Disclosures I have no financial disclosures Abortion in 2020: The - - PDF document

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Abortion in 2020: The Role of Primary Care

CME Medical Care of Vulnerable and Underserved Populations Jessica Beaman, MD MPH Assistant Professor of Medicine Division of General Internal Medicine at ZSFG

Disclosures

• I have no financial disclosures

Learning Objectives

1.

Recognize the prevalence and impact that abortion has on patients in the primary care setting.

2.

Demonstrate the intersectionality of abortion through its association with the executive, legislative and judicial branches of government.

3.

Recommend clinical changes and advocacy efforts that people can take to support abortion in primary care.

The Impact of Abortion

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Terminology

• Elective abortion = when a medication is taken or a procedure

is performed to end a pregnancy

• Also called an induced abortion, pregnancy termination, or

abortion

• It is not:
• Spontaneous abortion or miscarriage or early pregnancy loss

Reproductive age women in primary care

• 61 million US women of reproductive age (15-44)
• 10% become pregnant annually
• Half of all US women will seek primary care in an internal

medicine or family medicine clinic each year

Lifetime Prevalence of Common Medical Conditions

Lifetime Prevalence (%)

Perce nt Breast Cancer Cervical Cancer Depression Diabetes Hypertension

Breast Cancer Cervical Cancer Depression Diabetes Hypertension

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Unintended Pregnancy is Common

Unintended Pregnancy Cervical Cancer Diabetes Hypertension Breast Cancer Depression

Lifetime Prevalence (%)

Pregnancy Intentions

• 45% of all pregnancies are

unintended

• Mistimed = wants to become

pregnant in the future but not at the time she became pregnant

• Unwanted = did not want to

become pregnant then or at any time in the future

Pregnancy Outcomes

Computer modeling of how brains make complex decision

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1 in 5

Pregnancies in US result in abortion

1 in 4

Women will have an abortion by age 45

Trends in Abortion Care

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Access to Care

90% of women live in US county without an abortion clinic

Distance to nearest abortion facility, 2017

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Only 7%

• f practicing ob/gyns perform

abortions in their practice

35%

• f practicing ob/gyns would not refer

patients for abortion services

Turnaway Study (UCSF 2018 and ongoing)

ANSIRH (Advancing New Standards in Reproductive Health)

• Large, longitudinal study (N=1000)
• 8000 interviews
• Women turned away based on GA
• Lasting impacts
• Unemployment/living below FPL
• In relationship w/ abusive partner
• Less likely to have aspirational plans
• No increased likelihood for:
• Depression
• Anxiety
• Suicidal ideation

Legal Considerations

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The Executive Branch

First U.S. President to attend the annual March for Life

“Let us work together to build a culture that cherishes innocent life. And let us reaffirm a fundamental truth: all children, born and unborn, are made in the holy image of God.”

The Legislative Branch

A few examples

US Senator James Inhofe (R-OK) disproving climate change on the Senate floor by providing a snowball as evidence for lack of global warming

“

"I heard about it over the years. I never questioned it or gave it a lot of thought."

Ohio State Representative John Becker

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Types of Regulations

Physician/Clinic Patient

• Physician-only (40)
• Public funding (33+DC)
• Hospital-based (19)
• Two physicians (17)

Private insurance (12)

• Gestational limits (43)
• Parental involvement (37)
• Waiting periods (27)
• State-mandated counseling (18)

Ability of fetus to feel pain (13) Mental health consequences (8) Link to breast cancer (5)

Reversal of Medication Abortion

Who can provide abortion?

• 40 states require clinics who

perform abortions to be physicians

• Know your state laws
• Guttmacher Institute
• “An Overview of Abortion Laws”

(Updated January 1, 2020)

What if Roe v. Wade is overturned?

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Interactive Tool

The Judicial Branch

The Supreme Court

June Medical Services LLC v. Gee March 4, 2020 Whole Woman’s Health v. Hellerstedt June 27, 2016

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Evidence for Abortion in Primary Care

NASEM Report

Safety of Mifepristone and Abortion (2018)

• All forms of abortion are safe and effective
• Abortion can be safely performed in an office-

based setting

• Does not increase risk of:
• Secondary infertility
• Breast cancer
• Depression/anxiety/PTSD
• Serious complications are < 1%

Medication Abortion in Primary Care

• Power to destigmatize
• Integration in to routine care
• Lack of protestors
• Patient preference

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Incorporating Abortion into Primary Care

• 2012 by Page et al
• 90 Patients in academic PCC
• 67% felt PCC should offer medical abortions
• 87% would want PCP to perform
• 2005 by Schwarz and Luetkemeyer
• 212 Residents, 11 residencies
• 42% IM residents willing to prescribe medication abortion
• 2010 by Godfrey et al
• 299 Patients in NYC and Chicago
• 58% would choose primary care clinic (PCC) for abortion
• 2015 Wu et al
• 210 Patients in academic PCC
• 93% “very satisfied” with abortion experience
• 3.9/4 scores for quality of staff, doctor, and counseling experience

Medication Abortion in Primary Care

• Power to destigmatize
• Patient preference
• Patient satisfaction
• Achieving rapid appointment access
• Staff courtesy
• Ready information to questions

Clinical Integration: 5 Key Questions

Clinical Integration

5 Key Questions 1.

Who can receive a medication abortion?

2.

What are the medications and what do they do?

3.

Do I need an ultrasound or other labs?

4.

What follow-up is needed?

5.

How do I get abortion medications in to my clinic?

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• 1. Who can receive a medication abortion?

Indications

• Gestational age < 10

weeks

• Prefer medications over

procedure

80% US abortions occur <10 weeks

Early Abortion Options (< 10 weeks)

MEDICATION ABORTION ASPIRATION PROCEDURE

• 1. Who can receive a medication abortion?

Indications

• Gestational age < 10

weeks

• Prefer medications over

procedure Contraindications

• Ectopic pregnancy
• IUD in place
• Adrenal insufficiency
• Bleeding or clotting

disorders/anticoagulation

• Inherited porphyria

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Clinical Integration

5 Key Questions 1.

Who can receive a medication abortion?

2.

What are the medications and what do they do?

3.

Do I need an ultrasound or other labs?

4.

What follow-up is needed?

5.

How do I get abortion medications in to my clinic?

• 2. What are the medications and what do they do?
• Mifepristone: A progesterone receptor blocker
• Leads to detachment of pregnancy from endometrium
• Also softens/ripens cervix and primes myometrium for misoprostol
• Misoprostol: A prostaglandin analogue
• Stimulates uterine contractions

Cramping + expulsion

At home 24‐48 hours later

Typically no symptoms

MISOPROSTOL

Prostaglandin In office

Efficacy of Mifepristone and Misoprostol for Abortion

• Most studies = ~95%
• Society of Family Planning Guidelines (2014)
• 92% up to 49 days
• 85% from 49-70 days
• TEACH Workbook (Chen and Creinin 2015)
• 95-99% up to 63 days
• 91-94% from 64-70 days
• Danco Label
• 96-97% effective through 70 days

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FDA-Labeling for Mifepristone

• REMS

FDA-Labeling for Mifepristone

• REMS (Risk Evaluation and

Mitigation Strategies)

• 58 FDA-approved medications with

“serious safety concerns”

• Registration of clinicians in central

database

• Must be dispensed in-person
• No pharmacy
• No mail

FDA-Labeling for Mifepristone

• REMS
• Black Box warning
• Rare infection
• Clostridium sordellii
• Clostridium perfringens

Clinical Integration

5 Key Questions 1.

Who can receive a medication abortion?

2.

What are the medications and what do they do?

3.

Do I need an ultrasound or other labs?

4.

What follow-up is needed?

5.

How do I get abortion medications in to my clinic?

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• 3. Do I need an ultrasound?
• You do not need an ultrasound on-site or any other special

equipment

• For women with regular cycles, LMP is as effective as other

methods for determining GA

• Ultrasound versus labs (e.g., hCG)

What labs are needed?

Required

• Rh testing
• Rhogam 50mcg IM

within 72 hours of mifepristone

• Not required if GA < 8

weeks Recommended

• CBC
• R/o anemia
• Consider safety if Hb < 9.5
• Quantitative hCG
• If plan to follow levels

Clinical Integration

5 Key Questions 1.

Who can receive a medication abortion?

2.

What are the medications and what do they do?

3.

Do I need an ultrasound or other labs?

4.

What follow-up is needed?

5.

How do I get abortion medications in to my clinic?

Follow-up

Up to day 14

• In-person or not
• Ultrasound = absence of gestational sac or embryo
• Endometrial thickening is normal unless accompanied by symptoms
• Serial quantitative hCG
• Decline by 50% by 3 days
• Decline by 80% by 7 days
• Self-assessment is non-inferior to routine follow-up

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Anticipatory Guidance/Return Precautions

Concerning Symptoms and Return Precautions Excessive bleeding: soaking through 2 sanitary napkins per hour for 2 consecutive hours Lack of bleeding: no bleeding 24 hours after taking misoprostol Infectious symptoms: flu‐like symptoms that start 24 hours after taking misoprostol or fevers, chills, severe abdominal pain and/or malodorous discharge Pain: severe abdominal pain, cramping, and/or bloating Ongoing pregnancy symptoms: feeling pregnant (e.g., breast tenderness, nausea) at the follow‐up visit

Clinical Integration

5 Key Questions 1.

Who can receive a medication abortion?

2.

What are the medications and what do they do?

3.

Do I need an ultrasound or other labs?

4.

What follow-up is needed?

5.

How do I get abortion medications in to my clinic?

Protocols

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Protocols

Expense

GoodRx, NeedyMeds, Danco (as of 2/2020)

• Mifepristone
• GenBioPro = $50
• Danco = $80-100
• Misoprostol (800 mcg)
• Generic = $10-15

Legal Resources

For integrating mifepristone in to your clinic

• ACLU Reproductive Freedom Project
• Guttmacher Institute
• National Abortion Federation
• Physicians for Reproductive Health
• Reproductive Health Access Project (RHAP)
• Regional clusters and national IM cluster
• (Danco)

The Future

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“

“As scientists, the most compelling argument is yours, because you know that of which you speak. You are essential, and your contributions give us hope. Know your

• power. Know your responsibility.”

US Congresswoman and Speaker of the House Nancy Pelosi Speaking at the Global Climate and Health Forum at UCSF, 2018

Advocacy

Concrete ways to engage

• Talk to a friend or family member, a colleague, someone at your

institution

• Urge your representatives and senators to support the EACH

Woman Act (HR 1692, S 758)

• Join a RHAP Cluster
• Email Laura Riker (Laura@reproductiveaccess.org) for your region

and specialty

Patient Advocacy

Know how to support your patients

• Help patients utilize abortion funds
• Provide direct referrals for patients
• Title X? Refer to All-Options
• Hotlines for patients
• Options counseling: All-Options

1-888-493-0092

• After-abortion: Exhale

1-866-4-Exhale or text

Research Studies

UCSF + Multiple Community Sites

• Expanding primary-care provision of medication abortion via

mail-order mifepristone

• Recruiting for primary care sites to start later this year
• Sites will receive training, materials, ongoing support,

reimbursement for services

• After evaluation by clinician, patients will obtain medications from

mail-order pharmacy and will be asked to complete 2 surveys

• If interested, email Daniel.Grossman@UCSF.edu or

Jessica.Beaman@UCSF.edu

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CME Video

Abortionpillcme.teachtraining.org

Summary

• Unintended pregnancy and abortion are common and

disproportionately affect vulnerable and underserved communities.

• The landscape of abortion continues to evolve and

reproductive rights are being protected or limited at all levels

• f the government.
• Abortion is safe and effective and can be provided in primary

care settings without special equipment.

• Resources are available to support advocacy for and

integration of medication abortion in to primary care practice.