USA – Evaluation of a “smart” screening tool for asynchronous assessment of medication abortion eligibility +++ Experiences with misoprostol-only used for self-managed abortion +++ Sampling strategies among studies of barriers to abortion

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Evaluation of a “smart” screening tool for asynchronous assessment of medication abortion eligibility: a pilot study

by Elizabeth G Raymond, Laura J Frye, Kristina Tocce, Shay Gingras, Amy Almquist, Ann Firstenberg, Cynthia Ortega, Paul D Blumenthal, Beverly Winikoff, Christy Boraas

Contraception 20 November 2023  https://doi.org/10.1016/j.contraception.2023.110340

Abstract

Objectives: This study aimed to assess the feasibility, safety, and acceptability of asynchronous screening for medication abortion eligibility using a programmed questionnaire.

Study design: For this study, we developed an informational website about medication abortion with a linked questionnaire programmed to produce a conclusion regarding eligibility according to standard criteria. We enrolled people in Colorado and Minnesota who submitted questionnaires indicating eligibility. A study physician reviewed each questionnaire and medical records if available and determined whether the responses warranted treatment without a synchronous clinical consultation or ultrasound. If so, the physician prescribed a standard regimen of mifepristone and misoprostol. We collected posttreatment data on abortion outcome, adverse events, and satisfaction.

Results: We received questionnaires from 197 individuals, of whom 160 remained in the study until the physician made a final treatment decision. Physicians prescribed medication abortion to 156 (97.5%) individuals based on the questionnaire responses, whereas four needed further assessment to confirm eligibility. Of the 156 individuals, 130 had sufficient follow-up to assess abortion outcome, and 123 (95%) had complete medication abortions without additional treatment. One participant was hospitalized for bleeding, and one expelled a 15-week fetus; however, it is not clear that conventional synchronous history-based screening would have averted these events. Of the 197 questionnaires, 42% were submitted outside business hours. On satisfaction questionnaires, 134 (96%) of 144 participants said they would recommend the study to a friend who needed an abortion.

Conclusions: Data from this pilot project suggest that providing medication abortion based only on a self-administered, programmed questionnaire is likely to be effective, safe, efficient, and acceptable.

Implications: A programmed self-administered patient questionnaire to assess eligibility for medication abortion could reduce the cost of the service, augment clinic efficiency, improve quality of care, and enhance access to abortion.

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Experiences with misoprostol-only used for self-managed abortion and acquired from an online or retail pharmacy in the United States

by Dana M Johnson, Sruthi Ramaswamy, Rebecca Gomperts

Contraception, 2 December 2023 https://doi.org/10.1016/j.contraception.2023.110345 (Open access)

Objectives: This study aimed to understand individual experiences with medication abortion using misoprostol-only among people living in the United States.

Study design: We conducted 31 semi-structured anonymous in-depth interviews with individuals who used misoprostol-only for self-managed medication abortion. Participants were recruited from Aid Access, an online telemedicine organization that provided prescriptions for misoprostol to eligible people in all 50 states in May and June 2020 when a combined mifepristone and misoprostol regimen was unavailable. We coded transcripts with a flexible coding approach and focused on perceptions and experiences with use.

Results: Participants were knowledgeable about misoprostol. Previous abortion experiences shaped perceptions of misoprostol-only by allowing comparison to the mifepristone and misoprostol regimen. Most participants expressed an unwavering desire for an effective abortion method, regardless of the medications or regimen. Individual physical experiences with misoprostol, including bleeding, cramping, nausea, and diarrhea, varied in intensity and duration. Participants proactively managed symptoms with self-care strategies and drew extensively from their prior experiences with menstruation, miscarriage, abortion, and childbirth. Clear instructions and information on potential complications and what to expect throughout the abortion fostered a sense of preparedness, and personalized interactions with an online help desk brought comfort.

Conclusions: Misoprostol offered an essential abortion method for study participants. This regimen was physically challenging for some, and there is potentially a greater need for communication and support for individuals using misoprostol-only regimens. Prior reproductive experiences informed participant’s knowledge, preparedness, pain management, and ability to both recognize and manage potential complications.

Implications: As restrictions on mifepristone continue, more people may use misoprostol-only regimens. All regimens can be supported with detailed instructions, clear expectations, information on signs of potential complications, and personalized support. To achieve reproductive autonomy, people must have access to a range of abortion care options that meet their needs.

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Sampling strategies among studies of barriers to abortion in the United States: A scoping review of abortion access research

by Madison Lands, Rachel L Dyer, Jane W Seymour

Contraception 24 November 2023 https://doi.org/10.1016/j.contraception.2023.110342 (Open access)

Objectives: Understanding barriers to abortion care is particularly important post-Dobbs. However, many abortion access studies recruit from abortion-providing facilities, which overlook individuals who do not present for clinic-based care. To our knowledge, no studies have reviewed research recruitment strategies in the literature or considered how they might affect our knowledge of abortion barriers. We aimed to identify populations included and sampling methods used in studies of abortion barriers in the United States.

Study design: We used a scoping review protocol to search five databases for articles examining US-based individuals’ experiences accessing abortion. We included English-language articles published between January 2011 and February 2022. For included studies, we identified the sampling strategy and population recruited.

Results: Our search produced 2,763 articles, of which 71 met inclusion criteria. Half of the included papers recruited participants at abortion-providing facilities (n=35), while the remainder recruited from online sources (n=14), other health clinics (n=10), professional organizations (n=8), abortion funds (n=2), community organizations (n=2), key informants (n=2), and an abortion storytelling project (n=1). Most articles (n=61) reported information from people discussing their own abortions; the rest asked non-abortion seekers (e.g. physicians, genetic counsellors, attorneys) about barriers to care.

Conclusions: Studies of abortion barriers enrol participants from a range of venues, but the majority recruit people who obtained abortions, and half recruit from abortion clinics.

Implications: As abortion access becomes constrained and criminalized in the post-Roe context, our findings indicate how investigators might recruit study participants from a variety of settings to fully understand the abortion seeking experience.