Provision of medication abortion in Hawai‘i during COVID-19: Practical experience with multiple care delivery models

Abstract

Objective : To demonstrate the effectiveness of medication abortion with the implementation of telemedicine and a no-test protocol in response to the COVID-19 pandemic. Study design : This is a retrospective cohort study of patients who had a medication abortion up to 77 days gestation at the University of Hawai‘i between April and November 2020. Patients had the option of traditional in clinic care or telemedicine with either in clinic pickup or mailing of medications. During this time, a no-test protocol for medication abortion without prior labs or ultrasound was in place for eligible patients. The primary outcome was the rate of successful medication abortion without surgical intervention. Secondary outcomes included abortion-related complications. Results : A total of 334 patients were dispensed mifepristone and misoprostol, 149 (44.6%) with telemedicine with in-person pickup of medications, 75 (22.5%) via telemedicine with medications mailed, and 110 (32.9%) via traditional in person visits. The overall rate of complete medication abortion without surgical intervention was 95.8%, with success rates of 96.8, 97.1, and 93.6% for the clinic pickup, mail, and clinic visit groups, respectively. Success for those without an ultrasound performed prior to the procedure was 96.6%, compared to 95.5% for those with ultrasound. We obtained follow up data for 87.8% of participants. Conclusions : Medication abortion was safe and effective while offering multiple modes of care delivery including telemedicine visits without an ultrasound performed prior to dispensing medications. Implications : Incorporating telemedicine and a no-test protocol for medication abortion is safe and has the potential to expand access to abortion care. All care models had low rates of adverse events, which contradicts the idea that the Risk Evaluation and Mitigation Strategy increases the safety of medication abortion.

Mail-order pharmacy dispensing of mifepristone for medication abortion after in-person clinical assessment

“…We look forward to completing recruitment for the study in the coming year, which will provide more precise estimates of the effectiveness, acceptability, and feasibility of medication abortion with mail-order pharmacy dispensing of mifepristone. However, these interim results, together with studies of other care models that include mailing pills for medication abortion [23][24][25][26] and pharmacist dispensing at brick-and-mortar pharmacies [3], support the removal of the FDA's in-person dispensing requirement for mifepristone.…”

Mifepristone: A Safe Method of Medical Abortion and Self-Managed Medical Abortion in the Post-Roe Era

“…The authors noted that the no-test protocol is safe with low rates of adverse events. 117 A much larger study of 52,142 women in Great Britain examined outcomes before and after the no-test medical abortion protocol was implemented via telemedicine, in the wake of the COVID-19 pandemic, and found that the telemedicine group showed higher effectiveness, and the acceptability of telemedicine was also high. 118…”

“…The authors noted that the no-test protocol is safe with low rates of adverse events. 117 A much larger study of 52,142 women in Great Britain examined outcomes before and after the no-test medical abortion protocol was implemented via telemedicine, in the wake of the COVID-19 pandemic, and found that the telemedicine group showed higher effectiveness, and the acceptability of telemedicine was also high. 118 Self-managed abortion Self-managed abortion (SMA) is a termination of pregnancy performed by an individual outside of a formal health care system and has been observed across the world, even when there is access to safe and legal abortion.…”

Reproductive justice in the time of COVID-19: a systematic review of the indirect impacts of COVID-19 on sexual and reproductive health

“…A few exceptions were made in high-income countries, where the pandemic provided an opportunity to advance access to SRHR • Compared to countries with mildly restrictive abortion policies, countries with severely restrictive abortion policies reported less women accessing SRH-related services (69% vs 23%; p = 0.026); no abortion policy changes (69% vs 0%); p < 0.001); and decreased contraceptive policy changes (88% vs 46%; p = 0.023) Fuchs et al [ 53 ] Quantitative; Longitudinal Sexually active women between the ages of 18–40 years (n = 764) in Poland COVID-19 Sexual behavior • Total sexual function as measured by the Female Sexual Function Index (FSFI) significantly decreased (30.1 (4.4) vs 25.8 (9.7)) during the COVID-19 pandemic. Decreases were seen across every FSFI domain (desire, arousal, lubrication, orgasm, satisfaction, and pain) • Sexual dysfunction (FSFI score < 26) increased during COVID-19 control measures (15.3% vs 34.3%) • Frequency of sexual intercourse declined due to isolation, conflict with partner and mental health (stress, anxiety, depression) • Less educated women, those with worse living conditions, women who did not work, women living with their parents or those in informal relationships experienced lowest sexual functioning Kerestes et al [ 34 ] Quantitative; Retrospective cohort Patients who had medication abortion up to 77 days gestation between April and November 2020 in Hawaii (n = 334) COVID-19 Abortion • A total of 334 patients received medication abortion, of which 149 (45%) received telemedicine with in-person pickup of medications, 75 (23%) received telemedicine with medications mailed, and 110 (33%) received traditional in person visits • The rate of complete medication abortion without surgical intervention was 96%, with success rates of 97%, 97%, and 94% for the clinic pickup, mail, and clinic visit groups, respectively • Success rate for those with and without an ultrasound prior were similar (96% vs 97%), and 88% of patients returned for follow up care. Very few women (17; 5%) experienced any complications Leight et al [ 42 ] Quantitative; Quasi-experimental n = 109,129 women served by n = 132 unique promoters (community healthcare workers) and 192 unique public health facilities in Nampula and Sofala, Mozambique between January 21—May 20, 2020 COVID-19 Access to contraceptives • COVID-19 related lockdowns and disruptions were associated with a decrease in contraceptive receipt (OR 0.798, 95% CI [0.701–0.908], p = 0.001) • Easing lockdown restrictions was associated with an increase in contraceptive referrals (OR 1.187, 95% CI [1.034, 1.354], p = 0.015), especially amongst women who were not currently using contraceptives (OR 1.490, 95% CI [1.203, 1.841], p < 0.001); and in contraceptive receipt (OR 0...…”

“…The need for in-person visits for medication abortion decreased from two visits among most providers (71%) to no in-person visits among 50% of abortion providers surveyed across the US [ 33 ]. Telemedicine, with in-person medication pick up or mail order was found to be acceptable during the pandemic in Hawaii, and was found to have high rates of success, follow-up retention and very little complications [ 34 ]. In a separate study of 103 abortion clinics across the US, several providers reported having to postpone, cancel or temporarily close their clinics due to staff being sick with probable COVID-19, COVID-19 related travel restrictions, or caregiving responsibilities, especially in the Southern states [ 35 ].…”