Nicole E. Johns

Comparison of Outcomes before and after Ohio's Law Mandating Use of the FDA-Approved Protocol for Medication Abortion: A Retrospective Cohort Study

Background In February 2011, an Ohio law took effect mandating use of the United States Food and Drug Administration (FDA)-approved protocol for mifepristone, which is used with misoprostol for medication abortion. Other state legislatures have passed or enacted similar laws requiring use of the FDA-approved protocol for medication abortion. The objective of this study is to examine the association of this legal change with medication abortion outcomes and utilization. Methods and Findings We used a retrospective cohort design, comparing outcomes of medication abortion patients in the prelaw period to those in the postlaw period. Sociodemographic and clinical chart data were abstracted from all medication abortion patients from 1 y prior to the law’s implementation (January 2010–January 2011) to 3 y post implementation (February 2011–October 2014) at four abortion-providing health care facilities in Ohio. Outcome data were analyzed for all women undergoing abortion at ≤49 d gestation during the study period. The main outcomes were as follows: need for additional intervention following medication abortion (such as aspiration, repeat misoprostol, and blood transfusion), frequency of continuing pregnancy, reports of side effects, and the proportion of abortions that were medication abortions (versus other abortion procedures). Among the 2,783 medication abortions ≤49 d gestation, 4.9% (95% CI: 3.7%–6.2%) in the prelaw and 14.3% (95% CI: 12.6%–16.0%) in the postlaw period required one or more additional interventions. Women obtaining a medication abortion in the postlaw period had three times the odds of requiring an additional intervention as women in the prelaw period (adjusted odds ratio [AOR] = 3.11, 95% CI: 2.27–4.27). In a mixed effects multivariable model that uses facility-months as the unit of analysis to account for lack of independence by site, we found that the law change was associated with a 9.4% (95% CI: 4.0%–18.4%) absolute increase in the rate of requiring an additional intervention. The most common subsequent intervention in both periods was an additional misoprostol dose and was most commonly administered to treat incomplete abortion. The percentage of women requiring two or more follow-up visits increased from 4.2% (95% CI: 3.0%–5.3%) in the prelaw period to 6.2% (95% CI: 5.5%–8.0%) in the postlaw period (p = 0.003). Continuing pregnancy was rare (0.3%). Overall, 12.6% of women reported at least one side effect during their medication abortion: 8.4% (95% CI: 6.8%–10.0%) in the prelaw period and 15.6% (95% CI: 13.8%–17.3%) in the postlaw period (p < 0.001). Medication abortions fell from 22% (95% CI: 20.8%–22.3%) of all abortions the year before the law went into effect (2010) to 5% (95% CI: 4.8%–5.6%) 3 y after (2014) (p < 0.001). The average patient charge increased from US

Distance traveled for Medicaid-covered abortion care in California

426 in 2010 to US

Distance Traveled for an Abortion and Source of Care After Abortion

551 in 2014, representing a 16% increase after adjusting for inflation in medical prices. The primary limitation to the study is that it was a pre/post-observational study with no control group that was not exposed to the law. Conclusions Ohio law required use of a medication abortion protocol that is associated with a greater need for additional intervention, more visits, more side effects, and higher costs for women relative to the evidence-based protocol. There is no evidence that the change in law led to improved abortion outcomes. Indeed, our findings suggest the opposite. In March 2016, the FDA-protocol was updated, so Ohio providers may now legally provide current evidence-based protocols. However, this law is still in place and bans physicians from using mifepristone based on any new developments in clinical research as best practices continue to be updated.

Evaluating the impact of a mandatory pre-abortion ultrasound viewing law: A mixed methods study

BackgroundAccess to abortion care in the United States is limited by the availability of abortion providers and their geographic distribution. We aimed to assess how far women travel for Medicaid-funded abortion in California and identify disparities in access to abortion care.MethodsWe obtained data on all abortions reimbursed by the fee-for-service California state Medicaid program (Medi-Cal) in 2011 and 2012 and examined distance traveled to obtain abortion care by several demographic and abortion-related factors. Mixed-effects multivariable logistic regression models were constructed to examine factors associated with traveling 50 milesxa0or more. County-level t-tests and linear regressions were conducted to examine the effects of a Medi-Cal abortion provider in a county on overall and urban/rural differences in utilization.Results11.9% (95% CI: 11.5–12.2%) of women traveled 50 miles or more. Women obtaining second trimester or later abortions (21.7%), women obtaining abortions at hospitals (19.9%), and rural women (51.0%) were most likely to travel 50 miles or more. Across the state, 28 counties, home to 10% of eligible women, did not have a facility routinely providing Medi-Cal-covered abortions.ConclusionsEfforts are needed to expand the number of abortion providers that accept Medi-Cal. This could be accomplished by increasing Medi-Cal reimbursement rates, increasing the types of providers who can provide abortions, and expanding the use of telemedicine. If national trends in declining unintended pregnancy and abortion rates continue, careful attention should be paid to ensure that reduced demand does not lead to greater disparities in geographic and financial access to abortion care by ensuring that providers accepting Medicaid payment are available and widely distributed.

Access to Medication Abortion Among California's Public University Students

OBJECTIVEnTo examine the association between distance traveled for an abortion and site of postabortion care among low-income women.nnnMETHODSnWe conducted a retrospective cohort study using claims data from 39,747 abortions covered by Californias Medicaid program in 2011-2012. Primary outcomes were the odds of abortion-related visits to an emergency department (ED) and the original abortion site, and the secondary outcome was total abortion care costs. We used mixed-effects logistic regression adjusting for patient and abortion characteristics to examine the associations between distance traveled and subsequent abortion-related care at each location.nnnRESULTSnAmong all abortions (N=39,747), 3% (95% CI 2.9-3.3, n=1,232) were followed by an ED visit (3% first-trimester aspirations, 2% second trimester or later, and 4% medication abortions) and 25% (95% CI 24.1-24.9, n=9,745) were followed by a visit to the original abortion site (4% first-trimester aspirations, 3% second-trimester or later, and 77% medication abortions). Women traveling farther for their abortions had higher odds of visiting an ED (100 or more miles compared with less than 25 miles, first-trimester aspirations: adjusted odds ratio [OR] 2.29, 95% CI 1.50-3.49; medication abortions: adjusted OR 2.30, 95% CI 1.34-3.93) and lower odds of returning to their abortion site for follow-up (100 or more miles compared with less than 25 miles, first-trimester aspirations: adjusted OR 0.36, 95% CI 0.18-0.70; second trimester or later: adjusted OR 0.52, 95% CI 0.31-0.88; and medication abortions: adjusted OR 0.33, 95% CI 0.23-0.50). Costs were consistently higher when subsequent care occurred at an ED rather than the abortion site (median cost

Abortion-related emergency department visits in the United States: An analysis of a national emergency department sample

941 compared with

Coercing Women’s Behavior

536, P<.001).nnnCONCLUSIONnFor most patients, greater distance traveled for abortion was associated with increased likelihood of seeking subsequent care at an ED. Increasing the number of rural Medicaid abortion providers and reimbursing providers for telemedicine and alternatives to routine follow-up would likely improve continuity of care and reduce state costs by shifting the location of follow-up from EDs back to abortion providers.

Women's experiences of their preabortion ultrasound image printout

Background Since mid-2013, Wisconsin abortion providers have been legally required to display and describe pre-abortion ultrasound images. We aimed to understand the impact of this law. Methods We used a mixed-methods study design at an abortion facility in Wisconsin. We abstracted data from medical charts one year before the law to one year after and used multivariable models, mediation/moderation analysis, and interrupted time series to assess the impact of the law, viewing, and decision certainty on likelihood of continuing the pregnancy. We conducted in-depth interviews with women in the post-law period about their ultrasound experience and analyzed them using elaborative and modified grounded theory. Results A total of 5342 charts were abstracted; 8.7% continued their pregnancies pre-law and 11.2% post-law (p = 0.002). A multivariable model confirmed the law was associated with higher odds of continuing pregnancy (aOR = 1.23, 95% CI: 1.01–1.50). Decision certainty (aOR = 6.39, 95% CI: 4.72–8.64) and having to pay fully out of pocket (aOR = 4.98, 95% CI: 3.86–6.41) were most strongly associated with continuing pregnancy. Ultrasound viewing fully mediated the relationship between the law and continuing pregnancy. Interrupted time series analyses found no significant effect of the law but may have been underpowered to detect such a small effect. Nineteen of twenty-three women interviewed viewed their ultrasound image. Most reported no impact on their abortion decision; five reported a temporary emotional impact or increased certainty about choosing abortion. Two women reported that viewing helped them decide to continue the pregnancy; both also described preexisting decision uncertainty. Conclusions This law caused an increase in viewing rates and a statistically significant but small increase in continuing pregnancy rates. However, the majority of women were certain of their abortion decision and the law did not change their decision. Other factors were more significant in women’s decision-making, suggesting evaluations of restrictive laws should take account of the broader social environment.

Abortion-related emergency department visits:Analysis of a national emergency department sample

PURPOSEnA proposed California law will require student health centers at public universities to provide medication abortion. To understand its potential impact, we sought to describe current travel time, costs, and wait times to access care at the nearest abortion facilities.nnnMETHODSnWe projected total medication abortion use based on campus enrollment figures and age- and state-adjusted abortion rates. We calculated distance and public transit time from campuses to the nearest abortion facility. We contacted existing abortion-providing facilities to determine costs, insurance acceptance, and wait times.nnnRESULTSnWe estimate 322 to 519 California public university students seek medication abortions each month. As many as 62% of students at these universities were more than 30 minutes from the closest abortion facility via public transportation. Average cost of medication abortion was

State and Local Health Department Activities Related to Abortion: A Web Site Content Analysis

604, and average wait time to the first available appointment was one week.nnnCONCLUSIONSnCollege students face cost, scheduling, and travel barriers to abortion care. Offering medication abortion on campus could reduce these barriers.