ABORTION 3.0 New directions for protecting and expanding access to - - PowerPoint PPT Presentation

ABORTION 3.0

New directions for protecting and expanding access to abortion

Jennifer Kerns, MD, MS, MPH Associate Professor, UCSF Department of Ob, Gyn, and Repro Sci

 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

a.

500

b.

1500

c.

2500

d.

3500

Approximately how many abortion facilities are there in the US?

Who has abortions?

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

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 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

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 Aspiration abortion – D&C outdated procedure  75% providers are Ob/Gyns  50% are 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

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

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

Not only restrictions… some expansions and protections

Support or hostility for abortion

An overview of abortion restrictions

Abortion deserts

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 2016 Baum et al. PLoS One 2016 Fuentes et al. Contraception 2016 White 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  If all high risk states banned abortion…

 ↑ of 250 miles to access abortion; 33% ↓ in abortion rate

 Outlawing abortion  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 Myers et al. Contraception 2019

Telemedicine

 Broad application – 18 states use it for abortion (18 states prohibit it)  Abortion care – counseling, informed consent, clinical evaluation:

 Similar efficacy as in-person care; high satisfaction  Alaska: providers’ experiences – patient-centered approach, expedited care, easy to do  Utah: qualitative study Easy to use, high acceptability, felt attended to, private

Endler et al. BJOG 2019 (syst rev) Grossman and Grindlay. Obstet Gynecol 2017 Kohn et al. Obstet Gynecol 2019 Endler et al. BJOG 2019 Grindlay and Grossman. J TelemedTelecare 2017 Raymond et al. Contraception 2019 Grossman BJOG 2019 Ehrenreich et al. Women’s Health Issues 2019 Daniel et al. Contraception 2020

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 2016 Amico et al. Prim Care 2018

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) 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 2018 Cleland et al. Women’s Health Issues 2016 Samari et al. Int Perspect Sex Reprod Health 2018

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

Relationship between self managed abortion & safe abortion

 Associated with decreased morbidity and mortality

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

 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 feasible

Aiken et al. Perspectives Sex Reprod Health 2018 Aiken et al. BMJ Sex Reprod Health 2018 Murtagh et al. Contraception 2018

Self managed abortion: it’s happening

 2/3 of abortion providers reported seeing patients who had tried to interrupt the

pregnancy on their own

 60% reported it has increased in the past 5 years

 Texas:

 Knowledge of abortion meds outside the clinic (30%); interest in meds outside the clinic (40%)  7-13% of abortion clients tried to self-manage their abortion (2012, 2014, present)

 Women on waves (telemedicine service) received >6,000 requests/ 10 months

 76% from hostile states  Barriers to access + preference for self-management

Kerestes et al. Contraception 2019 Aiken et al. AJPH 2020 Fuentes et al. BMC Women’s Health 2020

Self managed abortion: it’s *safe*

 SMA with mife/miso or miso only: very effective and safe – less effective with herbs  Evidence for safety beyond first trimester (with linkages to health care system)  Emerging evidence for safety of self-managed abortion

 Clinicians, researchers, reproductive law experts

Conti and Cahill. Curr Opin Obstet Gynecol 2019 Stillman et al. BMJ Open 2020 Moseson et al. Best Pract Res Clin Obstet Gynecol 2020 Moseson et al. Contraception 2020

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

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 color Immigrants Poor women Non-English-speaking

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

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