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 Women’s Health 2019 Jennifer Kerns, MD, MS, MPH Associate Professor, UCSF Department of Obstetrics, Gynecology, and Reproductive Sciences 1 ¡ I have no disclosures 2 1

12/6/19 The story of abortion in the US Abortion 2.0 Abortion 3.0 Abortion 1.0 * Roe v Wade * New paradigm * Violence * Drop in morbidity * Access * Increased training * Advocacy * State restrictions * Equity 3 Approximately how many abortion facilities are there in the US? 500 a. 1500 b. 2500 c. 3500 d. 4 2

12/6/19 Who has abortions? 5 Abortion rates declining, but disparities persist ¡ 1 in 4 women will have an abortion by age 45 (20% by age 30) ¡ Declines seen among all groups, esp among adolescents (46% decline) ¡ Racial and disparities persist ¡ Black women have 2.7 times higher abortion rates than white women ¡ Abortion is twice as high for poor women (36.6 per 1000) 6 3

12/6/19 Abortion techniques 14-20 wks § 91.6% of all abortions < 13 weeks > 20 wks § 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 7 Medical abortion is associated with more complications than aspiration abortion True a. False a. 8 4

12/6/19 Abortions done in ambulatory surgery centers have fewer complications vs offices or clinics True a. False a. 9 First trimester abortion in 2018 ¡ Aspiration abortion – D&C outdated procedure ¡ 75% providers are Ob/Gyns ¡ Routine prophylactic antibiotics ¡ Misoprostol for cervical ripening in late first trimester ¡ Pain management ¡ Same-day contraception, including LARC ¡ Complications occur ~ 2-5% (higher for med ab, no difference by setting) White et al. Contraception 2018 Roberts et al. JAMA 2018 10 5

12/6/19 State-based abortion restrictions Second physician 36% Abortion in hospital 38% Licensed physician 82% Gestational limits 86% Waiting period 54% Mandated counseling 36% 11 Restrictions in 2019 12 6

12/6/19 Not only restrictions… some expansions and protections 13 Support or hostility for abortion 14 7

12/6/19 An overview of abortion restrictions 15 Abortion deserts 16 8

12/6/19 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 17 Abortion under the current Supreme Court ¡ 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 18 9

12/6/19 Post-Roe landscape ¡ If Roe is reversed and all high-risk states ban abortion… ¡ 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 19 If Roe were reversed, and all high-risk states banned abortion… …approximately how many women in the US would be prevented from accessing abortion care due to increase in travel distance? 10,000 a. 25,000 b. 80,000 c. 120,000 d. 20 10

12/6/19 Telemedicine ¡ Broad application – 18 states use it for abortion (17 states prohibit it) ¡ Abortion care: ¡ Systematic review: similar efficacy as in-person care; high satisfaction ¡ Poland: > 9 weeks à 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 study à 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 21 Telemedicine Online telemedicine abortion service – Women on Waves – study over 10 months ¡ 6022 requests from US residents ¡ 76% from hostile states ¡ Mississippi had the highest rate of requests (24.9 per 100 000 women of reproductive age) ¡ In both hostile and supportive states, a majority (60%) reported a combination of barriers to clinic access and ¡ preferences for self-management Cost was the most common barrier (71% in hostile states; 63% in supportive states; P < .001). ¡ 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 22 11

12/6/19 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 23 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 24 12

12/6/19 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) à 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 25 Can medication abortion be over the counter? Criteria for OTC status • acceptable toxicity profile • unlikely to be addictive ¡ Self-selection • low abuse potential ¡ Label • consumers can appropriately, and therefore safely, use the medicine without medical supervision comprehension • ability to self diagnose for the treatment indication • self-screen for eligibility and contraindications based on label ¡ Actual use 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 Kapp et al. BJOG 2017 26 13

12/6/19 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 27 Relationship between self managed abortion & safe abortion ¡ Associated with decreased morbidity and mortality Health inequity Harm reduction Social change Erdman et al. Reprod Health Matters 2018 Berry-Bibee et al. BMJ Sex Reprod Health 2018 28 14

12/6/19 Self-managed abortion ¡ Poor access, stigma, fear, discomfort in the medical setting, lack of knowledge ¡ Self-managed abortion as a preference ¡ Support needed, regardless of how the abortion is managed ¡ Websites vary in accuracy and product ¡ Pre- and post-abortion support needed ¡ Most women seeking abortion investigated online options (1/3 – miso for home use) Aiken et al. Perspectives Sex Reprod Health 2018 Aiken et al. BMJ Sex Reprod Health 2018 ¡ Online purchase is feasible Murtagh et al. Contraception 2018 Kerestes et al. Sex Reprod Health Matters 2019 29 Providers’ knowledge and experience with self-managed abortion 335 abortion provider respondents 35% witnessed 69% had seen 59% thought the 53% think that SMA complications attempts at SMA practice had is safe (most incomplete) (most with mife/miso) increased ¡ 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 30 15