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ABORTION 3.0New directions for protecting and expanding access to abortion

Jennifer Kerns, MD, MS, MPH

Associate Professor, UCSF

Department of Ob, Gyn, and Repro Sci

¡ Notes – add this study

¡ Exploring the feasibility of obtaining mifepristone and misoprostol from the internet☆☆☆

¡ Author links open overlay panelChloeMurtaghaElisaWellsbElizabethG.RaymondaFrancineCoeytauxbBeverlyWinikoffa

¡ Show more

¡ https://doi.org/10.1016/j.contraception.2017.09.016

¡ Also add vice.com piece – turnaway study showing 2 women denied abortion died from pregnancy complications

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¡ I have no disclosures

Abortion – version 3.0

Abortion 1.0* Roe v Wade* Drop in morbidity

Abortion 2.0

* Violence* Increased training

* State restrictions

Abortion 3.0* New paradigm* Access

* Advocacy* Equity

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a. 500

b. 1500

c. 2500

d. 3500

Approximately how many abortion facilities are there in the US?

Who has abortions?

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Abortion in the US

¡ 1 in 4 women will have an abortion by age 45 (20% by age 30)

¡ Decline in abortion rate from 2008-2014

¡ Adolescents (46% decline)

¡ Abortion rate remains twice as high for poor women (36.6 per 1000)

¡ Black women have higher abortion rates than white women (2.7 times higher)

Guttmacher Institute

Abortion rates by race and ethnicity

¡ Declines seen among all groups

¡ Racial/ ethnic disparities persist

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Abortion among poor women

Abortion techniques

§ 91.6% of all abortions < 13 weeks

§ 140,000 per year in US

§ Medical abortion accounts for 30%

§ D&E accounts for 96% in US

§ What abortions aren’t being counted?

Jatloui et al. MMWR Surveill Summ 2017 Tang et al. Best Pract Res Clin Obstet Gynaecol 1993Jones et al. Perspect Sex Reprod Health 2008 Strauss et al. MMWR Surveill Summ 2007Kafrissen et al. JAMA 1984

14-20 wks

> 20 wks

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First trimester abortion in 2018

¡ Aspiration abortion – D&C outdated procedure

¡ 75% providers are Ob/Gyns

¡ 50% are < 50 years old (versus 36% in 2002)

¡ Routine prophylactic antibiotics

¡ Misoprostol for cervical ripening in late first trimester

¡ Pain management

¡ Same-day contraception, including LARC

White et al. Contraception 2018

a. True

a. False

Abortions done in ambulatory surgery centers have fewer complications vs offices or clinics

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a. True

a. False

Medical abortion is associated with more complications than aspiration abortion

Complications of abortion are rare

¡ In a study of > 50,000 abortions in the US…

¡ First-trimester aspiration: 2.5%

¡ First-trimester medication abortion: 5.4%

¡ Second-trimester abortion: 2.6%

¡ And no difference according to setting (ambulatory surgery center vs office)

Rpberts et al. JAMA 2018

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State-based abortion restrictions

82%

38%

36%

Licensed physician

Abortion in hospital

Second physician

86%Gestational limits

54%Waiting period

36%Mandated counseling

Restrictions in 2019

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Not only restrictions… some expansions and protections

Support or hostility for abortion

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An overview of abortion restrictions

Abortion deserts

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Abortion deserts

¡ 27 US cities where women have to travel > 100 miles

¡ 6 states with only 1 abortion provider:

¡ North Dakota, South Dakota, Missouri, Kentucky, West Virginia, Mississippi

¡ Effect on existing services:¡ Longer wait¡ Leave from job¡ Child care

Grossman et al. JAMA 2017 Gerdts et al. AJPH 2016Baum et al. PLoS One 2016 Fuentes et al. Contraception 2016White et al. Women’s Health Issues 2017

Abortion under the new supreme court

¡ 13 cases may come before the Supreme Court, and if Roe is overturned¡ 8 states have “trigger bans” in place

¡ 22 states may ban abortion outright

¡ Other states may make it exceedingly difficult to access

¡ Outlawing abortion à women will pursue other methods¡ Turnaway study¡ Make misoprostol abortions available (Peru harm reduction example)

¡ Preparation for complications from unsafe abortion

¡ Neighboring states will play a big role

Ganatra et al. Lancet 2017 Ralph et al. Annals Int Med 2019Grossman et al. PLoS One 2018

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Telemedicine

¡ Broad application – 18 states use it for abortion (17 states prohibit it)

¡ Abortion care:

¡ Systematic review: similar efficacy as in-person care; high satisfaction

¡ Poland: > 9 weeksà more clinical visits, not heavier bleeding

¡ Iowa: no difference in med ab complications telemedicine vs in-person (0.18% vs 0.32%)

¡ Alaska: providers’ experiences – patient-centered approach, expedited care, easy to do

¡ Utah: qualitative studyà Easy to use, high acceptability, felt attended to, private

Endler et al. BJOB 2019 (syst rev) Grossman and Grindlay. Obstet Gynecol 2017Endler et al. BJOG 2019 Grindlay and Grossman. J TelemedTelecare 2017Grossman BJOG 2019 Ehrenreich et al. Women’s Health Issues 2019

Finding our allies… primary care

¡ Scope of primary care includes abortion

¡ Family medicine: requires exposure to aspiration

¡ Counseling

¡ Referrals

¡ Provision of services

¡ Opportunity (and risk) for telemedicine

¡ Organizational challenges/ strategies for successful integration

White et al. Health Serv Res 2018 Yang and Kozhimannil. Obstet Gynecol 2016Amico et al. Prim Care 2018

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Pharmacy provision – REMS requirement

¡ Risk Evaluation Mitigation Strategy (REMS)

¡ REMS for mifepristone – prohibits dispensing at pharmacies

¡ Australia & Canada

¡ After pharmacy access

¡ 62 certified prescribers

¡ 147 certified dispensers (1/3 rural areas)

Raifman et al. J Am Pharm Assoc 2018

Pharmacy provision can be successful and is safe

¡ Nepal – Safety and effectiveness of mifepristone when dispensed through pharmacies vs. public facilities – non-inferiority trial

¡ Complete abortion (99% pharmacy vs 97% clinics)à pharmacy not inferior

¡ Pharmacy workers feel confident

¡ Emergency contraception – success story, AND

¡ Ongoing management to ensure access

Rocca et al. PLoS One 2018 Tamang et al. Contraception 2018Cleland et al. Women’s Health Issues 2016 Samari et al. Int Perspect Sex Reprod Health 2018

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Can medication abortion be over the counter?

¡ Self-selection

¡ Label comprehension

¡ Actual use

Kapp et al. BJOG 2017

Criteria for OTC status

• acceptable toxicity profile• unlikely to be addictive• low abuse potential • consumers can appropriately, and therefore safely, use the medicine

without medical supervision• ability to self diagnose for the treatment indication• self-screen for eligibility and contraindications based on label

instructions (self-selection)• comprehension of written instructions (label comprehension)• knowledge of when to seek medical care for complications or

side effects (actual use)• benefit–risk profile sufficiently positive

De-medicalization

¡ History of medicalization – effect on public health?

¡ Roe v. Wade: power of abortion decision making – patients or doctors?

¡ First reference: power with both the pregnant woman and her doctor

¡ All subsequent references, including the final summation referred only to the doctor:

‘The abortion decision in all its aspects is inherently, and primarily, a medical decision, and basic responsibility for it must rest with the physician’ (Roe v. Wade: 165–166).

Halfmann. Health 2011

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Relationship between self managed abortion & safe abortion

¡ Associated with decreased morbidity and mortality

Erdman et al. Reprod Health Matters 2018Berry-Bibee et al. BMJ Sex Reprod Health 2018

Health inequity

Harm reduction

Social change

Self managed abortion

¡ Poor access, stigma, fear, discomfort in the medical setting, lack of knowledge

¡ Self-managed abortion as a preference (vs harm reduction)

¡ Support needed, regardless of how the abortion is managed¡ Most websites either had meds or info but

not both, and unclear if trusted info

¡ Pre- and post-abortion support needed

¡ Online purchase is feasibleAiken et al. Perspectives Sex Reprod Health 2018Aiken et al. BMJ Sex Reprod Health 2018Murtagh et al. Contraception 2018

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The path forward – ADVOCACY

¡ Individual level – clinical care

¡ Media – don’t wait for an invitation!

¡ Policy work

¡ Educating legislators

¡ Sharing stories

The path forward – TRAINING

¡ Ryan Programs

¡ Fellowship in Family Planning

¡ RHEDI

¡ Apprenticeships

¡ New opportunities¡ Self-managed abortion support

¡ Abortion training centers¡ Non-physicians¡ Specialties outside obgyn, family med, peds

Turk et al. Contraception 2016

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The path forward – EQUITY

¡ Who has been left out of the conversation:

¡ Experiences with & preferences for abortion

¡ Roadmap:¡ Reproductive justice framework – Loretta Ross

¡ Increasing diversity in workforce for abortion care

¡ Structural barriers to abortion access – includes structural racism

Women of colorImmigrants

Poor women

Final thoughts

¡ Access is worsening, especially for vulnerable populations¡ Clinics are declining

¡ States imposing restrictive legislation

¡ Supreme Court may overturn Roe v. Wade

¡ How to improve access while maintaining safety¡ Expeditious referral, continue training providers, advocacy work

¡ New paradigm for medication abortion – primary care allies, telemedicine, pharmacy provision, OTC, self-managed abortion

¡ Lens of equity

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a. Develop/ refresh a working referral list of the nearest abortion providers in your area

b. Use social media to post or re-post a piece/ message about abortion access

c. Discuss with colleagues how your institution (clinic, office, group, you) can better serve women seeking abortion services

d. Find out if there are telemedicine options for your patients in your area

e. Write an op-ed, a letter to a newspaper, a blog post

f. Learn or improve your options counseling for pregnant patients

Which of the following can you commit to doing in the next several months?

We are all part of Abortion 3.0