beaman abortion 2020€¦ · 2020. 2. 19. · jessica beaman, md mph assistant professor of...
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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
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Disclosures
I have no financial disclosures
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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.
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The Impact of Abortion
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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
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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
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Lifetime Prevalence of Common Medical Conditions47
39
33
27
12
10
5
10
15
20
25
30
35
40
45
50
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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Unintended Pregnancy is Common47
39
33
27
12
10
5
10
15
20
25
30
35
40
45
50
Uni
nten
ded
Preg
nanc
y
Cer
vica
l Can
cer
Dia
bete
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Hyp
erte
nsio
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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
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Pregnancy Outcomes
Computer modeling of how brains make complex decision
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1 in 5Pregnancies in US result in abortion
Guttmacher Institute 2019
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1 in 4Women will have an abortion by age 45
Guttmacher Institute 2019
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Trends in Abortion Care
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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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Only 7%of practicing ob/gyns perform
abortions in their practice
AHRQ 2018Desai Contraception 2018
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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
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Legal Considerations
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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.”
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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
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“"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
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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
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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)
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What if Roe v. Wade is overturned?
Washington Post 2018
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Interactive Tool
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The Judicial Branch
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The Supreme Court
June Medical Services LLC v. GeeMarch 4, 2020
Whole Woman’s Health v. HellerstedtJune 27, 2016
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Evidence for Abortion in Primary Care
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NASEM Report
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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
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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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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
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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
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Clinical Integration: 5 Key Questions
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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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1. Who can receive a medication abortion?
Indications Gestational age < 10
weeks Prefer medications over
procedure
Danco 2019FDA 2019
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80% US abortions occur
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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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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
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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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FDA-Labeling for Mifepristone
REMS
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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
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FDA-Labeling for Mifepristone
REMS Black Box warning
- Rare infection Clostridium sordellii Clostridium perfringens
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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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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
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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
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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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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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Anticipatory Guidance/Return Precautions
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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
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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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Protocols
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Protocols
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ExpenseGoodRx, NeedyMeds, Danco (as of 2/2020)
Mifepristone- GenBioPro = $50- Danco = $80-100
Misoprostol (800 mcg)- Generic = $10-15
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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)
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The Future
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““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
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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
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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
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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
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CME VideoAbortionpillcme.teachtraining.org
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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.