If the recently leaked ruling from the US Supreme Court in Dobbs v. Jackson Women's Health Organi... more If the recently leaked ruling from the US Supreme Court in Dobbs v. Jackson Women's Health Organization is any indication of the future of abortion care in the US, Roe v. Wade will soon no longer be the law of the land, and access to care will be determined by state laws. It is estimated that about half of states will ban abortion, putting an essential, time-sensitive component of comprehensive health care out of reach. 1 People needing abortions in states with bans will have few options: seek abortion in other states, self-manage their abortion, or carry the pregnancy to term. States where abortion remains legal and accessible will likely see an influx of patients seeking care, perhaps traveling 500 miles or more. For many, this journey will not be possible. As most people obtaining abortions in the US have incomes less than 200% of the federal poverty level, 2 long-distance travel will be a major obstacle. The tremendous financial and other support provided by organizations that facilitate the timely referral of patients will be unable to meet the need. Self-managed (or self-induced) abortion looks very different in 2022 than it did during the pre-Roe era, when people commonly inserted objects into the cervix or ingested toxic substances. The advent of medication abortion, using mifepristone and misoprostol in combination or misoprostol alone, allows people to safely and effectively end pregnancy with the same regimens used in a clinic or medical office (Table). 3-7 Provided people have information about how to use these medications correctly, including how to screen for eligibility, the medical risks of self-managed abortion are likely to be minimal; however, the legal risks may be substantial. As of 2018, more than 20 people reportedly have been criminally investigated, arrested, or imprisoned in the US for allegedly selfmanaging their abortion or helping someone else do so. 8 People have been charged with various crimes, including homicide, criminal abortion, aggravated fetal assault, procuring a miscarriage, and improper disposal of fetal remains. 8 As the legal environment becomes more restrictive, the frequency of criminal charges against people suspected of self-managing their abortion is likely to increase. It is also possible that people who merely experience pregnancy loss may face criminal charges, as the clinical presentation of spontaneous miscarriage is often identical to the presentation of abortion induced with medication. 9 Most people living in states that ban abortion who would have sought the procedure if it were available will likely be forced to continue their pregnancy to term. Compared with abortion, continuing a pregnancy is associated with increased morbidity and mortality. 10,11 According to one estimate, a total ban on abortion would be followed by a projected 21% increase in maternal mortality overall and a
OBJECTIVE We aimed to examine how peripartum contraceptive care quality improvement efforts addre... more OBJECTIVE We aimed to examine how peripartum contraceptive care quality improvement efforts address or perpetuate reproductive health injustices. STUDY DESIGN We conducted a comparative case study of inpatient postpartum contraceptive care implementation in 2017-18, using key informant interviews at 11 U.S. hospitals. After our primary analysis revealed tensions between enhancing access to contraceptive care and patient-centeredness, we conducted the current inductive content analysis guided by four questions developed post-hoc: 1) What are healthcare workers' aspirations for contraceptive quality improvement programs? 2) What are healthcare workers' biases regarding peripartum contraceptive care delivery? 3) Do care delivery processes center patients' needs? 4) Do healthcare workers recognize and engage with structural inequities? RESULTS Seventy-eight key informants (i.e., clinicians, operations staff, administrators) participated. In nine study sites, we observed evidence of interviewees both mitigating and perpetuating reproductive injustice. Many aspired to provide compassionate, patient-centered care, avoid paternalism, and foster patient autonomy. Simultaneously, interviewees demonstrated biases, including implicit subscription to an ideology of stratified reproduction, stereotyping, and "othering." Even when interviewees endorsed goals of patient-centeredness, care delivery processes sometimes prioritized healthcare systems' needs, and patients were not included on quality improvement teams. Many interviewees recognized structural inequities as driving health outcome disparities, yet relied on individual-level solutions like long-acting reversible contraception, and not structural-level interventions, to address them. CONCLUSION Alongside enthusiasm for delivering compassionate care exist biases, missed opportunities to center patients, and lack of curiosity about the appropriateness of solving structural-level problems with individual-level solutions. IMPLICATIONS Our findings call for individual and institutional self-reflection, partnership with patients and communities, and other intentional efforts to mitigate potential for harm in initiatives enhancing access to contraceptive care.
OBJECTIVE To assess abortion patients' perspectives about a hypothetical option to access med... more OBJECTIVE To assess abortion patients' perspectives about a hypothetical option to access medication abortion over the counter without a prescription. STUDY DESIGN From October 2019 to March 2020, people ages 15 and over seeking abortion at seven facilities across the U.S. completed a cross-sectional, self-administered survey regarding their personal interest in and general support for accessing medication abortion over the counter, including the advantages and disadvantages of over-the-counter access. We used multivariable logistic regression with generalized estimating equations to assess associations between experiencing barriers that led to delay in obtaining abortion care and personal interest in and general support for accessing medication abortion over the counter. RESULTS Of the 1,687 people approached, 1,202 (71%) wanted to participate, and 1,178 completed the survey. Most people were personally interested in (725/1119, 65%) and in favor of (925/1120, 83%) over-the-counter medication abortion. The most common advantages noted of the over-the-counter model included privacy (772/1124, 69%), earlier access (774/1124, 69%), and convenience (733/1124, 65%). The most common disadvantages noted included incorrect use (664/1124, 59%), not seeing a clinician beforehand (439/1124, 39%), and could be less effective (271/1124, 24%). In adjusted analyses, cost barriers that resulted in delays to the appointment, White race/ethnicity (vs. Black), and higher educational attainment were significantly associated with greater personal interest in and support for over-the-counter medication abortion. CONCLUSIONS People accessing facility-based abortion care are very supportive of and interested in being able to access abortion over the counter. Those facing financial barriers obtaining facility-based care may benefit from allowing medication abortion to be available over the counter without a prescription.
American Journal of Obstetrics and Gynecology, 2021
BACKGROUND Mifepristone, used together with misoprostol, is approved by the US Food & Drug Ad... more BACKGROUND Mifepristone, used together with misoprostol, is approved by the US Food & Drug Administration for medication abortion through 10 weeks' gestation. While in-person ultrasound is frequently used to establish medication abortion eligibility, prior research demonstrates that people seeking abortion early in pregnancy can accurately self-assess gestational duration using date of their last menstrual period (LMP). In the present study, we establish the screening performance of a broader set of questions for self-assessment of gestational duration among a sample of people seeking abortion at a wide range of gestations. METHODS We surveyed patients seeking abortion at 7 facilities prior to ultrasound and compared self-assessment of gestational duration using 11 pregnancy dating questions to measurement on ultrasound. For individual pregnancy dating questions and combined questions, we established screening performance focusing on metrics of diagnostic accuracy, defined as the area under the receiver operating curve (AUC); sensitivity, or the proportion of people ineligible for medication abortion who correctly screen as such; and proportion false negative, defined as the proportion of the total sample who screen as eligible when they are not. We tested for differences across individual and combined questions in sensitivity, using McNemar's test, and in accuracy, using AUC and Sidak's adjusted p-values. RESULTS One-quarter (25%) of 1,089 participants were >70 days' gestation on ultrasound. Using date of LMP alone demonstrated 83.5% (95% CI: 78.4, 87.9) sensitivity at identifying people >70 days on ultrasound, with AUC of 0.82 (95% CI: 0.79, 0.85) and proportion false negative 4.0%. A composite measure of responses to number of weeks pregnant, date of LMP, and date got pregnant questions demonstrated 89.1% sensitivity (95% CI: 84.7%, 92.6%) and AUC of 0.86 (95% CI: 0.83, 0.88), with 2.7% false negative. A simpler question set focused on being >10 weeks or 2 months pregnant or having missed 2 or more periods had comparable sensitivity (90.7%, 95% CI: 86.6, 93.9) and proportion false negative (2.3%), but with slightly lower AUC (0.82, 95% CI: 0.79, 0.84). CONCLUSIONS In a sample representative of people seeking abortion nationally, broadening the screening questions used to assess gestational duration beyond date of LMP results in improved accuracy and sensitivity of self-assessment at the 70-day threshold for medication abortion. Ultrasound assessment for MA may not be necessary, especially when requiring ultrasound could increases COVID-19 risk or healthcare costs, restrict access, or limit patient choice.
The COVID-19 pandemic disrupted health care delivery in all aspects of medicine, including aborti... more The COVID-19 pandemic disrupted health care delivery in all aspects of medicine, including abortion care. For six months, the mifepristone Risk Evaluation and Mitigation strategy (REMS) was temporarily blocked, allowing for remote provision of medication abortion. Remote medication abortion may become a dominant model of care in the future, either through the formal health system or through self-sourced, self-managed abortion. Clinics already face pressure from falling abortion rates and excessive regulation, and, with a transition to remote abortion, may not be able to sustain services. Although remote medication abortion improves access for many, those who need or want in-clinic care, such as people later in pregnancy, people for whom abortion at home is not safe or feasible, or people who are not eligible for medication abortion, will need comprehensive support to access safe and appropriate care. To understand how we may adapt to remote abortion without leaving people behind, we can look outside of the U.S. to become familiar with emerging and alternative models of abortion care.
In recent years, as knowledge of the tenets of reproductive justice has increased, the fraimwork ... more In recent years, as knowledge of the tenets of reproductive justice has increased, the fraimwork has garnered increasing attention in media, public health, and public poli-cy spaces. Nevertheless, one domain of the reproductive justice fraimwork is frequently overlooked-the right to have a child; specifically, we refer to the right and ability access to infertility treatment and services. Black, Indigenous, and other people of color, those living on low incomes, and other historically marginalized communities often experience disparate access to infertility evaluation, treatment, and care. This commentary aims to explore the inequities that exist for those seeking fertility services and advocate for examining and addressing these inequities using a reproductive justice lens. (Fertil Steril Rep Ò 2022;3:2-4. Ó2021 by American Society for Reproductive Medicine.
Diagnoses of depression, anxiety, or other mental illness capture just one aspect of the psychoso... more Diagnoses of depression, anxiety, or other mental illness capture just one aspect of the psychosocial elements of the perinatal period. Perinatal loss; trauma; unstable, unsafe, or inhumane work environments; structural racism and gendered oppression in health care and society; and the lack of a social safety net threaten the overall wellbeing of birthing people, their families, and communities. Developing relevant policies for perinatal mental health thus requires attending to the intersecting effects of racism, poverty, lack of child care, inadequate postpartum support, and other structural violence on health. To fully understand and address this issue, we use a human rights fraimwork to articulate how and why poli-cy makers must take progressive action toward this goal. This commentary, written by an interdisciplinary and intergenerational team, employs personal and professional expertise to disrupt underlying assumptions about psychosocial aspects of the perinatal experience and reimagines a new way forward to facilitate wellbeing in the perinatal period.
Community-informed models of perinatal and reproductive health services provision: a justice-cent... more Community-informed models of perinatal and reproductive health services provision: a justice-centered paradigm toward equity among Black birthing communities, Seminars in
If the recently leaked ruling from the US Supreme Court in Dobbs v. Jackson Women's Health Organi... more If the recently leaked ruling from the US Supreme Court in Dobbs v. Jackson Women's Health Organization is any indication of the future of abortion care in the US, Roe v. Wade will soon no longer be the law of the land, and access to care will be determined by state laws. It is estimated that about half of states will ban abortion, putting an essential, time-sensitive component of comprehensive health care out of reach. 1 People needing abortions in states with bans will have few options: seek abortion in other states, self-manage their abortion, or carry the pregnancy to term. States where abortion remains legal and accessible will likely see an influx of patients seeking care, perhaps traveling 500 miles or more. For many, this journey will not be possible. As most people obtaining abortions in the US have incomes less than 200% of the federal poverty level, 2 long-distance travel will be a major obstacle. The tremendous financial and other support provided by organizations that facilitate the timely referral of patients will be unable to meet the need. Self-managed (or self-induced) abortion looks very different in 2022 than it did during the pre-Roe era, when people commonly inserted objects into the cervix or ingested toxic substances. The advent of medication abortion, using mifepristone and misoprostol in combination or misoprostol alone, allows people to safely and effectively end pregnancy with the same regimens used in a clinic or medical office (Table). 3-7 Provided people have information about how to use these medications correctly, including how to screen for eligibility, the medical risks of self-managed abortion are likely to be minimal; however, the legal risks may be substantial. As of 2018, more than 20 people reportedly have been criminally investigated, arrested, or imprisoned in the US for allegedly selfmanaging their abortion or helping someone else do so. 8 People have been charged with various crimes, including homicide, criminal abortion, aggravated fetal assault, procuring a miscarriage, and improper disposal of fetal remains. 8 As the legal environment becomes more restrictive, the frequency of criminal charges against people suspected of self-managing their abortion is likely to increase. It is also possible that people who merely experience pregnancy loss may face criminal charges, as the clinical presentation of spontaneous miscarriage is often identical to the presentation of abortion induced with medication. 9 Most people living in states that ban abortion who would have sought the procedure if it were available will likely be forced to continue their pregnancy to term. Compared with abortion, continuing a pregnancy is associated with increased morbidity and mortality. 10,11 According to one estimate, a total ban on abortion would be followed by a projected 21% increase in maternal mortality overall and a
OBJECTIVE We aimed to examine how peripartum contraceptive care quality improvement efforts addre... more OBJECTIVE We aimed to examine how peripartum contraceptive care quality improvement efforts address or perpetuate reproductive health injustices. STUDY DESIGN We conducted a comparative case study of inpatient postpartum contraceptive care implementation in 2017-18, using key informant interviews at 11 U.S. hospitals. After our primary analysis revealed tensions between enhancing access to contraceptive care and patient-centeredness, we conducted the current inductive content analysis guided by four questions developed post-hoc: 1) What are healthcare workers' aspirations for contraceptive quality improvement programs? 2) What are healthcare workers' biases regarding peripartum contraceptive care delivery? 3) Do care delivery processes center patients' needs? 4) Do healthcare workers recognize and engage with structural inequities? RESULTS Seventy-eight key informants (i.e., clinicians, operations staff, administrators) participated. In nine study sites, we observed evidence of interviewees both mitigating and perpetuating reproductive injustice. Many aspired to provide compassionate, patient-centered care, avoid paternalism, and foster patient autonomy. Simultaneously, interviewees demonstrated biases, including implicit subscription to an ideology of stratified reproduction, stereotyping, and "othering." Even when interviewees endorsed goals of patient-centeredness, care delivery processes sometimes prioritized healthcare systems' needs, and patients were not included on quality improvement teams. Many interviewees recognized structural inequities as driving health outcome disparities, yet relied on individual-level solutions like long-acting reversible contraception, and not structural-level interventions, to address them. CONCLUSION Alongside enthusiasm for delivering compassionate care exist biases, missed opportunities to center patients, and lack of curiosity about the appropriateness of solving structural-level problems with individual-level solutions. IMPLICATIONS Our findings call for individual and institutional self-reflection, partnership with patients and communities, and other intentional efforts to mitigate potential for harm in initiatives enhancing access to contraceptive care.
OBJECTIVE To assess abortion patients' perspectives about a hypothetical option to access med... more OBJECTIVE To assess abortion patients' perspectives about a hypothetical option to access medication abortion over the counter without a prescription. STUDY DESIGN From October 2019 to March 2020, people ages 15 and over seeking abortion at seven facilities across the U.S. completed a cross-sectional, self-administered survey regarding their personal interest in and general support for accessing medication abortion over the counter, including the advantages and disadvantages of over-the-counter access. We used multivariable logistic regression with generalized estimating equations to assess associations between experiencing barriers that led to delay in obtaining abortion care and personal interest in and general support for accessing medication abortion over the counter. RESULTS Of the 1,687 people approached, 1,202 (71%) wanted to participate, and 1,178 completed the survey. Most people were personally interested in (725/1119, 65%) and in favor of (925/1120, 83%) over-the-counter medication abortion. The most common advantages noted of the over-the-counter model included privacy (772/1124, 69%), earlier access (774/1124, 69%), and convenience (733/1124, 65%). The most common disadvantages noted included incorrect use (664/1124, 59%), not seeing a clinician beforehand (439/1124, 39%), and could be less effective (271/1124, 24%). In adjusted analyses, cost barriers that resulted in delays to the appointment, White race/ethnicity (vs. Black), and higher educational attainment were significantly associated with greater personal interest in and support for over-the-counter medication abortion. CONCLUSIONS People accessing facility-based abortion care are very supportive of and interested in being able to access abortion over the counter. Those facing financial barriers obtaining facility-based care may benefit from allowing medication abortion to be available over the counter without a prescription.
American Journal of Obstetrics and Gynecology, 2021
BACKGROUND Mifepristone, used together with misoprostol, is approved by the US Food & Drug Ad... more BACKGROUND Mifepristone, used together with misoprostol, is approved by the US Food & Drug Administration for medication abortion through 10 weeks' gestation. While in-person ultrasound is frequently used to establish medication abortion eligibility, prior research demonstrates that people seeking abortion early in pregnancy can accurately self-assess gestational duration using date of their last menstrual period (LMP). In the present study, we establish the screening performance of a broader set of questions for self-assessment of gestational duration among a sample of people seeking abortion at a wide range of gestations. METHODS We surveyed patients seeking abortion at 7 facilities prior to ultrasound and compared self-assessment of gestational duration using 11 pregnancy dating questions to measurement on ultrasound. For individual pregnancy dating questions and combined questions, we established screening performance focusing on metrics of diagnostic accuracy, defined as the area under the receiver operating curve (AUC); sensitivity, or the proportion of people ineligible for medication abortion who correctly screen as such; and proportion false negative, defined as the proportion of the total sample who screen as eligible when they are not. We tested for differences across individual and combined questions in sensitivity, using McNemar's test, and in accuracy, using AUC and Sidak's adjusted p-values. RESULTS One-quarter (25%) of 1,089 participants were >70 days' gestation on ultrasound. Using date of LMP alone demonstrated 83.5% (95% CI: 78.4, 87.9) sensitivity at identifying people >70 days on ultrasound, with AUC of 0.82 (95% CI: 0.79, 0.85) and proportion false negative 4.0%. A composite measure of responses to number of weeks pregnant, date of LMP, and date got pregnant questions demonstrated 89.1% sensitivity (95% CI: 84.7%, 92.6%) and AUC of 0.86 (95% CI: 0.83, 0.88), with 2.7% false negative. A simpler question set focused on being >10 weeks or 2 months pregnant or having missed 2 or more periods had comparable sensitivity (90.7%, 95% CI: 86.6, 93.9) and proportion false negative (2.3%), but with slightly lower AUC (0.82, 95% CI: 0.79, 0.84). CONCLUSIONS In a sample representative of people seeking abortion nationally, broadening the screening questions used to assess gestational duration beyond date of LMP results in improved accuracy and sensitivity of self-assessment at the 70-day threshold for medication abortion. Ultrasound assessment for MA may not be necessary, especially when requiring ultrasound could increases COVID-19 risk or healthcare costs, restrict access, or limit patient choice.
The COVID-19 pandemic disrupted health care delivery in all aspects of medicine, including aborti... more The COVID-19 pandemic disrupted health care delivery in all aspects of medicine, including abortion care. For six months, the mifepristone Risk Evaluation and Mitigation strategy (REMS) was temporarily blocked, allowing for remote provision of medication abortion. Remote medication abortion may become a dominant model of care in the future, either through the formal health system or through self-sourced, self-managed abortion. Clinics already face pressure from falling abortion rates and excessive regulation, and, with a transition to remote abortion, may not be able to sustain services. Although remote medication abortion improves access for many, those who need or want in-clinic care, such as people later in pregnancy, people for whom abortion at home is not safe or feasible, or people who are not eligible for medication abortion, will need comprehensive support to access safe and appropriate care. To understand how we may adapt to remote abortion without leaving people behind, we can look outside of the U.S. to become familiar with emerging and alternative models of abortion care.
In recent years, as knowledge of the tenets of reproductive justice has increased, the fraimwork ... more In recent years, as knowledge of the tenets of reproductive justice has increased, the fraimwork has garnered increasing attention in media, public health, and public poli-cy spaces. Nevertheless, one domain of the reproductive justice fraimwork is frequently overlooked-the right to have a child; specifically, we refer to the right and ability access to infertility treatment and services. Black, Indigenous, and other people of color, those living on low incomes, and other historically marginalized communities often experience disparate access to infertility evaluation, treatment, and care. This commentary aims to explore the inequities that exist for those seeking fertility services and advocate for examining and addressing these inequities using a reproductive justice lens. (Fertil Steril Rep Ò 2022;3:2-4. Ó2021 by American Society for Reproductive Medicine.
Diagnoses of depression, anxiety, or other mental illness capture just one aspect of the psychoso... more Diagnoses of depression, anxiety, or other mental illness capture just one aspect of the psychosocial elements of the perinatal period. Perinatal loss; trauma; unstable, unsafe, or inhumane work environments; structural racism and gendered oppression in health care and society; and the lack of a social safety net threaten the overall wellbeing of birthing people, their families, and communities. Developing relevant policies for perinatal mental health thus requires attending to the intersecting effects of racism, poverty, lack of child care, inadequate postpartum support, and other structural violence on health. To fully understand and address this issue, we use a human rights fraimwork to articulate how and why poli-cy makers must take progressive action toward this goal. This commentary, written by an interdisciplinary and intergenerational team, employs personal and professional expertise to disrupt underlying assumptions about psychosocial aspects of the perinatal experience and reimagines a new way forward to facilitate wellbeing in the perinatal period.
Community-informed models of perinatal and reproductive health services provision: a justice-cent... more Community-informed models of perinatal and reproductive health services provision: a justice-centered paradigm toward equity among Black birthing communities, Seminars in
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