Disclosures ⇾ I have nothing to disclose A world post Roe v. Wade Daniel Grossman, MD October 2019 UCSF Obstetrics and Gynecology Update University of California, San Francisco | Bixby Center for Global Reproductive Health 1 2 Objectives Limited clinic access Estimated distance to nearest 89% of US ⇾ Review potential scenarios that could abortion facility counties do not weaken or overturn Roe have an abortion ⇾ What can we expect in areas with limited provider or no access to clinic-based abortion 38% of care? reproductive age ⇾ What is role of haven states? women live in one of those counties Jones, 2019; Cartwright, 2018 3 4
State restrictions enacted per year Risk to abortion rights if Roe fell Center for Reproductive Rights Guttmacher Institute 5 6 Low-access areas ⇾ Increased need for logistic support to help patients travel to where they need to go ⇾ Travel costs, support ⇾ Role of abortion funds What can we expect in low- ⇾ Role of local clinicians to provide direct access states? referral ⇾ Need to know where patients can travel to access services and what logistic support exists ⇾ May be opportunity to facilitate care by starting work-up locally ⇾ Increased self-managed abortion 7 8
Medication abortion Medication abortion regimens ⇾ Mifepristone 96% 100% 90% 85% ⇾ Progesterone receptor blocker 80% ⇾ Causes lining of uterus 70% to thin, helping to 60% Efficacy separate pregnancy from 50% uterus 40% ⇾ Misoprostol 30% ⇾ Prostaglandin 20% ⇾ Causes softening of 10% cervix, uterine 0% contractions Mifepristone-misoprostol Misoprostol alone Spitz, Contraception 2010 9 10 Self-managed abortion Self-induction among abortion clients in the US 2.2% ⇾ How common is it? Ever used ⇾ What methods do women use? something to self-induce ⇾ Why do women do this? ⇾ Is it safe and effective? 0.9% 1.3% ⇾ Is there a role for healthcare providers as Used something else Used misoprostol (Vitamin C, herbs) access to clinic-based care becomes more constrained? ~2% Foreign-born women more likely took something in to have ever used current pregnancy in misoprostol or other 2008 substance Jerman, 2016 11 12
Self-induction among abortion clients in Texas Self-induction among Texas women age 18-49 Among a sample of Among abortion clients: the general ⇾ 6.9% reported attempting population of Texas to end current pregnancy prior to seeking abortion women age 18-49: care ⇾ 1.7% reported ever ⇾ 2.8% used herbs attempting ⇾ 1% used misoprostol self-induction ⇾ 12% in cities near the ⇾ Approximately Mexican border 100,000 women Texas Policy Evaluation Project, 2015 Grossman, et al., 2014 13 14 Methods women in national sample reported using Self-Induction Methods reported by Texas women, for SIA (n=7,022) 2015 60 12 50 10 8 40 6 30 N N 4 20 2 10 0 Misoprostol Other Herb, tea or 0 Herbs Other drug Misoprostol Physical (hit EC after Other medication vitamin in abdomen) Texas Policy Evaluation Project, 2015 15 16
Reasons for attempting self-abortion Is self-induced abortion safe? Barriers to clinic- Preference for based care self-abortion ⇾ Lack of knowledge ⇾ More like menstrual about services regulation ⇾ Young age ⇾ “Less of an abortion” ⇾ Financial barriers ⇾ Interest in alternative medicine ⇾ Desire to avoid clinic ⇾ Safer, quicker, more natural Grossman, et al., 2010 17 18 Medications obtained online in the US Safety of self-use in other countries ⇾ Limited data on self-use of medication ⇾ Ordered 20 mifepristone-misoprostol combination abortion shows promise products and 2 misoprostol-only products ⇾ Obtained 18 mife-miso and 2 miso-only products ⇾ OTC use in Bangladesh (mife/miso) ⇾ 71% reported correct use and 96% pregnancies terminated ⇾ No site required Rx or medical information ⇾ Harm-reduction model in Peru (miso only) ⇾ Took 9.5 days to receive (range 3-21 business days) ⇾ Of those who took miso, 89% reported complete abortion and ⇾ Price of combination products: $110-$360 only 8% had self-reported adverse event ⇾ Women on Web in Ireland (mife/miso) Tablet Assay results ⇾ 95% reported successfully ending pregnancy without surgical intervention Mifepristone 200 mg 184 – 204 mg ⇾ 0.7% reported receiving blood transfusion Misoprostol 200 mcg 34 – 201 mcg ⇾ 2.6% reported receiving antibiotics Murtagh, et al., 2018 Kapp, 2017; Footman, 2018; Grossman, et al., 2018; Aiken, 2017 19 20
Post-abortion care in post-Roe, low-access states Legal risks >> medical risks ⇾ Be prepared for life-threatening complications (uterine ⇾ At least 20 people have perforation, hemorrhage, infection)…but hopefully been prosecuted for these will be few allegedly attempting or helping someone attempt ⇾ Be aware of medication abortion and normal course to self-manage an ⇾ Don’t intervene when unnecessary (treat signs and abortion symptoms, not ultrasound findings) ⇾ Women of color and ⇾ Most cases of incomplete abortion can be treated those with low incomes with any of the following: at highest risk ⇾ Expectant management ⇾ No jurisdiction currently ⇾ Medication (usually misoprostol 800 mcg buccal or 600 mcg SL) mandates physician ⇾ Vacuum aspiration reporting of self- managed abortion 21 22 ACOG Position Statement on Decriminalization of SIA Learn to live with diagnostic uncertainty ⇾ Opposes the prosecution of a pregnant woman for conduct ⇾ Clinically may be difficult to distinguish spontaneous alleged to have harmed her fetus, including the early pregnancy loss from self-managed/induced criminalization of self-induced abortion. The threat of abortion prosecution may result in negative health outcomes by ⇾ Management largely the same deterring women from seeking needed care, including care ⇾ How should we balance what we gain by trying to related to complications after abortion. determine cause of pregnancy loss versus the risk of ⇾ ACOG also opposes administrative policies that interfere criminalizing the patient if they disclose an attempt to with the legal and ethical requirement to protect private self-manage their abortion? medical information by mandating obstetrician– gynecologists and other clinicians to report to law enforcement women they suspect have attempted self- induced abortion. Such actions compromise the integrity of the patient–physician relationship. December 2017 23 24
Harm Reduction Model What is the role of clinicians in BEFORE AFTER ABORTION 1. Counseling regarding 1. Post-abortion care haven states? alternatives to ILLEGAL 2. Prevention of abortion complications DENIED 2. Information about 3. Referrals for other abortion methods and services their risks (including 4. Contraception misoprostol) counseling Briozzo et al., 2006; Briozzo et al, 2016 25 26 Meeting the needs of patients traveling for services Expanding access in haven states ⇾ Expand capacity of services providing care, ⇾ Expansion of telemedicine services, as well as including for abortion after the first trimester coverage for telemedicine ⇾ Consider expansion to provide care closer to borders using ⇾ Policies such as provision of medication telemedicine or mobile clinics abortion on college campuses ⇾ Expand training opportunities both to meet ⇾ Expansion of provision by advanced practice demand for care and to allow for learners from clinicians low-access states ⇾ Increased need for logistic and financial support ⇾ Examples of Austin and New York City funding 27 28
Thank you! Daniel Grossman, MD Daniel.Grossman@ucsf.edu University of California, San Francisco | Bixby Center for Global Reproductive Health 29
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