Mifepristone use for early pregnancy loss: A qualitative study of barriers and facilitators among OB/GYNS in Massachusetts, USA

Abstract

ContextEarly pregnancy loss (EPL) affects 1 million patients in the United States (US) annually, but integration of mifepristone into EPL care may be complicated by regulatory barriers, practice‐related factors, and abortion stigma.MethodsWe conducted qualitative, semi‐structured interviews among obstetrician‐gynecologists in independent practice in Massachusetts, US on mifepristone use for EPL. We recruited participants via professional networks and purposively sampled for mifepristone use, practice type, time in practice, and geographic location within Massachusetts until we reached thematic saturation. We analyzed interviews using inductive and deductive coding under a thematic analysis framework to identify facilitators of and barriers to mifepristone use.ResultsWe interviewed 19 obstetrician‐gynecologists; 12 had used mifepristone for EPL and 7 had not. Participants were in private practice (n = 12), academic practice (n = 6), or worked at a federally qualified health center (n = 1). Seven had fellowship training, including four in complex family planning. The most common facilitators of mifepristone use for EPL were access to the expertise or protocols of local‐regional experts, leadership from a “champion,” prior experience with abortion care, and hospital capacity constraints during the COVID‐19 pandemic. The most common barriers were related to the Mifepristone Risk Evaluation and Mitigation Strategy (REMS) Program imposed by the US Food and Drug Administration (FDA). Additionally, mifepristone's affiliation with abortion was a barrier to its use in EPL for some obstetrician‐gynecologists.ConclusionThe FDA Mifepristone REMS Program presents substantial barriers to obstetrician‐gynecologists incorporating mifepristone into their EPL care.

Abortion Stigma as a Barrier to Mifepristone Use among Obstetrician-Gynecologists in Alabama for Early Pregnancy Loss

“…As noted previously, the Massachusetts study highlighted the predominant barrier to mifepristone use for miscarriage management as the FDA REMS, with abortion stigma cited much less frequently. 10,13 In comparison, we found an outsized effect of abortion stigma in this abortion-restrictive setting. In the current politicolegal environment in the United States, an increasing number of states have adopted abortion restrictions similar to those of Alabama, 18 which affects the evidence-based provision of abortion-adjacent care, including miscarriage management.…”

“…Prior work among US primary care providers and OB-GYNs in Massachusetts found burdensome regulations to be the major factor preventing the use of mifepristone for early pregnancy loss. 10,11,13 Mifepristone remains subject to rapidly changing legislation and legal debate. As of January 2023, the FDA REMS program allows dispensing of mifepristone by pharmacies, potentially relieving logistical barriers contributing to nonuse, but state-level abortion bans and legal and legislative challenges to mifepristone may complicate this.…”

“…12 In a study of mifepristone use among Massachusetts OB-GYNs for early pregnancy loss, most used misoprostol-only regimens for medical management. 13 In this study of Massachusetts providers, the primary barrier to mifepristone use for miscarriage was the FDA REMS, but several participants cited abortion stigma as a source of mifepristone hesitancy. 10,13,14 Conversely, those who provided medication abortion were more likely also to use mifepristone for early pregnancy loss in their patients.…”

“…13 In this study of Massachusetts providers, the primary barrier to mifepristone use for miscarriage was the FDA REMS, but several participants cited abortion stigma as a source of mifepristone hesitancy. 10,13,14 Conversely, those who provided medication abortion were more likely also to use mifepristone for early pregnancy loss in their patients. 10 In this qualitative study, we explore provider use of mifepristone in a southern US state, where abortion restrictions and the sociopolitical landscape differ considerably from Massachusetts.…”

“…We conducted individual semistructured telephone interviews of English-speaking OB-GYNs in Alabama between April and August 2021. The interview guide, included in the supplemental materials (http://links.lww.com/SMJ/A406), was adapted from a study of mifepristone use among OB-GYNs in Massachusetts for early pregnancy loss in their patients, 13 with revisions made to contextualize OB-GYNs' experience providing reproductive health care in Alabama. The interview guide was revised with the input of the primary investigator (S.N.…”