ABORTION 3.0 NEW DIRECTIONS FOR PROTECTING AND EXPANDING ACCESS TO - - PDF document
ABORTION 3.0 NEW DIRECTIONS FOR PROTECTING AND EXPANDING ACCESS TO ABORTION I have no disclosures JENNIFER KERNS, MD, MPH ASSOCIATE PROFESSOR, UCSF DEPARTMENT OF OB, GYN, AND REPRO SCI ABORTION VERSION 3.0 WHO HAS ABORTIONS Abortion
Abortion 1.0 * Roe v Wade Abortion 2.0 * Drop in morbidity * Increased training * Violence * State restrictions Abortion 3.0 * New paradigm * Access * Advocacy * Equity
1 in 4 women will have an abortion by age 45 (20% by age 30) Decline in abortion rate from 2008-2014 (19.4 to 14.6 per 1000 women)
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 (27.1 vs 10 per 1000)
Jatloui et al. MMWR Surveill Summ 2017 Tang et al. Best Pract Res Clin Obstet Gynaecol 1993 Jones et al. Perspect Sex Reprod Health 2008 Strauss et al. MMWR Surveill Summ 2007 Kafrissen et al. JAMA 1984
14‐20 wks > 20 wks
Aspiration abortion – D&C outdated procedure 75% providers are obgyns ½ are 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
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 don’t differ according to setting (ambulatory surgery center vs office)
Rpberts et al. JAMA 2018
84% 45% 45%
Licensed physician Abortion in hospital Second physician
86%
Gestational limits
54%
Waiting period
36%
Mandated counseling
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 2016 Baum et al. PLoS One 2016 Fuentes et al. Contraception 2016 White et al. PSRH 2016 White et al. Women’s Health Issues 2017
13 cases may come before the Supreme Court and if Roe is overturned, 22 states may ban abortion outright Other states may make it exceedingly difficult to access Outlawing abortion women pursue less safe methods Make misoprostol abortions available (Peru example) Preparation for complications from unsafe abortion Neighboring states will play a big role
Ganatra et al. Lancet 2017 Grossman et al. PLoS One 2018
Specialty care: dermatology, pediatric subspecialties, dermatology, HIV Abortion care: 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
Grossman and Grindlay. Obstet Gynecol 2017 Grindlay and Grossman. J TelemedTelecare 2017
Scope of primary care includes abortion Family med: requires exposure to aspiration Opportunity for telemedicine Referrals from primary care Organizational challenges: training for providers (IUD and implant insertions), other health issues taking priority Strategies for successful integration
White et al. Health Serv Res 2018 Yang and Kozhimannil. Obstet Gynecol 2016 Amico et al. Prim Care 2018
Risk Evaluation Mitigation Strategy (REMS) – misapplied to mifepristone Australia & Canada – mifepristone dispensed in pharmacies Patient counseling Follow up
Raifman et al. J Am Pharm Assoc 2018
Safety and effectiveness pharmacy vs. public facilities – non-inferiority trial Pharmacy dispensation not inferior to clinic Emergency contraception
Rocca et al. PLoS One 2018 Cleland et al. Women’s Health Issues 2016
Does mife/miso meet the US FDA regulatory criteria for OTC status? Label comprehension Self-selection Actual use studies
Kapp et al. BJOG 2017
History of medicalization Does medicalization undercut 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).
Associated with decreased morbidity and mortality
Singh et al. Obstet Gynecol 2016 Erdman et al. Reprod Health Matters 2018 Berry-Bibee et al. BMJ Sex Reprod Health 2018
Health inequity Harm reduction Social change
Self-managed abortion may be a preference over clinical care Versus harm reduction Desperation while searching unsafe attempts 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
Aiken et al.. Perspectives Sex Reprod Health 2018 Aiken et al. BMJ Sex Reprod Health 2018
Individual level – clinical care Media – don’t wait for an invitation! Policy work Educating legislators Sharing stories Health equity Harm reduction Social change
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
Health equity Harm reduction Social change
Turk et al. Contraception 2016
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 Health equity Harm reduction Social change
Women of color Immigrants Poor women
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 – in the hands of patients Lens of equity