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 2.0 Abortion 3.0 Abortion 1.0 * Roe v Wade * New paradigm * Violence * Drop in morbidity * Access * Increased training * Advocacy * State restrictions * Equity
Approximately how many abortion facilities are there in the US? 500 a. 1500 b. 2500 c. 3500 d.
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 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
First trimester abortion in 2018 Aspiration abortion – D&C outdated procedure 75% providers are Ob/Gyns 50% are 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
Abortions done in ambulatory surgery centers have fewer complications vs offices or clinics True a. False a.
Medical abortion is associated with more complications than aspiration abortion True a. False a.
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 Second physician 36% Abortion in hospital 38% Licensed physician 82% Gestational limits 86% Waiting period 54% Mandated counseling 36%
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? Criteria for OTC status • acceptable toxicity profile • unlikely to be addictive Self-selection • low abuse potential • consumers can appropriately, and therefore safely, use the medicine Label 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
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 Health inequity Harm reduction Social change Erdman et al. Reprod Health Matters 2018 Berry-Bibee et al. BMJ Sex Reprod Health 2018
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 Aiken et al. Perspectives Sex Reprod Health 2018 Online purchase is feasible 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
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