I have no disclosures to report A Patient Centered Approach to - PDF document

 I have no disclosures to report A Patient ‐ Centered Approach to Abortion Essentials of Women’s Health Conference Big Island, Hawaii July 2016 Jennifer Kerns, MD, MS, MPH Assistant Professor, UCSF Department of Obstetrics, Gynecology and Reproductive Sciences Your role in abortion? Incidence of abortion  Have a working knowledge of the safety of abortion  1.21 million abortions per year in US  Recognize the social context of abortion  Be familiar with misinformation so you can dispel myths  By age 45, ~1/3 of all US women will have had an  Help patients avoid stigmatizing experiences abortion  Be able to explain what she can expect  The internet is a scary place  Abortion is one of the most common surgical  Be an advocate, provide resources procedures in the US  Act in a timely fashion

Pregnancies in the US: ~6.4 million/ year Pregnancies in the US: ~6.4 million/year 100% 100% 80% 80% 60% 60% 51% 51% 49% 49% ½ used 40% 40% birth control 20% 20% 0% 0% unintended unintended intended intended Finer 2011 Contraception Finer 2011 Contraception Outcomes of unintended pregnancies: Abortions by gestational age ~ 3.1 million/ year % of unintended pregnancies (excluding miscarriages) % of abortions 100% 100% 80% 80% 63% 60% 60% 52% 48% 40% 40% 17% 9% 20% 7% 20% 3% 1% 0% 0% <9 9–10 11–12 13–15 16–20 21+ Abortions Births Weeks gestation Finer, 2011 Contraception Henshaw adjustments to Strauss et al., 2007 (2004 data)

How safe is abortion? Abortions by gestational age Is it more or less safe than  Colonoscopy 1/3,333 – 1/33,333  Penicillin 1/50,000 11%  Pregnancy 1/8,474 1%  Being a pedestrian 1/47,273 88%  As a motorcycle rider 1/89,562  As an occupant of a pickup truck or van 1/67,182 1st Trimester  Surgical abortion: 1/142,857 13-20 Weeks 21+ Weeks And so… Well, weighing risks… it’s personal

Deaths from abortions after legalization Abortion safety, by gestational age Deaths per 100,000 abortions Number of abortion-related deaths 10 200 8.9 180 1970: Abortion laws liberalized in 15 states* 8 160 140 6 Roe v. Wade , 120 Jan. 22, 1973 3.4 100 4 80 1.7 60 2 0.6 0.4 0.1 0.2 40 0 20 0 <9 9–10 11–12 13–15 16–20 21+ All abs. 1965 1969 1973 1977 1981 1985 1989 1993 1997 Weeks gestation Grimes DA, 2006 CDC Abortion surveillance Bartlett et al., 2004 (1988–1997 data) Long ‐ term safety of abortion Causes of abortion ‐ related deaths  Abortion does not cause % of abortion deaths (on average, 8 per year)  Infertility 100%  Ectopic pregnancy 80%  Miscarriage 60%  Breast cancer 40%  Negative mental health outcomes 24% 27% 17% 16% 15% 20% 0% Infection Hemorrhage Embolism Anesthesia Other Boonstra 2006 Bartlett et al., 2004 (1988–1997 data) Steinberg 2012 Melbye 1997

Who has abortions: economic status Who has abortions: race/ethnicity 1% 27% 25% Native ≥ 300% of <100% of 6% Asian/PI American poverty poverty 20% Hispanic 41% White 18% 200–299% 31% 32% of poverty 100–199% Black of poverty Jones, 2002 Who has abortions: religious Who has abortions: prior pregnancies identification 22% None 27% 12% None Previous abortion 43% Protestant 8% 36% Other Previous abortion and previous birth 25% Previous birth 27% Catholic

Methods of induced abortion Abortion: evidence-based practices  Antibiotic prophylaxis 1 st trimester 2 nd trimester  High risk women: RR 0.50, NNT 10 (5 ‐ 14 weeks) (14 ‐ 24 weeks)  Low risk women: RR 0.64, NNT 35 Surgical Dilation & curettage (D&C) Dilation and evacuation (D&E)  Pain control –Manual suction –Standard D&E –Electric suction –Intact D&E  Vasopressin in paracervical block to reduce bleeding Medical Medication Labor induction  Immediate contraception –Misoprostol + Mifepristone –Misoprostol +/ ‐ Mifepristone –Misoprostol only  Cervical preparation Sawaya 1996 Stubblefield 2004 Kapp 2012 1 st trimester surgical abortion: uterine aspiration Manual and electric aspirators  Pelvic exam, GC/CT culture, betadine prep  Anesthesia  IV or PO or SL and/or paracervical block  Cervical dilation if needed Manual uterine aspirator  Aspiration of uterine contents  manual or electric  Visual examination of products of conception  Observation, antibiotics, Rhogam prn  Home with contraception Electric vacuum

Manual uterine aspiration (MUA): key points Medical abortion agents Mifepristone Misoprostol  Safety and efficacy same as (RU ‐ 486, Mifeprex) (Cytotec) electric  Anti ‐ progesterone  Prostaglandin E1 analog  Quiet  Necrotizes decidua,  Uterine contractions +  Low ‐ tech/ low ‐ resource softens cervix, increases sensitivity to  Simple prostaglandins  Portable  Low ‐ cost  Small 1 st trimester medication abortion regimen Medication abortion  High efficacy (92 – 99.5%) Evidence ‐ based & FDA regimen  Extremely safe  Infection risk 13/100,000 Mife dose 200 mg  Risk of death 1/100,000 Miso dose/ route 800 mcg vaginally or buccally (at home)  Counseling is critical Miso timing 6 ‐ 72 hrs after Mife (FDA 24 ‐ 48 hrs after)  Bleeding  Pain GA 10 weeks  Passage of POCs Efficacy 96% ‐ 99%  Follow up 1 ‐ 2 weeks 93% complete in 4 hrs  Description of cramping/ bleeding  Ultrasound to confirm no sac

Cervical preparation for 2 nd trimester 2 nd trimester surgical abortion: D&E surgical abortion  History, exam, STI screening  Misoprostol  Cervical dilation (1.5 or 2 cm) with osmotic dilators  Manual dilators (Pratt)  IV sedation  at time of procedure  Evacuation of fluid with suction  Osmotic Dilators  Evacuation of fetus with forceps  Laminaria or Dilapan  Ultrasound guidance  1 ‐ 15 dilators placed  Inspection of POCs  Expand and create radial pressure  Left in cervix for 6 – 48hrs  Recovery, antibiotics, Rhogam  Contraception Dilation & extraction (D&X, or intact D&E) Standard D&E Induction  Anesthesia Local + IV sedation IV narcotics, regional  “Partial ‐ Birth Abortion” coined by anti ‐ abortion groups  Duration 1 ‐ 3 days 6 ‐ 11 hours (mife + miso) through focus groups  Location Outpatient Inpatient (L&D, wards)  Led to Federal Abortion Ban in 2008  Cost $3530 ($1K ‐ $5K) $5029 ($3K ‐ $9K)  Risk mgmt, feticidal injections, cessation of services  Contact Usually none Patient’s decision  Goal to minimize uterine instrumentation and deliver with fetus an intact fetus  Providers Specialized training No extra training  Cervical dilation usually requires 2 days  Fetal autopsy Less accurate? More accurate patient < provider patient > provider  Involvement  No evidence of increased risk

Case 1: Josie Rosie Options counseling for Josie Rosie  32yo para 1 comes into your office complaining of lower  How to start the conversation: abdominal pain. She has her 5yo son with her.  “We are happy to take care of you no matter what you decide.”  You order a UPT (because you always order a UPT).  Normalize unintended pregnancy. Because it’s normal.  It’s positive!  Options… abortion, continuation, adoption Is this news  “Would you like to hear about these options now?” surprising? Congratulations!  Follow up with the patient if she needs time to think Is this something you were hoping for?  You talk to her a week later and she tells you she’s decided on abortion because her 5yo son has autism and she wants to be able to care for him. Josie Rosie’s 1 st trimester abortion Reasons given for abortion  Know your local Concern for/ responsibility to other individuals……………………………74% abortion providers Cannot afford a baby now…………………………………………………………….73% Would interfere w/school, job, ability to care for others…..............69%  Help connect her – Would be a single parent/ having relationship problems………………48% don’t make her do the research Has completed childbearing…………………………………………………………38% http://prochoice.org/think ‐ youre ‐ pregnant/find ‐ a ‐ provider/ Finer et al., 2005 (2004 data)

Josie Rosie’s 1 st trimester abortion Abortion training ObGyn residency programs  Know your local abortion providers  Give anticipatory guidance about the procedure (aspiration vs medical)  Know the local restrictions  Tell her about what she can expect (24 hr waiting period? Parental consent? Mandatory ultrasound?)  Guttmacher Institute website for all state ‐ level restrictions  Follow up with the patient to ensure she made an appt  Assist with any barriers in getting an appt What happens if Josie can’t get the Disproportionate effects of restrictions abortion she wants  Women denied an abortion are:  More likely to be in poverty  More likely to stay tethered to abusive partners  More likely to experience anxiety afterwards