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 1.0 Abortion 2.0 Abortion 3.0 * Roe v Wade * Drop in morbidity * New paradigm * Increased training * Access * Violence * Advocacy * State restrictions * Equity
ABORTION IN THE US ABORTION RATES BY RACE AND ETHNICITY 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) ABORTION TECHNIQUES ABORTION AMONG POOR WOMEN 14‐20 wks 91.6% of all abortions < 13 weeks > 20 wks 140,000 per year in US D&E accounts for 96% in US 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
FIRST TRIMESTER ABORTION COMPLICATIONS OF ABORTION ARE RARE Aspiration abortion – D&C outdated procedure In a study of > 50,000 abortions in the US… 75% providers are obgyns First-trimester aspiration: 2.5% ½ are < 50 years old (versus 36% in 2002) First-trimester medication abortion: 5.4% Routine prophylactic antibiotics Second-trimester abortion: 2.6% Misoprostol for cervical ripening in late first trimester Pain management And don’t differ according to setting (ambulatory surgery center vs office) Same-day contraception, including LARC White et al. Contraception 2018 Rpberts et al. JAMA 2018 STATE-BASED ABORTION RESTRICTIONS AN OVERVIEW OF ABORTION RESTRICTIONS Second physician 45% Abortion in hospital 45% Licensed physician 84% Gestational limits 86% Waiting period 54% Mandated counseling 36%
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. PSRH 2016 White et al. Women’s Health Issues 2017 ABORTION UNDER THE NEW SUPREME COURT TELEMEDICINE 13 cases may come before the Supreme Court and if Roe is overturned, Specialty care: dermatology, pediatric 22 states may ban abortion outright subspecialties, dermatology, HIV Other states may make it exceedingly difficult to access Abortion care: Outlawing abortion women pursue less safe methods Iowa: no difference in med ab complications Make misoprostol abortions available (Peru example) telemedicine vs in-person (0.18% vs 0.32%) Alaska: providers’ experiences – patient-centered Preparation for complications from unsafe abortion approach, expedited care, easy to do Neighboring states will play a big role Grossman and Grindlay. Obstet Gynecol 2017 Ganatra et al. Lancet 2017 Grindlay and Grossman. J TelemedTelecare 2017 Grossman et al. PLoS One 2018
FINDING OUR ALLIES… PRIMARY CARE PHARMACY PROVISION Scope of primary care includes abortion Risk Evaluation Mitigation Strategy (REMS) – misapplied to mifepristone Family med: requires exposure to aspiration Opportunity for telemedicine Referrals from primary care Australia & Canada – mifepristone dispensed in pharmacies Organizational challenges: training for providers (IUD and implant insertions), other Patient counseling health issues taking priority Follow up Strategies for successful integration White et al. Health Serv Res 2018 Yang and Kozhimannil. Obstet Gynecol 2016 Raifman et al. J Am Pharm Assoc 2018 Amico et al. Prim Care 2018 EXAMPLES OF SUCCESSFUL PHARMACY PROVISION OVER THE COUNTER Safety and effectiveness pharmacy vs. public facilities – non-inferiority trial Does mife/miso meet the US FDA regulatory criteria for OTC status? Pharmacy dispensation not inferior to clinic Label comprehension Self-selection Emergency contraception Actual use studies Rocca et al. PLoS One 2018 Kapp et al. BJOG 2017 Cleland et al. Women’s Health Issues 2016
DEMEDICALIZATION SELF MANAGED ABORTION History of medicalization Associated with decreased morbidity and mortality Does medicalization undercut public health? Health inequity 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: Harm reduction Social change ‘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). Singh et al. Obstet Gynecol 2016 Halfmann. Health 2011 Erdman et al. Reprod Health Matters 2018 Berry-Bibee et al. BMJ Sex Reprod Health 2018 Health equity Harm reduction SELF MANAGED ABORTION THE PATH FORWARD – ADVOCACY Social change Self-managed abortion may be a preference over clinical care Versus harm reduction Individual level – clinical care Media – don’t wait for an invitation! Desperation while searching unsafe attempts Policy work Support needed, regardless of how the abortion is managed Educating legislators Most websites either had meds or info but not both, and unclear if trusted info Sharing stories Pre- and post-abortion support needed Aiken et al.. Perspectives Sex Reprod Health 2018 Aiken et al. BMJ Sex Reprod Health 2018
Health equity Health equity Harm reduction Harm reduction THE PATH FORWARD – TRAINING THE PATH FORWARD – EQUITY Social change Social change Ryan Programs Fellowship in Family Planning Who has been left out of the conversation: Women of color Immigrants RHEDI Experiences with & preferences for abortion Poor women Apprenticeships Roadmap: New opportunities Reproductive justice framework – Loretta Ross Self-managed abortion support Increasing diversity in workforce for abortion care Abortion training centers Non-physicians Structural barriers to abortion access – includes structural racism Specialties outside obgyn, family med, peds Turk et al. Contraception 2016 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 – in the hands of patients Lens of equity
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