Providing Medication Abortion Research Articles

Barriers to medication abortion among Massachusetts public university students

ObjectiveProposed legislation in Massachusetts would require public university health centers to provide medication abortion services on campus. This study assesses need for these services by investigating current travel time, costs, wait times and insurance acceptance at off-campus, abortion-providing facilities nearest to public universities in Massachusetts. Study DesignThis investigation projected the total number of students obtaining medication abortions each year at the 13 Massachusetts public universities based on campus enrollment figures and age- and state-adjusted medication abortion rates. Using a cross-sectional study design, the research calculated the distance and public transit time from campuses to the nearest abortion-providing facilities. Researchers contacted facilities to determine costs, wait times and insurance acceptance. ResultsWe estimate 50 to 115 of Massachusetts public university students obtain medication abortion services each month, or 600 to 1,380 each year. Students have to travel between 2 and 42 miles to reach the nearest abortion-providing facility, with a population-weighted average distance of 19 miles each way. Travel time on public transportation to reach the nearest abortion-providing facility takes between 18 and 400 hundred minutes, with a population-weighted average of 103 minutes each way. Average cost of medication abortion was $680, and average wait time to the first available appointment was 8 days. Eight of 13 abortion-providing facilities did not have weekend appointments. All of the nearest abortion-providing facilities in Massachusetts accepted Mass Health, but one nearest facility was out of state and did not. All accepted multiple private insurance plans. ConclusionsCollege students face cost, scheduling, and travel barriers to abortion care. Offering medication abortion on campus would reduce these barriers. ImplicationsThe barriers to medication abortion experienced by students attending public universities in Massachusetts fall particularly hard on female and low-income students, who are disproportionately students of color. Offering medication abortion on campus would reduce these barriers and enhance gender and racial equity on campus.

POSTER ABSTRACTS: P29 MESSAGING RECOMMENDATIONS TO ADVANCE INTEGRATING MEDICATION ABORTION INTO FAMILY MEDICINE

Objectives: While providing medication abortion in primary care has the potential to expand abortion access and decrease stigma, provision of this care is still largely limited to specialized reproductive health clinics. Family physicians are well-positioned to provide medication abortions given their geographic distribution and long-term relationships with patients but face logistical, institutional, and other structural barriers. Our multidisciplinary research team conducted a qualitative study to understand how communications messaging and strategies could be leveraged to encourage family physicians to overcome these barriers.

Perspectives of internal medicine physicians regarding medication abortion provision in the primary care setting

ObjectiveTo better understand medication abortion attitudes and interest in future provision among Internal Medicine primary care providers (IM PCPs), and to characterize barriers to provision. Study DesignWe conducted a survey with IM attendings and trainees at a large academic medical center in Western Pennsylvania. We used descriptive statistics to characterize attitudes towards medication abortion provision, including the belief that it is within their scope of practice and interest in future provision, and to explore perceived barriers to provision. We used logistic regression models to assess factors associated with each of these attitudes. ResultsOf 397 eligible attendings and trainees, 121 (30%) completed the survey. Among those surveyed, 44% believed medication abortion is within the scope of practice of IM PCPs with trainees and female-identifying providers being significantly more likely to believe medication abortion is within their scope of practice compared to attending physicians and male physicians (60% vs 30%, p < 0.01 and 53% vs 31%, p = 0.01, respectively). Similarly, 43% endorsed interest in future provision, with trainees (67% vs 23%, p < 0.001) and female providers (54% vs 27%, p = 0.002) being more likely to express interest. The most cited barriers to provision included limited training in residency (70%) and low familiarity with abortion medications (57%). ConclusionsMany IM providers— particularly trainees— believe medication abortion is within their scope of practice and would like to provide this care. Interventions are needed to provide education and assistance complying with state and federal regulations to enable safe and efficient medication abortion provision by IM providers. ImplicationsIM departments and residency programs should seek to ensure training is offered to clinicians interested in providing medication abortion as a part of their primary care practice.

Attitudes of US adults toward using telemedicine to prescribe medication abortion during COVID-19: A mixed methods study

ObjectivesWe explored public opinion about using telemedicine to provide medication abortion during the COVID-19 pandemic in 2020. We also investigated the associations between socio-demographic characteristics and support for using telemedicine in this context and explored factors that influenced respondents’ attitudes on the topic. Study designIn a nationally representative, web-based survey of US adults (n = 711), we asked open- and closed-ended questions about using telemedicine to prescribe medication abortion during COVID-19. We used multinomial logistic regression to assess the relationship between socio-demographic characteristics, endorsement of abortion labels, and political affiliation and support for telemedicine in this circumstance. Then, we conducted content and thematic analyses with the open-ended data to explore what influenced respondents’ opinions. ResultsOverall, 332 (44%) of respondents supported using telemedicine for medication abortion during the pandemic; 237 (35%) opposed and 138 (21%) were unsure. Respondents who identified as prochoice were more likely to support using telemedicine for abortion during the pandemic than those who identified as prolife were to oppose it in this context (RRR 2.95; 95% CI 1.31–6.64). Via our content and thematic analysis, we identified that concerns about safety, the legitimacy of telemedicine, and the belief that abortion should occur as early in the pregnancy as possible influenced respondents’ beliefs about using telemedicine for medication abortion. ConclusionsMore respondents supported using telemedicine for medication abortion during COVID-19 than opposed it. Among respondents who expressed support, most thought that medication abortion was safe and that telemedicine was equivalent to the in-person provision of care. ImplicationsThere appears to be support among US adults for the provision of medication abortion via telemedicine during COVID-19. Policymakers may consider public sentiment as well as clinical evidence when considering legislation about abortion.

Obstetrician-gynecologist willingness to provide medication abortion with removal of the in-person dispensing requirement for mifepristone

ObjectiveTo estimate obstetrician-gynecologists’ (ob-gyns) willingness to provide medication abortion if the in-person dispensing requirement for mifepristone were removed. Study designWe analyzed a subsample (n = 868) from a 2016 to 2017 national survey of ob-gyns, focusing on questions related to provision of medication abortion. ResultsIn the survey, 164 (19%) ob-gyns reported providing medication abortion in the prior year. When we asked those not providing medication abortion if they would offer the method to their patients if the in-person dispensing requirement for mifepristone were removed, 171 (24%) ob-gyns reported they would, suggesting a potential doubling of providers (+104%, 95% confidence interval (CI): 97%−112%). The largest theoretical increases were in the Midwest (+189%, 95% CI: 172%−207%) and South (+118%, 95% CI: 103%−134%). In multivariable regression analysis, female ob-gyns and those in university faculty practices had higher odds of reporting they would start providing medication abortion if the dispensing requirement were removed, while those in practice >10 years had lower odds. ConclusionsRemoval of the in-person dispensing requirement could increase provision of medication abortion, including in regions with limited abortion access. ImplicationsIn order to improve access to medication abortion, the mifepristone Risk Evaluation and Mitigation Strategy should be modified or removed to allow clinicians to prescribe the medication with dispensing by pharmacies, including mail-order pharmacies.

Expanding access to medication abortion through pharmacy dispensing of mifepristone: Primary care perspectives from Illinois

ObjectiveMedication abortion is safe and effective, yet access is limited by a strict Risk Evaluation and Mitigation Strategy (REMS) that prohibits pharmacy dispensing of mifepristone. Given the ability of primary care providers (PCPs) to expand medication abortion access, we assessed PCP perspectives on how lifting the mifepristone REMS would affect the provision of medication abortion in primary care. Study designWe conducted a qualitative study of PCPs and administrators in Illinois with experience or interest in providing medication abortion care at their practice. The final sample (N=19) consisted of seven family medicine physicians, three nurse practitioners, four certified nurse midwives, and five administrators. We queried participants on how removing the REMS to allow pharmacy dispensing of mifepristone would affect their ability to provide medication abortion. We conducted interviews via telephone and used ATLAS.ti to manage our transcripts; we analyzed these data for major themes regarding pharmacy dispensing. ResultsPrimary care providers expressed support for pharmacy dispensing due to its ability to help normalize medication abortion, reduce implementation barriers in primary care, and expand abortion access. Further challenges to address if the REMS restrictions are lifted include federal funding restrictions on abortion, concerns about unsupervised mifepristone use, and pharmacy cooperation. ConclusionRemoving the mifepristone REMS to allow pharmacy dispensing could help normalize medication abortion care, facilitate provision in primary care, and address disparities in abortion access. ImplicationsOur findings illuminate novel benefits of removing the mifepristone REMS and highlight methods to promote successful implementation of pharmacy dispensing. Combined with prior literature, these results support prompt reevaluation and removal of the REMS to align medication abortion care with evidence-based practices.

Advanced practice clinicians and medication abortion safety: A 10-year Retrospective Review

Introduction Expanding the pool of trained, competent medication abortion providers is critical to filling gaps in access to safe abortion across the U.S. Despite a compelling public health argument for advanced practice clinicians (APCs) as abortion providers and the recent label change to mifepristone, 34 states currently mandate that clinicians providing medication abortion must be physicians. Method We performed a retrospective observational cohort study of medication abortion and clinician personnel data from the electronic medical record (EMR), quality management incident tracking, and human resources records at a large, urban-based sexual and reproductive health care provider between January 2009 and December 2018 to describe medication abortion outcomes when provided by APCs. We calculated descriptive statistics to assess overall abortion outcomes and complications. In order to assess complications by provider years of experience, we ran a negative binomial regression on total complications, using an offset term of the natural log of the total number of procedures with follow up to estimate a rate ratio. Results A total of 59,189 patients initiated medication abortion during the observation period under the supervision of 47 APCs. Among the 37,909 (64%) patients who completed follow up, outcomes included: 98.4% complete abortion, 1.1% failed abortion, 0.4% incomplete abortion, and 0.1% ectopic pregnancy. There were no meaningful differences in characteristics among patients who completed or failed to complete follow-up. 246 (0.6%) patients experienced complications requiring in-clinic management, ED referral, or hospital admission. .Most common interventions included aspiration (n = 112), blood transfusion (n = 36), and/or IV fluids (n = 34). We found no association between provider years of experience and complication rates (RR = 1.00, 95% CI 0.97, 1.04), restricting analyses to providers for whom there was follow-up data on at least 60% of cases in a given year. Conclusions Outcomes of medication abortion provided by APCs in our study are well within published benchmarks for medication abortion effectiveness (95–99%) and safety (

Abortion among married young women: findings from a community-based study in Rajasthan and Uttar Pradesh, India.

Abortion service provision has changed noticeably in the recent past and medication abortion currently accounts for four-fifths of all induced abortions taking place in India. How these changes have modified abortion experiences among young women - a group known to be more disadvantaged than adult women - remains unanswered. This paper fills this gap and examines the experiences of married young abortion seekers, including pre-abortion decision-making, abortion seeking and experiences of the procedure, and post-abortion complications. Data were drawn from a community-based survey of 4952 married young women aged 15-24 years conducted in Uttar Pradesh and Rajasthan in 2015. The study focused on 166 young women who had an induced abortion in the two years before the survey, and used descriptive statistics to describe their abortion experiences. Seventy-four per cent of abortion seekers had relied on medication abortion and 47% had obtained it over the counter without a physician's prescription. Moreover, 90% accessed abortion services from private facilities, including drug sellers. A small proportion (4%) had undergone abortion in the second trimester of pregnancy. At the same time, 13% reported multiple abortion attempts; 17% underwent dilation and curettage; and 52% experienced self-reported complications, including 5% who experienced moderate to severe complications. The findings call for greater attention to providing contraceptive counselling and services to married young women, ensuring abortion services in public health facilities and exploring mechanisms to improve drug sellers' knowledge and practices in providing medication abortion.

An "Invaluable Skill": Reflections on Abortion Training and Postresidency Practice.

The goal of this study was to explore family medicine residents' experiences with abortion training and identify positive and negative influences, and facilitators and barriers to providing abortion care. We conducted a qualitative study of recent graduates of an urban family medicine residency in the Northeast United States with an opt-out abortion curriculum. Individual recorded interviews were conducted with two classes of graduated residents until data saturation was reached. Data were coded and interpreted by both authors using the template analysis method. Twenty residents completed interviews. Most trainees had limited or no abortion exposure prior to residency but were open to learning abortion care. By graduation, residents reported confidence in providing options counseling for unintended pregnancy. Overall, residents felt more comfortable providing medication abortion than aspiration abortion. Many reported feeling less emotional reaction to medication abortion and noted more technical and logistical barriers to learning aspiration abortion. Logistical barriers impede integration of medication abortion into practice for many, but were perceived to be less difficult to overcome than barriers to aspiration abortion integration. All participants agreed abortion care fits into the scope of primary care. Due to a variety of barriers, few of those who had not previously planned to become abortion providers after graduation incorporated it in their practice. Abortion training prepared residents to counsel women with unintended pregnancy, but numerous barriers inhibit integration of abortion care into practice. Given limited abortion training resources and fewer perceived barriers to medication abortion provision, family medicine residencies may consider focusing training on medication abortion.

Access to Medication Abortion Among California's Public University Students

PurposeA proposed California law will require student health centers at public universities to provide medication abortion. To understand its potential impact, we sought to describe current travel time, costs, and wait times to access care at the nearest abortion facilities. MethodsWe projected total medication abortion use based on campus enrollment figures and age- and state-adjusted abortion rates. We calculated distance and public transit time from campuses to the nearest abortion facility. We contacted existing abortion-providing facilities to determine costs, insurance acceptance, and wait times. ResultsWe estimate 322 to 519 California public university students seek medication abortions each month. As many as 62% of students at these universities were more than 30 minutes from the closest abortion facility via public transportation. Average cost of medication abortion was $604, and average wait time to the first available appointment was one week. ConclusionsCollege students face cost, scheduling, and travel barriers to abortion care. Offering medication abortion on campus could reduce these barriers.

Evaluating the capacity of California's publicly funded universities to provide medication abortion

ObjectiveTo explore capacity of University of California (UC) and California State University (CSU) student health centers (SHCs) to provide medication abortion (MA) and SHC staff perspectives on providing MA. Study designSHC staff completed an online survey; we conducted site visits and conference calls with a subset of SHCs. The survey focused on barriers to abortion, resources needed for MA, and potential benefits and challenges. Results11 UCs (100%) and 20 CSUs (87%) completed surveys. All facilities provided basic primary care, including sexual and reproductive health services and some contraceptive services, but not abortion. All sites had adequate staffing and physical plant, but most would require training, access to ultrasound when needed, 24-hour hotlines (CSUs), and back-up care to provide MA. ConclusionIt would be feasible to provide MA at SHCs, but investment is needed to support staff training, equipment, 24-hour hotlines, back-up care, and minimal security upgrades, in order to implement MA services. ImplicationsIf SB320 is passed, provision of MA services at student health centers could improve access to early abortion for students in California. This model may be scaled up at other universities around the country.

Effectiveness and safety of early medication abortion provided in pharmacies by auxiliary nurse-midwives: A non-inferiority study in Nepal.

BackgroundExpanding access to medication abortion through pharmacies is a promising avenue to reach women with safe and convenient care, yet no pharmacy provision interventions have been evaluated. This observational non-inferiority study investigated the effectiveness and safety of mifepristone-misoprostol medication abortion provided at pharmacies, compared to government-certified public health facilities, by trained auxiliary nurse-midwives in Nepal.MethodsAuxiliary nurse-midwives were trained to provide medication abortion through twelve pharmacies and public facilities as part of a demonstration project in two districts. Eligible women were ≤63 days pregnant, aged 16–45, and had no medical contraindications. Between 2014–2015, participants (n = 605) obtained 200 mg mifepristone orally and 800 μg misoprostol sublingually or intravaginally 24 hours later, and followed-up 14–21 days later. The primary outcome was complete abortion without manual vacuum aspiration; the secondary outcome was complication requiring treatment. We assessed risk differences by facility type with multivariable logistic mixed-effects regression.ResultsOver 99% of enrolled women completed follow-up (n = 600). Complete abortions occurred in 588 (98·0%) cases, with ten incomplete abortions and two continuing pregnancies. 293/297 (98·7%) pharmacy participants and 295/303 (97·4%) public facility participants had complete abortions, with an adjusted risk difference falling within the pre-specified 5 percentage-point non-inferiority margin (1·5% [-0·8%, 3·8%]). No serious adverse events occurred. Five (1.7%) pharmacy and two (0.7%) public facility participants experienced a complication warranting treatment (aRD, 0.8% [-1.0%-2.7%]).ConclusionsEarly mifepristone-misoprostol abortion was as effective and safe when provided by trained auxiliary nurse-midwives at pharmacies as at government-certified health facilities. Findings support policy expanding provision through registered pharmacies by trained auxiliary nurse-midwives to improve access to safe care.

The incidence of abortion and unintended pregnancy in India, 2015.

SummaryBackgroundReliable information on the incidence of induced abortion in India is lacking. Official statistics and national surveys provide incomplete coverage. Since the early 2000s, medication abortion has become increasingly available, improving the way women obtain abortions. The aim of this study was to estimate the national incidence of abortion and unintended pregnancy for 2015.MethodsNational abortion incidence was estimated through three separate components: abortions (medication and surgical) in facilities (including private sector, public sector, and non-governmental organisations [NGOs]); medication abortions outside facilities; and abortions outside of facilities and with methods other than medication abortion. Facility-based abortions were estimated from the 2015 Health Facilities Survey of 4001 public and private health facilities in six Indian states (Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu, and Uttar Pradesh) and from NGO clinic data. National medication abortion drug sales and distribution data were obtained from IMS Health and six principal NGOs (DKT International, Marie Stopes International, Population Services International, World Health Partners, Parivar Seva Santha, and Janani). We estimated the total number of abortions that are not medication abortions and are not obtained in a health facility setting through an indirect technique based on findings from community-based study findings in two states in 2009, with adjustments to account for the rapid increase in use of medication abortion since 2009. The total number of women of reproductive age and livebirth data were obtained from UN population data, and the proportion of births from unplanned pregnancies and data on contraceptive use and need were obtained from the 2015–16 National Family Health Survey-4.FindingsWe estimate that 15·6 million abortions (14·1 million–17·3 million) occurred in India in 2015. The abortion rate was 47·0 abortions (42·2–52·1) per 1000 women aged 15–49 years. 3·4 million abortions (22%) were obtained in health facilities, 11·5 million (73%) abortions were medication abortions done outside of health facilities, and 0·8 million (5%) abortions were done outside of health facilities using methods other than medication abortion. Overall, 12·7 million (81%) abortions were medication abortions, 2·2 million (14%) abortions were surgical, and 0·8 million (5%) abortions were done through other methods that were probably unsafe. We estimated 48·1 million pregnancies, a rate of 144·7 pregnancies per 1000 women aged 15–49 years, and a rate of 70·1 unintended pregnancies per 1000 women aged 15–49 years. Abortions accounted for one third of all pregnancies, and nearly half of pregnancies were unintended.InterpretationHealth facilities can have a greater role in abortion service provision and provide quality care, including post-abortion contraception. Interventions are needed to expand access to abortion services through better equipping existing facilities, ensuring adequate and continuous supplies of medication abortion drugs, and by increasing the number of trained providers. In view of how many women rely on self-administration of medication abortion drugs, interventions are needed to provide women with accurate information on these drugs and follow-up care when needed. Research is needed to test interventions that improve knowledge and practice in providing medication abortion, and the Indian Government at the national and state level needs to prioritise improving policies and practice to increase access to comprehensive abortion care and quality contraceptive services that prevent unintended pregnancy.FundingGovernment of UK Department for International Development (until 2015), the David and Lucile Packard Foundation, the John D. and Catherine T. MacArthur Foundation, and the Ford Foundation.

Medication Abortion by Telemedicine or in Person Is Equally Safe

About 90% of U.S. counties have no abortion providers. Providing medication abortion by telemedicine could increase access to early pregnancy

Patient Attitudes Toward Early Abortion Services in the Family Medicine Clinic

To examine urban, inner-city female patients' acceptability of the provision of early abortion services by their family physician in the family medicine clinic (FMC). We administered a survey with open- and closed-ended questions to a convenience sample of English- or Spanish-speaking female patients aged 18 to 45 recruited from a FMC in the Bronx, New York. Responses were analyzed using quantitative and qualitative methods. One hundred forty-eight women completed the survey. The majority of respondents stated the FMC should offer abortion services. Seventy percent agreed their clinic should provide medication abortion, and 47% agreed their clinic should provide suction abortion. Of those who would personally consider an abortion, 73% responded that they would prefer to have it done by their family physician in the FMC, whereas 22% would prefer it at a freestanding, high-volume abortion clinic, and 5% had no preference. The majority of patients surveyed accepted the integration of abortion services into our FMC setting, and would choose to have an early abortion at their FMC. Increasing options for abortion provision within our FMC was acceptable to the majority of our sample.

Medication abortion employing routine sequential measurements of serum hCG and sonography only when indicated

Objectives This study was designed to demonstrate the safety and efficacy of providing medication abortion in a primary care site without routine use of pre- and postprocedure transvaginal sonography. Methods We performed a retrospective record review of 172 consecutive patients choosing medication abortion at our clinic. Our protocol used sonography only as needed for specific indications. All patients were intended to be followed up with serum human chorionic gonadotropin (hCG) testing pre- and posttreatment. Results Of the 151 patients not lost to follow-up, 96 (63%) had pretreatment sonography according to protocol or physician preference and 55 did not. Ninety-nine percent (95/96) of those receiving initial sonography had a successful, and uneventful, medication abortion treatment, while 98.2% (54/55) of those not receiving an initial sonography did so. This difference was not statistically significant (.597 by one-sided Fisher's Exact Test). All 119 of the women who did not receive postabortion sonography aborted completely. Only 4 of the 91 women who had both pre- and postprocedure hCG measurements, all of whom aborted successfully, had follow-up-to-initial hCG ratios of greater than 0.2 (20%). Conclusion Using a clinical protocol that involves obtaining pre- and posttreatment serum hCG measurements, with sonograms only when indicated, has similar outcomes to a protocol that uses mandatory pre- and posttreatment sonograms.

Medication abortion in the private sector in South Africa

Objectives To collect information about how private physicians in South Africa provide medication abortion services to their patients.Methods In April 2003 we asked physicians in private practice in South Africa who had purchased mifepristone (Mifegyne®) from the South African distributor about the medication abortion regimen they offered, satisfaction with the method, and how services have been incorporated into their practices.Results Forty-four providers participated in the survey. They report using a range of doses and regimens. Most respondents offer mifepristone–misoprostol to their patients, although a significant minority also offer misoprostol-alone for pregnancy termination. While the majority of medication abortion providers also offer surgical abortions, a significant number of non-surgical providers were only offering medication abortion.Conclusion South African medication abortion providers find the method acceptable, indicate that their staff are largely supportive of offering it to their patients, and report that clients like the method. Those surveyed believe that most of their patients are eligible for the regimen, although uptake has been limited.