, 8% (1,135/13,904) switched from a high- or medium-efficacy method to a low-efficacy or no method; 0.4% (60/13,904) experienced a contraceptive incident. In adjusted regression analyses, women who paid for the abortion with Medicaid were significantly more likely to use any method (adjusted odds ratio [OR] 3.70, 95% CI 3.09-4.42) or an intrauterine device or implant (adjusted OR 2.14, 95% CI 1.92-2.38) on the day of the abortion than those who did not pay with insurance. Experiencing a contraceptive-related incident was associated with switching to a low-efficacy or no method by the 4-week survey (adjusted OR 3.98, 95% CI 2.20-7.22). Insurance coverage for abortion is associated with postabortion contraceptive provision and use, even in settings that cover abortions and contraception for low-income women.

Assessing the effectiveness of patient-centered nonpharmacologic pain management techniques on pain during first-trimester aspiration abortion: a randomized controlled trial

Assessing the effectiveness of patient-centered nonpharmacologic pain management techniques on pain during first-trimester aspiration abortion: a randomized controlled trial

Standardizing the classification of abortion incidents: the Procedural Abortion Incident Reporting and Surveillance (PAIRS) Framework

ObjectivesTo develop and validate standardized criteria for assessing abortion-related incidents (adverse events, morbidities, near misses) for first-trimester aspiration abortion procedures and to demonstrate the utility of a standardized framework [the Procedural Abortion Incident Reporting & Surveillance (PAIRS) Framework] for estimating serious abortion-related adverse events. Study designAs part of a California-based study of early aspiration abortion provision conducted between 2007 and 2013, we developed and validated a standardized framework for defining and monitoring first-trimester (≤14weeks) aspiration abortion morbidity and adverse events using multiple methods: a literature review, framework criteria testing with empirical data, repeated expert reviews and data-based revisions to the framework. ResultsThe final framework distinguishes incidents resulting from procedural abortion care (adverse events) from morbidity related to pregnancy, the abortion process and other nonabortion related conditions. It further classifies incidents by diagnosis (confirmatory data, etiology, risk factors), management (treatment type and location), timing (immediate or delayed), seriousness (minor or major) and outcome. Empirical validation of the framework using data from 19,673 women receiving aspiration abortions revealed almost an equal proportion of total adverse events (n=205, 1.04%) and total abortion‐ or pregnancy-related morbidity (n=194, 0.99%). The majority of adverse events were due to retained products of conception (0.37%), failed attempted abortion (0.15%) and postabortion infection (0.17%). Serious or major adverse events were rare (n=11, 0.06%). ConclusionsDistinguishing morbidity diagnoses from adverse events using a standardized, empirically tested framework confirms the very low frequency of serious adverse events related to clinic-based abortion care. ImplicationsThe PAIRS Framework provides a useful set of tools to systematically classify and monitor abortion-related incidents for first-trimester aspiration abortion procedures. Standardization will assist healthcare providers, researchers and policymakers to anticipate morbidity and prevent abortion adverse events, improve care metrics and enhance abortion quality.

Use of emergency contraceptive pills in the 6 months after advance provision at time of first-trimester aspiration abortion

Use of emergency contraceptive pills in the 6 months after advance provision at time of first-trimester aspiration abortion

Nonpharmaceutical Pain Control Adjuncts During First-Trimester Aspiration Abortion: A Review.

First-trimester aspiration abortion is associated with moderate to severe pain. The effectiveness of adjunctive therapies for pain control is not well understood. This critical review summarizes the existing literature regarding nonpharmacologic interventions to reduce pain during first-trimester office-based abortion. PubMed and Google Scholar were searched using the following search terms in various combinations: "abortion," "pain," "nonpharmaceutical," "nonpharmacologic," "anxiety," "fear," "pain management," "pain reduction," "anxiety reduction," "complementary and alternative medicine," and "integrative medicine." Seven articles meeting inclusion criteria were entered into a matrix for comparison. Findings from each study are summarized describing design, results, and themes. These results are summarized to provide evidence-based clinical guidelines and identify areas for further research. None of the nonpharmacologic interventions studied were significantly associated with a reduction in pain or anxiety scores. However, women in many studies strongly endorsed future use of these techniques. The data included in this critical review did not demonstrate a relationship between the nonpharmacologic interventions and pain or anxiety scores, yet participants endorsed these as positive and helpful. Women found value in these supportive interventions, and ongoing investigation into these techniques is warranted.

Eggs and Abortion: "Women-Protective" Language Used by Opponents in Legislative Debates over Reproductive Health.

In this paper we undertake an examination of the presence of similar "women-protective" discourses in policy debates occurring over two bills on reproductive-related topics considered during the 2013 California legislature session. The first bill (AB154), now signed into law, allows nurse practitioners, certified nurse midwives, and physician assistants to perform first-trimester aspiration abortions. The second bill (AB926), had it passed, would remove the prohibition on paying women for providing eggs to be used for research purposes. Using frame analysis we find evidence of similar protective arguments by opponents of both bills, although these advocates do not share ideological positions on abortion rights or women's autonomy. In the case of AB154, anti-abortion advocates use language and frames that call for protecting the health of women against the imputed interests of the "abortion industry." In the case of AB926, feminists and pro-choice advocates evoke similar frameworks for the protection of women against the interests of the "medical research industry." Both sides argue for the "protection of women," from opposing positions on the rights and autonomy of women in relationship to reproductive freedom.

Incidence of emergency department visits and complications after abortion.

To conduct a retrospective observational cohort study to estimate the abortion complication rate, including those diagnosed or treated at emergency departments (EDs). Using 2009-2010 abortion data among women covered by the fee-for-service California Medicaid program and all subsequent health care for 6 weeks after having an abortion, we analyzed reasons for ED visits and estimated the abortion-related complication rate and the adjusted relative risk. Complications were defined as receiving an abortion-related diagnosis or treatment at any source of care within 6 weeks after an abortion. Major complications were defined as requiring hospital admission, surgery, or blood transfusion. A total of 54,911 abortions among 50,273 fee-for-service Medi-Cal beneficiaries were identified. Among all abortions, 1 of 16 (6.4%, n=3,531) was followed by an ED visit within 6 weeks but only 1 of 115 (0.87%, n=478) resulted in an ED visit for an abortion-related complication. Approximately 1 of 5,491 (0.03%, n=15) involved ambulance transfers to EDs on the day of the abortion. The major complication rate was 0.23% (n=126, 1/436): 0.31% (n=35) for medication abortion, 0.16% (n=57) for first-trimester aspiration abortion, and 0.41% (n=34) for second-trimester or later procedures. The total abortion-related complication rate including all sources of care including EDs and the original abortion facility was 2.1% (n=1,156): 5.2% (n=588) for medication abortion, 1.3% (n=438) for first-trimester aspiration abortion, and 1.5% (n=130) for second-trimester or later procedures. Abortion complication rates are comparable to previously published rates even when ED visits are included and there is no loss to follow-up. II.

Comparison of Intrauterine Device Expulsion Rates After Aspiration Abortion or Interval Insertion

INTRODUCTION: Twenty-two percent of all pregnancies in the United States result in termination, reflecting the need for more robust contraception. The intrauterine device (IUD) is highly effective and reversible although underused in the United States compared with other countries. Several institutions in the United States insert IUDs immediately after abortions with success despite international research that suggests a higher rate of expulsion. OBJECTIVE: To compare the rate of IUD expulsion in immediate postabortion insertion compared with interval insertion. METHODS: A retrospective cohort study was performed to ascertain complications after immediate compared with interval IUD placement after first-trimester aspiration abortions between April 1, 2006, and September 30, 2011, at all Kaiser Permanente Northern California facilities. The primary outcome was the rate of expulsion within 90 days of IUD insertion. Secondary outcomes included rates of uterine perforation, upper genital tract infection, and early removal of IUD. Statistical analysis used χ2 and t test comparisons. Logistic regression was performed for multiple variable analysis. RESULTS: Four hundred forty-seven women with same-day insertions were compared with 316 women with interval insertions. The overall rate of expulsion was low with no statistically significant differences seen between cohorts at 4.1% and 1.7%, respectively (P<.073). Secondary outcome rates were all low. In multivariate analysis, African American race was noted to be an independent risk factor for expulsion with an odds ratio of 3.95. CONCLUSION: In a diverse, American population, levonorgestrel or Cu-T IUD insertion immediately after first-trimester abortion appears to be safe with no significant increase in rates of expulsion or other complications when compared with interval insertion.

Experiences of patients receiving first-trimester aspiration abortion care from nurse practitioners, certified nurse–midwives and physician assistants

To understand the experiences of patients receiving first-trimester aspiration abortion care from nurse practitioners, certified nurse���midwives and physician assistants in California community clinics. Under a legal waiver from the state of California's Health Workforce Pilot Project (HWPP) program, these clinicians are the first in the state to be trained in aspiration abortion provision. We analyze qualitative and quantitative data on patients' expectations, anxiety, satisfaction and other aspects of their experience.

The effect of perioperative ketorolac on pain control in pregnancy termination

BackgroundThe study was conducted to evaluate the effect of perioperative ketorolac on pain associated with first-trimester aspiration abortion. Study DesignA double-blind, randomized, placebo-controlled trial was performed involving pregnant women up to 14 weeks' gestation who desired pregnancy termination. Subjects were randomized to receive ketorolac 30 mg intravenously (n=31) or placebo (n=45) at the time of induction of anesthesia. Postoperative pain was assessed using a visual analog scale (VAS). The primary outcome was pain control as determined by VAS score. Secondary measures of patient use of supplemental postoperative pain medications and patient satisfaction were assessed. ResultsSubjects in the ketorolac group had lower postoperative pain scores on the VAS at all time points compared to the placebo group, but the difference was not statistically significant. The ketorolac group used less postoperative acetaminophen compared to the placebo group (6.5% versus 35.6%), respectively. Subjects in the placebo group and the ketorolac group had similar requirements for postoperative narcotics in the recovery room (22.2% versus 19.4%). Patient satisfaction with pain level was equivalent between the groups at all postoperative end points. There was no observed difference in perioperative blood loss observed between the two groups. ConclusionPerioperative ketorolac has the same effect on postoperative pain as determined by VAS as placebo. The use of ketorolac at the 30-mg dose cannot be recommended for better pain control for patients undergoing first-trimester pregnancy termination by suction curettage. The only positive effect of the use of ketorolac compared to placebo was a reduction in the use of acetaminophen. Ketorolac use does not appear to change blood loss in the operating room or through postoperative day 1 compared to placebo.

PARADIGM SHIFT: MOVING TOWARD ACCESS IN EVERY OFFICE

Dehlendorf and Grumbach should be commended for their recent piece on medical liability insurance for abortion care in family medicine.1 Their work highlights that family medicine physicians are uniquely positioned to provide early abortion care to their patients. Medication abortion and first-trimester aspiration abortion are skills that family medicine physicians can easily incorporate into their practices as a service to their patients. As mentioned by Dehlendorf and Grumbach, it is estimated that 44% of women have an abortion sometime during their life.2 This fact makes early abortion relevant to all primary care physicians, but especially to family medicine physicians, who have clinical training in obstetrics and gynecology. Additionally, in the more rural parts of the United States, family medicine physicians are often the only physicians in town. In the 87% of US counties that do not have an abortion provider, family medicine physicians could be the answer to this unmet need.3 Anthony McWilliams, left, and “L” Lawrence Warren, right, participate in the 2nd Annual Stand Up and Represent National Black Gay Pride march in the West End section of Atlanta, GA, on September 2, 2002. Photograph by Ric Feld. Printed with permission of AP Images. Currently, only 2% of abortions are provided in private doctors' offices.3 The majority are performed in specialty abortion clinics. Patients are often referred to these specialty clinics from the gynecologist or primary care doctor who diagnosed their pregnancy. This is the current model of abortion care in this country. Imagine however, if first-trimester abortions were available in the majority of primary care practices. The paradigm of abortion care in the United States could be fundamentally altered, and the negative stigma of abortion could be lessened. Family medicine physicians have other advantages beyond their physical proximity and training skills: the ability to provide continuity of care and make use of the acquired trust of their patients. In times of crisis, primary care physicians have a unique opportunity to intervene to effect positive change as a result of the relationship they have built with their patients.4 Delivering abortion care in the primary care setting has the potential to improve postabortion family planning and contraceptive services, such as patient selection of intrauterine devices or other highly effective contraceptive methods. Better contraception means fewer repeat abortions, and that is a goal that almost everyone can agree on.5