beaman abortion 2020€¦ · 2020. 2. 19. · jessica beaman, md mph assistant professor of...

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1 | [footer text here] Zuckerberg San Francisco General Abortion in 2020: The Role of Primary Care CME Medical Care of Vulnerable and Underserved Populations Jessica Beaman, MD MPH Assistant Professor of Medicine Division of General Internal Medicine at ZSFG Zuckerberg San Francisco General Disclosures I have no financial disclosures Zuckerberg San Francisco General Learning Objectives 1. Recognize the prevalence and impact that abortion has on patients in the primary care setting. 2. Demonstrate the intersectionality of abortion through its association with the executive, legislative and judicial branches of government. 3. Recommend clinical changes and advocacy efforts that people can take to support abortion in primary care. Zuckerberg San Francisco General The Impact of Abortion

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  • 1 | [footer text here]

    Zuckerberg San Francisco General

    Abortion in 2020: The Role of Primary Care

    CME Medical Care of Vulnerable and Underserved Populations

    Jessica Beaman, MD MPHAssistant Professor of MedicineDivision of General Internal Medicine at ZSFG

    Zuckerberg San Francisco General

    Disclosures

    I have no financial disclosures

    Zuckerberg San Francisco General

    Learning Objectives

    1. Recognize the prevalence and impact that abortion has on patients in the primary care setting.

    2. Demonstrate the intersectionality of abortion through its association with the executive, legislative and judicial branches of government.

    3. Recommend clinical changes and advocacy efforts that people can take to support abortion in primary care.

    Zuckerberg San Francisco General

    The Impact of Abortion

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    Zuckerberg San Francisco General Zuckerberg San Francisco General

    Terminology

    Elective abortion = when a medication is taken or a procedure is performed to end a pregnancy- Also called an induced abortion, pregnancy termination, or

    abortion

    It is not:- Spontaneous abortion or miscarriage or early pregnancy loss

    ACOG 2018

    Zuckerberg San Francisco General

    Reproductive age women in primary care

    61 million US women of reproductive age (15-44)- 10% become pregnant annually

    Half of all US women will seek primary care in an internal medicine or family medicine clinic each year

    CDC NCHS 2010 Pregnancy Rates Amongst U.S. Women (most recent data available) Daniels et al. Natl Health Stat Report 2015Petterson et al. J Women’s Health 2014

    Zuckerberg San Francisco General

    Lifetime Prevalence of Common Medical Conditions47

    39

    33

    27

    12

    10

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    35

    40

    45

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    Life

    time

    Prev

    alenc

    e (%

    )

    Percent Breast Cancer

    Cervical CancerDepressionDiabetesHypertension

    Breast CancerCervical CancerDepressionDiabetesHypertension

    Guttmacher InstituteNational Center for Health StatisticsNational Cancer Institute Surveillance, Epidemiology, and End Results Program

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    Zuckerberg San Francisco General

    Unintended Pregnancy is Common47

    39

    33

    27

    12

    10

    5

    10

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    Uni

    nten

    ded

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    nanc

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    vica

    l Can

    cer

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    bete

    s

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    erte

    nsio

    n

    Bre

    ast

    Can

    cer

    Dep

    ress

    ion

    Life

    time

    Prev

    alenc

    e (%

    )

    Guttmacher InstituteNational Center for Health StatisticsNational Cancer Institute Surveillance, Epidemiology, and End Results Program

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    Pregnancy Intentions

    45% of all pregnancies are unintended

    Mistimed = wants to become pregnant in the future but not at the time she became pregnant

    Unwanted = did not want to become pregnant then or at any time in the future

    Intended55%

    Unintended -mistimed

    27%

    Uninteded -unwanted

    18%

    Finer and Zolna N Engl J Med 2016

    Zuckerberg San Francisco General Zuckerberg San Francisco General

    Pregnancy Outcomes

    Computer modeling of how brains make complex decision

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    Zuckerberg San Francisco General

    1 in 5Pregnancies in US result in abortion

    Guttmacher Institute 2019

    Zuckerberg San Francisco General

    1 in 4Women will have an abortion by age 45

    Guttmacher Institute 2019

    Zuckerberg San Francisco General

    Trends in Abortion Care

    Zuckerberg San Francisco General

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    Zuckerberg San Francisco General Zuckerberg San Francisco General

    Zuckerberg San Francisco General Zuckerberg San Francisco General

    Access to Care90% of women live in US county without an abortion clinic

    Cartwright et al. J Med Internet Res 2018

    Distance to nearest abortion facility, 2017

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    Zuckerberg San Francisco General

    Only 7%of practicing ob/gyns perform

    abortions in their practice

    AHRQ 2018Desai Contraception 2018

    Zuckerberg San Francisco General

    35%of practicing ob/gyns would not refer

    patients for abortion services

    AHRQ 2018Desai Contraception 2018

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    Turnaway Study (UCSF 2018 and ongoing)ANSIRH (Advancing New Standards in Reproductive Health)

    Large, longitudinal study (N=1000)- 8000 interviews

    Women turned away based on GA Lasting impacts

    - Unemployment/living below FPL- In relationship w/ abusive partner- Less likely to have aspirational plans

    No increased likelihood for:- Depression- Anxiety- Suicidal ideationFoster et al. ANSIRH 2018

    Zuckerberg San Francisco General

    Legal Considerations

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    Zuckerberg San Francisco General

    The Executive BranchFirst U.S. President to attend the annual March for Life

    “Let us work together to build a culture that

    cherishes innocent life. And let us reaffirm a fundamental truth: all

    children, born and unborn, are made in the

    holy image of God.”

    Zuckerberg San Francisco General

    The Legislative BranchA few examples

    US Senator James Inhofe (R-OK)

    disproving climate change on the Senate

    floor by providing a snowball as evidence

    for lack of global warming

    Zuckerberg San Francisco General

    “"I heard about it over the years. I never questioned it or gave it a lot of thought."

    Ohio State Representative John BeckerIn responding to reporter asking if he had done any research on reimplantation of ectopic pregnancies

    Zuckerberg San Francisco General

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    Zuckerberg San Francisco General

    Types of RegulationsPhysician/Clinic Patient

    Physician-only (40) Public funding (33+DC) Hospital-based (19) Two physicians (17)

    Private insurance (12)

    Gestational limits (43) Parental involvement (37) Waiting periods (27) State-mandated counseling (18)

    Ability of fetus to feel pain (13)Mental health consequences (8)Link to breast cancer (5)

    Guttmacher Institute 2019

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    Reversal of Medication Abortion

    Zuckerberg San Francisco General

    Who can provide abortion?

    40 states require clinics who perform abortions to be physicians

    Know your state laws- Guttmacher Institute “An Overview of Abortion Laws”

    (Updated January 1, 2020)

    Zuckerberg San Francisco General

    What if Roe v. Wade is overturned?

    Washington Post 2018

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    Zuckerberg San Francisco General

    Interactive Tool

    Zuckerberg San Francisco General

    Zuckerberg San Francisco General

    The Judicial Branch

    Zuckerberg San Francisco General

    The Supreme Court

    June Medical Services LLC v. GeeMarch 4, 2020

    Whole Woman’s Health v. HellerstedtJune 27, 2016

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    Zuckerberg San Francisco General

    Evidence for Abortion in Primary Care

    Zuckerberg San Francisco General

    NASEM Report

    Zuckerberg San Francisco General

    Safety of Mifepristone and Abortion (2018)• All forms of abortion are safe and effective

    • Abortion can be safely performed in an office-

    based setting

    • Does not increase risk of:

    • Secondary infertility

    • Breast cancer

    • Depression/anxiety/PTSD

    • Serious complications are < 1%NASEM 2018

    Zuckerberg San Francisco General

    Medication Abortion in Primary Care

    Power to destigmatize- Integration in to routine care- Lack of protestors

    Patient preference

    Taylor Am J Med Qual 2013

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    Zuckerberg San Francisco General

    Incorporating Abortion into Primary Care

    • 2012 by Page et al• 90 Patients in academic PCC• 67% felt PCC should offer medical abortions• 87% would want PCP to perform

    • 2005 by Schwarz and Luetkemeyer• 212 Residents, 11 residencies• 42% IM residents willing to prescribe medication abortion

    • 2010 by Godfrey et al• 299 Patients in NYC and Chicago• 58% would choose primary care clinic (PCC) for abortion

    • 2015 Wu et al• 210 Patients in academic PCC• 93% “very satisfied” with abortion experience• 3.9/4 scores for quality of staff, doctor, and counseling experience

    Zuckerberg San Francisco General

    Medication Abortion in Primary Care

    Power to destigmatize Patient preference Patient satisfaction

    - Achieving rapid appointment access- Staff courtesy- Ready information to questions

    Taylor Am J Med Qual 2013

    Zuckerberg San Francisco General

    Clinical Integration: 5 Key Questions

    Zuckerberg San Francisco General

    Clinical Integration5 Key Questions

    1. Who can receive a medication abortion? 2. What are the medications and what do they do? 3. Do I need an ultrasound or other labs? 4. What follow-up is needed? 5. How do I get abortion medications in to my clinic?

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    Zuckerberg San Francisco General

    1. Who can receive a medication abortion?

    Indications Gestational age < 10

    weeks Prefer medications over

    procedure

    Danco 2019FDA 2019

    Zuckerberg San Francisco General

    80% US abortions occur

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    Zuckerberg San Francisco General

    Clinical Integration5 Key Questions

    1. Who can receive a medication abortion? 2. What are the medications and what do they do? 3. Do I need an ultrasound or other labs? 4. What follow-up is needed? 5. How do I get abortion medications in to my clinic?

    Zuckerberg San Francisco General

    2. What are the medications and what do they do?

    Mifepristone: A progesterone receptor blocker- Leads to detachment of pregnancy from endometrium- Also softens/ripens cervix and primes myometrium for misoprostol

    Misoprostol: A prostaglandin analogue- Stimulates uterine contractions

    Cramping + expulsion

    At home 24‐48 hours later

    Typically no symptoms

    MISOPROSTOLProstaglandin

    In office

    Zuckerberg San Francisco General

    Efficacy of Mifepristone and Misoprostol for Abortion Most studies = ~95% Society of Family Planning Guidelines (2014)

    - 92% up to 49 days- 85% from 49-70 days

    TEACH Workbook (Chen and Creinin 2015)- 95-99% up to 63 days- 91-94% from 64-70 days

    Danco Label- 96-97% effective through 70 days

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    Zuckerberg San Francisco General

    FDA-Labeling for Mifepristone

    REMS

    Zuckerberg San Francisco General

    FDA-Labeling for Mifepristone

    REMS (Risk Evaluation and Mitigation Strategies)- 58 FDA-approved medications with

    “serious safety concerns”- Registration of clinicians in central

    database- Must be dispensed in-person No pharmacy No mail

    Zuckerberg San Francisco General

    FDA-Labeling for Mifepristone

    REMS Black Box warning

    - Rare infection Clostridium sordellii Clostridium perfringens

    Zuckerberg San Francisco General

    Clinical Integration5 Key Questions

    1. Who can receive a medication abortion? 2. What are the medications and what do they do? 3. Do I need an ultrasound or other labs? 4. What follow-up is needed? 5. How do I get abortion medications in to my clinic?

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    Zuckerberg San Francisco General

    3. Do I need an ultrasound?

    You do not need an ultrasound on-site or any other special equipment

    For women with regular cycles, LMP is as effective as other methods for determining GA

    Ultrasound versus labs (e.g., hCG)NAF 2019Raymond et al., Contraception 2018

    Zuckerberg San Francisco General

    What labs are needed?

    Required Rh testing

    - Rhogam 50mcg IM within 72 hours of mifepristone

    - Not required if GA < 8 weeks

    Recommended CBC

    - R/o anemia- Consider safety if Hb < 9.5

    Quantitative hCG- If plan to follow levels

    Hollenback et al. Contraception 2019Mark et al. Contraception 2019NAF 2019

    Zuckerberg San Francisco General

    Clinical Integration5 Key Questions

    1. Who can receive a medication abortion? 2. What are the medications and what do they do? 3. Do I need an ultrasound or other labs? 4. What follow-up is needed? 5. How do I get abortion medications in to my clinic?

    Zuckerberg San Francisco General

    Follow-upUp to day 14

    In-person or not Ultrasound = absence of gestational sac or embryo

    - Endometrial thickening is normal unless accompanied by symptoms Serial quantitative hCG

    - Decline by 50% by 3 days- Decline by 80% by 7 days

    Self-assessment is non-inferior to routine follow-up

    NAF 2019Schmidt-Hansen et al., Am J Obstet Gynecol 2019Steinquist et al., Contraception 2017

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    Zuckerberg San Francisco General

    Anticipatory Guidance/Return Precautions

    Zuckerberg San Francisco General

    Concerning Symptoms and Return Precautions

    Excessive bleeding: soaking through 2 sanitary napkins per hour for 2 consecutive hours 

    Lack of bleeding: no bleeding 24 hours after taking misoprostolInfectious symptoms: flu‐like symptoms that start 24 hours after taking 

    misoprostol or fevers, chills, severe abdominal pain and/or malodorous discharge

    Pain: severe abdominal pain, cramping, and/or bloating Ongoing pregnancy symptoms: feeling pregnant (e.g., breast tenderness, 

    nausea) at the follow‐up visit 

    FDA 2019NAF 2019TEACH 2019WHO 2019

    Zuckerberg San Francisco General

    Clinical Integration5 Key Questions

    1. Who can receive a medication abortion? 2. What are the medications and what do they do? 3. Do I need an ultrasound or other labs? 4. What follow-up is needed? 5. How do I get abortion medications in to my clinic?

    Zuckerberg San Francisco General

    Protocols

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    Zuckerberg San Francisco General

    Protocols

    Zuckerberg San Francisco General

    ExpenseGoodRx, NeedyMeds, Danco (as of 2/2020)

    Mifepristone- GenBioPro = $50- Danco = $80-100

    Misoprostol (800 mcg)- Generic = $10-15

    Zuckerberg San Francisco General

    Legal ResourcesFor integrating mifepristone in to your clinic

    ACLU Reproductive Freedom Project Guttmacher Institute National Abortion Federation Physicians for Reproductive Health Reproductive Health Access Project (RHAP)

    - Regional clusters and national IM cluster (Danco)

    Zuckerberg San Francisco General

    The Future

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    Zuckerberg San Francisco General

    ““As scientists, the most compelling argument is yours, because you know that of which you speak. You are essential, and your contributions give us hope. Know your power. Know your responsibility.”US Congresswoman and Speaker of the House Nancy PelosiSpeaking at the Global Climate and Health Forum at UCSF, 2018

    Zuckerberg San Francisco General

    AdvocacyConcrete ways to engage

    Talk to a friend or family member, a colleague, someone at your institution

    Urge your representatives and senators to support the EACH Woman Act (HR 1692, S 758)

    Join a RHAP Cluster- Email Laura Riker ([email protected]) for your region

    and specialty

    Zuckerberg San Francisco General

    Patient AdvocacyKnow how to support your patients

    Help patients utilize abortion funds Provide direct referrals for patients

    - Title X? Refer to All-Options Hotlines for patients

    - Options counseling: All-Options1-888-493-0092

    - After-abortion: Exhale1-866-4-Exhale or text

    Zuckerberg San Francisco General

    Research StudiesUCSF + Multiple Community Sites

    Expanding primary-care provision of medication abortion via mail-order mifepristone

    Recruiting for primary care sites to start later this year Sites will receive training, materials, ongoing support,

    reimbursement for services After evaluation by clinician, patients will obtain medications from

    mail-order pharmacy and will be asked to complete 2 surveys If interested, email [email protected] or

    [email protected]

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    Zuckerberg San Francisco General

    CME VideoAbortionpillcme.teachtraining.org

    Zuckerberg San Francisco General

    Summary Unintended pregnancy and abortion are common and

    disproportionately affect vulnerable and underserved communities.

    The landscape of abortion continues to evolve and reproductive rights are being protected or limited at all levels of the government.

    Abortion is safe and effective and can be provided in primary care settings without special equipment.

    Resources are available to support advocacy for and integration of medication abortion in to primary care practice.