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

Disclosures  I have no financial disclosures 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 Zuckerberg San Francisco General Zuckerberg San Francisco General Learning Objectives Recognize the prevalence and impact that abortion has on 1. patients in the primary care setting. The Impact of Abortion Demonstrate the intersectionality of abortion through its 2. association with the executive, legislative and judicial branches of government. Recommend clinical changes and advocacy efforts that 3. people can take to support abortion in primary care. Zuckerberg San Francisco General Zuckerberg San Francisco General 1 | [footer text here]

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 ACOG 2018 Zuckerberg San Francisco General Zuckerberg San Francisco General Reproductive age women in primary care Lifetime Prevalence of Common Medical Conditions Perce nt Breast Cancer 50 47 Breast Cancer  61 million US women of reproductive age (15-44) Cervical Cancer 45 Cervical Lifetime Prevalence (%) 39 Cancer 40 Depression - 10% become pregnant annually Depression 33 Diabetes 35 Diabetes Hypertension 30 27 Hypertension  Half of all US women will seek primary care in an internal 25 medicine or family medicine clinic each year 20 15 12 10 5 1 0 CDC NCHS 2010 Pregnancy Rates Amongst U.S. Women (most recent data available) Guttmacher Institute Daniels et al. Natl Health Stat Report 2015 National Center for Health Statistics Petterson et al. J Women’s Health 2014 National Cancer Institute Surveillance, Epidemiology, and End Results Program Zuckerberg San Francisco General Zuckerberg San Francisco General 2 | [footer text here]

Pregnancy Intentions Unintended Pregnancy is Common 50 47 Uninteded -  45% of all pregnancies are 45 unwanted 18% Lifetime Prevalence (%) 39 Unintended Pregnancy 40 Depression unintended Cervical Cancer 35 33  Mistimed = wants to become 30 27 Intended pregnant in the future but not at Hypertension 55% Diabetes 25 Unintended - the time she became pregnant mistimed 20 Breast Cancer 27% 15  Unwanted = did not want to 12 10 become pregnant then or at 5 1 any time in the future 0 Guttmacher Institute National Center for Health Statistics National Cancer Institute Surveillance, Epidemiology, and End Results Program Finer and Zolna N Engl J Med 2016 Zuckerberg San Francisco General Zuckerberg San Francisco General Pregnancy Outcomes Computer modeling of how brains make complex decision Zuckerberg San Francisco General Zuckerberg San Francisco General 3 | [footer text here]

1 in 5 1 in 4 Pregnancies in US result in abortion Women will have an abortion by age 45 Guttmacher Institute 2019 Guttmacher Institute 2019 Zuckerberg San Francisco General Zuckerberg San Francisco General Trends in Abortion Care Zuckerberg San Francisco General Zuckerberg San Francisco General 4 | [footer text here]

Zuckerberg San Francisco General Zuckerberg San Francisco General Access to Care 90% of women live in US county without an abortion clinic Distance to nearest abortion facility, 2017 Cartwright et al. J Med Internet Res 2018 Zuckerberg San Francisco General Zuckerberg San Francisco General 5 | [footer text here]

Only 7% 35% of practicing ob/gyns perform of practicing ob/gyns would not refer abortions in their practice patients for abortion services AHRQ 2018 AHRQ 2018 Desai Contraception 2018 Desai Contraception 2018 Zuckerberg San Francisco General Zuckerberg San Francisco General 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  Legal Considerations - Unemployment/living below FPL - In relationship w/ abusive partner - Less likely to have aspirational plans  No increased likelihood for: - Depression - Anxiety - Suicidal ideation Foster et al. ANSIRH 2018 Zuckerberg San Francisco General Zuckerberg San Francisco General 6 | [footer text here]

The Executive Branch The Legislative Branch First U.S. President to attend the annual March for Life A few examples “Let us work together to US Senator James build a culture that Inhofe (R-OK) cherishes innocent life. disproving climate And let us reaffirm a change on the Senate fundamental truth: all floor by providing a children, born and snowball as evidence unborn, are made in the for lack of global holy image of God.” warming Zuckerberg San Francisco General Zuckerberg San Francisco General “ "I heard about it over the years. I never questioned it or gave it a lot of thought." Ohio State Representative John Becker In responding to reporter asking if he had done any research on reimplantation of ectopic pregnancies Zuckerberg San Francisco General Zuckerberg San Francisco General 7 | [footer text here]

Types of Regulations Reversal of Medication Abortion Physician/Clinic Patient  Physician-only (40)  Gestational limits (43)  Public funding (33+DC)  Parental involvement (37)  Hospital-based (19)  Waiting periods (27)  Two physicians (17)  State-mandated counseling (18) Private insurance (12) Ability of fetus to feel pain (13) Mental health consequences (8) Link to breast cancer (5) Guttmacher Institute 2019 Zuckerberg San Francisco General Zuckerberg San Francisco General Who can provide abortion? What if Roe v. Wade is overturned?  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) Washington Post 2018 Zuckerberg San Francisco General Zuckerberg San Francisco General 8 | [footer text here]

Interactive Tool Zuckerberg San Francisco General Zuckerberg San Francisco General The Judicial Branch The Supreme Court June Medical Services LLC v. Gee March 4, 2020 Whole Woman’s Health v. Hellerstedt June 27, 2016 Zuckerberg San Francisco General Zuckerberg San Francisco General 9 | [footer text here]

NASEM Report Evidence for Abortion in Primary Care Zuckerberg San Francisco General Zuckerberg San Francisco General Medication Abortion in Primary Care Safety of Mifepristone and Abortion (2018) • All forms of abortion are safe and effective  Power to destigmatize • Abortion can be safely performed in an office- - Integration in to routine care based setting - Lack of protestors • Does not increase risk of:  Patient preference • Secondary infertility • Breast cancer • Depression/anxiety/PTSD • Serious complications are < 1% NASEM 2018 Taylor Am J Med Qual 2013 Zuckerberg San Francisco General Zuckerberg San Francisco General 10 | [footer text here]

Medication Abortion in Primary Care Incorporating Abortion into Primary Care • 2005 by Schwarz and Luetkemeyer • 212 Residents, 11 residencies • 42% IM residents willing to prescribe medication abortion  Power to destigmatize • 2010 by Godfrey et al  Patient preference • 299 Patients in NYC and Chicago • 58% would choose primary care clinic (PCC) for abortion  Patient satisfaction - Achieving rapid appointment access • 2012 by Page et al • 90 Patients in academic PCC - Staff courtesy • 67% felt PCC should offer medical abortions - Ready information to questions • 87% would want PCP to perform • 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 Taylor Am J Med Qual 2013 Zuckerberg San Francisco General Zuckerberg San Francisco General Clinical Integration 5 Key Questions Who can receive a medication abortion? 1. What are the medications and what do they do? Clinical Integration: 2. Do I need an ultrasound or other labs? 3. 5 Key Questions What follow-up is needed? 4. How do I get abortion medications in to my clinic? 5. Zuckerberg San Francisco General Zuckerberg San Francisco General 11 | [footer text here]

1. Who can receive a medication abortion? 80% US abortions occur <10 weeks Indications  Gestational age < 10 weeks  Prefer medications over procedure Danco 2019 FDA 2019 Zuckerberg San Francisco General Zuckerberg San Francisco General 1. Who can receive a medication abortion? Early Abortion Options (< 10 weeks) MEDICATION ABORTION ASPIRATION PROCEDURE Indications Contraindications  Gestational age < 10  Ectopic pregnancy weeks  IUD in place  Prefer medications over  Adrenal insufficiency procedure  Bleeding or clotting disorders/anticoagulation Completes at home Completes in office or OR Pregnancy usually passes 1-2d Pregnancy passes in minutes  Inherited porphyria Efficacy = 95-97% Efficacy = 98-99% 61 % of early abortions 39% of early abortions Danco 2019 FDA 2019 Zuckerberg San Francisco General Zuckerberg San Francisco General 12 | [footer text here]