ABORTION 3.0 New directions for protecting and expanding access to - - PDF document
12/6/19 ABORTION 3.0 New directions for protecting and expanding access to abortion Controversies in Womens Health 2019 Jennifer Kerns, MD, MS, MPH Associate Professor, UCSF Department of Obstetrics, Gynecology, and Reproductive Sciences
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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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¡ 1 in 4 women will have an abortion by
¡ Declines seen among all groups, esp
¡ Racial and disparities persist ¡ Black women have 2.7 times higher
¡ Abortion is twice as high for poor
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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
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White et al. Contraception 2018 Roberts et al. JAMA 2018
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82% 38% 36%
Licensed physician Abortion in hospital Second physician
86%
Gestational limits
54%
Waiting period
36%
Mandated counseling
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¡ 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. Women’s Health Issues 2017
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¡ 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 2019 Grossman et al. PLoS One 2018
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¡ 39% of the population would experience increases in travel distances ¡ the average resident is expected to experience a 249 mile increase in travel distance ¡ the abortion rate is predicted to fall by 32.8%
Myers et al. Contraception 2019
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¡ 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. BJOG 2019 (syst rev) Grossman and Grindlay. Obstet Gynecol 2017 Endler et al. BJOG 2019 Grindlay and Grossman. J TelemedTelecare 2017 Grossman BJOG 2019 Ehrenreich et al. Women’s Health Issues 2019
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¡
Online telemedicine abortion service – Women on Waves – study over 10 months
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6022 requests from US residents
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76% from hostile states
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Mississippi had the highest rate of requests (24.9 per 100 000 women of reproductive age)
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In both hostile and supportive states, a majority (60%) reported a combination of barriers to clinic access and preferences for self-management
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Cost was the most common barrier (71% in hostile states; 63% in supportive states; P < .001).
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Privacy was the most common preference (49% in both hostile and supportive states; P = .66). There is considerable demand in the US for self-managed medication abortion through online telemedicine
Aiken et al. AJPH 2020
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¡ Counseling ¡ Referrals ¡ Provision of services
White et al. Health Serv Res 2018 Yang and Kozhimannil. Obstet Gynecol 2016 Amico et al. Prim Care 2018
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¡ After pharmacy access
¡ 62 certified prescribers ¡ 147 certified dispensers (1/3 rural areas)
Raifman et al. J Am Pharm Assoc 2018
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¡ Complete abortion (99% pharmacy vs 97% clinics)à pharmacy not inferior
¡ Ongoing management to ensure access
Rocca et al. PLoS One 2018 Tamang et al. Contraception 2018 Cleland et al. Women’s Health Issues 2016 Samari et al. Int Perspect Sex Reprod Health 2018
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Kapp et al. BJOG 2017
medicine without medical supervision
instructions (self-selection)
side effects (actual use)
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Erdman et al. Reprod Health Matters 2018 Berry-Bibee et al. BMJ Sex Reprod Health 2018
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¡ Poor access, stigma, fear, discomfort in the
¡ Self-managed abortion as a preference ¡ Support needed, regardless of how the
¡ Websites vary in accuracy and product ¡ Pre- and post-abortion support needed ¡ Most women seeking abortion investigated
¡ Online purchase is feasible
Aiken et al. Perspectives Sex Reprod Health 2018 Aiken et al. BMJ Sex Reprod Health 2018 Murtagh et al. Contraception 2018 Kerestes et al. Sex Reprod Health Matters 2019
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¡ Self-managed abortion, is an overall safe and effective way to end a pregnancy; however
stigma and legal barriers are significant.
¡ The safest environment for SMA is one where accurate information is available, medical
care is accessible when needed, and all methods of abortion remain legal.
Conti and Cahill. Curr Opin Obstet Gynecol 2019 Kerestes et al. Contraception 2019
335 abortion provider respondents
attempts at SMA (most with mife/miso)
practice had increased
is safe
complications (most incomplete)
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¡ Educating legislators ¡ Sharing stories 32
¡ Self-managed abortion support ¡ Abortion training centers ¡ Non-physicians ¡ Specialties outside obgyn, family med, peds
Turk et al. Contraception 2016
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¡ Reproductive justice framework – Loretta Ross ¡ Increasing diversity in workforce for abortion care ¡ Structural barriers to abortion access – includes structural racism
Women of color Immigrants Poor women
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¡ Clinics are declining ¡ States imposing restrictive legislation ¡ Supreme Court may overturn Roe v. Wade
¡ Expeditious referral, continue training providers, advocacy work ¡ New paradigm for medication abortion – primary care allies, telemedicine, pharmacy
provision, OTC, self-managed abortion
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