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Adolescent Medicine Providers: A Critical Extension of the Abortion Service Network

Published:September 07, 2022DOI:https://doi.org/10.1016/j.jadohealth.2022.08.004
      Access to safe abortion is a critical element of reproductive freedom as per the World Health Organization [
      • Abortion care Guidelines
      World Health Organization.
      ]. However, following the United States Supreme Court's ruling in Dobbs v. Jackson Women's Health Organization which overturned Roe v. Wade and vacated the constitutional right to abortion, 26 states are expected to heavily restrict or ban abortions [
      • Vinekar K.
      • Karlapudi A.
      • Nathan L.
      • et al.
      Projected Implications of overturning Roe v wade on abortion training in U.S. Obstetrics and gynecology residency programs.
      ]. While the policy environment surrounding abortion continues to change rapidly, the ensuing geographic shift in both patients and service provision will eliminate or delay access to this time-sensitive medical procedure and disproportionately impact adolescents and young adults (AYAs), especially those already experiencing health disparities stemming from systemic racism and bias [
      • Goyal V.
      • McLoughlin Brooks I.H.
      • Powers D.A.
      Differences in abortion rates by race-ethnicity after implementation of a restrictive Texas law.
      ]. For example, Black and Latinx people are more likely to seek an abortion but have more limited access to healthcare and face more structural barriers (travel, childcare, and funding) when accessing abortion [
      • Artiga S.
      • Follow H.L.
      • Ranji U.
      • et al.
      What are the Implications of the overturning of Roe v. Wade for racial disparities? Kaiser Family Foundation. Published July 15,.
      ]. Black and Indigenous people are also at a 3 to 4 times greater risk for maternal mortality, which will likely increase in the face of unplanned pregnancies [
      • Artiga S.
      • Follow H.L.
      • Ranji U.
      • et al.
      What are the Implications of the overturning of Roe v. Wade for racial disparities? Kaiser Family Foundation. Published July 15,.
      ,
      • Kozhimannil K.B.
      • Interrante J.D.
      • Tofte A.N.
      • Admon L.K.
      Severe maternal morbidity and mortality among indigenous women in the United States.
      ].
      As of 2019, AYAs aged 20–24 years had the highest abortion rates among all age groups (19.0 abortions per 1,000 women) accounting for 27.6% of all abortions. AYAs aged 15–19 years obtained 8.6% of US abortions (6.0 abortions per 1,000 women). Overall, 77% of AYA abortions occur at ≤ 9 weeks gestation, with older AYAs more likely than younger teens to get abortions at ≤ 9 weeks gestation [
      • Kortsmit K.
      Abortion surveillance — United States, 2019.
      ].
      At this turning point, it is incumbent on Adolescent Medicine clinicians to provide abortion care where it is legal to do so. As clinicians who specialize in AYA reproductive healthcare, including office gynecology and long-acting reversible contraception procedures, we are well-poised to integrate medical abortion (MA) into our scope of practice. By providing MAs, Adolescent Medicine clinicians can facilitate timely access to care when our patients will be facing overwhelming structural barriers to abortion including cost, transportation, parental notification requirements, confidentiality concerns, and a rapidly changing legal landscape. Because so many AYA abortions occur at ≤ 9 gestation [
      • Kortsmit K.
      Abortion surveillance — United States, 2019.
      ], the majority of AYA patients are candidates for MA, which can be safely managed by Adolescent Medicine clinicians.
      MA is the most common form of abortion in the United States [
      Medication abortion now Accounts for more than Half of all US abortions. Guttmacher Institute. Published February 22,.
      ]. MA regimens typically consist of mifepristone, a progesterone receptor modulator that acts as an antiprogestin, and misoprostol, a prostaglandin analogue [
      American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology, Society of Family Planning
      Medication abortion up to 70 Days of gestation: ACOG practice Bulletin, Number 225.
      ]. Mifepristone was approved for pregnancy termination in the United States in 2000 and is used in more than 60 countries. Mifepristone–misoprostol regimens are more effective and are preferred over misoprostol-only regimens. Historically, the Food and Drug Administration's risk evaluation and mitigation strategy program restricted mifepristone access by requiring “in-person dispensing” at clinics, medical offices, or hospitals, by certified prescribers. These restrictions were not evidence-based, decreased access to care, and did not increase safety. During the COVID-19 pandemic, the in-person requirement was not enforced. In December 2021, after data review, the Food and Drug Administration permanently removed the in-person dispensing requirement, expanding access through the option of mailed prescriptions from certified pharmacies and prescribers [
      • Schneider M.E.
      FDA removes in-person dispensing requirement for abortion medication. Regulatory Focus. Published December 17,.
      ].
      Traditionally MA has involved a visit to a clinician for an ultrasound, pelvic examination, and/or blood tests, directly observed mifepristone ingestion and follow-up 1–2 weeks later to ensure abortion completion. In 2020, as access to abortion was limited by the COVID pandemic, a “no-test” protocol was proposed for patients with gestational ages (GAs) up to 77 days, wherein clinicians could evaluate patients remotely for medical eligibility based on history and without reliance on ultrasound, blood tests (Rh, Hemoglobin), and pelvic examination, for those deemed eligible [
      • Raymond E.
      • Grossman D.
      • Mark A.
      • et al.
      Commentary: No-test medication abortion: A sample protocol for increasing access during a pandemic and beyond.
      ]. The American College of Obstetricians and Gynecologists guidance specifies a definite last menstrual period date of up to 56 days prior for a no-test approach and 70 days prior for all MAs [
      Medication abortion now Accounts for more than Half of all US abortions. Guttmacher Institute. Published February 22,.
      ]. Notably, recent data from 14 US sites using a no-test protocol up to 70 days or 77 days showed rare (<1%) complications at rates comparable to a more traditional testing approach [
      • Upadhyay U.D.
      • Raymond E.G.
      • Koenig L.R.
      • et al.
      Outcomes and safety of history-based Screening for medication abortion: A Retrospective Multicenter Cohort Study.
      ], which is consistent with prior international studies [
      • Karlin J.
      • Perritt J.
      It is time to change the standard of medication abortion.
      ]. In addition, in states where telemedicine abortion is legal, these protocols allow remote, timely MA for patients unable to travel to clinic, although reimbursement for these services needs to be maintained in a postpandemic era. The evidence supporting these more flexible protocols brings an era of opportunity for new clinicians to join the MA service field.
      Given the data supporting the safety of MA and “no-test” MA for medically eligible patients, MA training should be incorporated into all Adolescent Medicine training programs, including those for medical, nursing, and physician assistant trainees. Of the 30 Adolescent Medicine fellowship programs on the Society for Adolescent Health and Medicine's website, 20 programs are in states that are likely to protect abortion access post-Roe. However, eight programs are in states with near total abortion bans, including pre-Roe bans (Michigan, Wisconsin), laws that challenged Roe v. Wade (Alabama, Oklahoma, two programs in Texas), and restrictive trigger laws that are expected to take effect (Indiana, Florida) [
      • Vinekar K.
      • Karlapudi A.
      • Nathan L.
      • et al.
      Projected Implications of overturning Roe v wade on abortion training in U.S. Obstetrics and gynecology residency programs.
      ]. The two programs in Ohio will also be impacted with a 6-week abortion ban. In addition to the grave impact on patients, trainees across all disciplines will not receive abortion training in these restrictive states, translating into a grave reduction in our future workforce. Approximately 44% of gynecological residents will be training in states where abortion is illegal [
      • Vinekar K.
      • Karlapudi A.
      • Nathan L.
      • et al.
      Projected Implications of overturning Roe v wade on abortion training in U.S. Obstetrics and gynecology residency programs.
      ]. Thus, training programs in states without abortion restrictions/bans must maximize access for trainees from other institutions through sharing of curricula, opening online trainings for outside learners, and facilitating travel for away electives. Training should include AYA physicians and AYA allies from Pediatrics, Family Medicine, Internal Medicine, Emergency Medicine, and advanced practice nurses and physicians assistants as legally permitted. Educational opportunities can be leveraged across disciplines to train residents, fellows, and clinicians in practice (Box 1). Expanding MA clinicians will be particularly critical in states with abortion restrictions based on weeks of pregnancy.
      Medication abortion: steps and considerations in implementationa
      aReferences current as of this publication.
      In addition to expanding training in states where abortion rights will be maintained, Adolescent Medicine clinicians will need to create and enhance partnerships with other specialties to maximize MA access. Collaborations with Gynecology, Family Medicine, and Emergency Medicine must be established for patients who are not candidates for MA. Nurses, Physician Assistants, Social workers, and Pharmacists all play critical roles in expanding MA access within health systems (Box 1). Clinicians in states with policies hostile to abortion services can support their patients by connecting them with reliable resources (Box 2). Providers across the country can also provide anticipatory options counseling as a part of routine well visits and contraceptive counseling where they are legally allowed to do so. In addition, clinicians everywhere should expect to see an increase in self-managed or self-sourced abortions (SMAs) obtained outside the formal healthcare system, most commonly with mifepristone and misoprostol obtained online. Approximately 7% of pregnant people have sought SMAs and data support the safety and efficacy of SMA for patients who can estimate their GA based on last menstrual period [
      • Harris L.H.
      • Grossman D.
      Complications of unsafe and self-managed abortion.
      ,
      • Aiken A.R.A.
      • Romanova E.P.
      • Morber J.R.
      • Gomperts R.
      Safety and effectiveness of self-managed medication abortion provided using online telemedicine in the United States: A population based study.
      ]. Clinicians will need skills in addressing patient concerns about SMA, and most importantly, refrain from criminalizing patients who pursue SMAs regardless of state residence [
      • Harris L.H.
      • Grossman D.
      Complications of unsafe and self-managed abortion.
      ]. Collectively these practices could help alleviate the pressure that will be placed on dedicated abortion clinics. Through the direct provision of services, Adolescent Medicine clinicians have an opportunity to provide evidence-based reproductive health services now, when our patients need them the most.
      Resources for providers in low-abortion access settingsa
      aReferences current as of this publication.

      Acknowledgments

      Dr. Raymond-Flesch's time was supported in part by the National Institute of Health's Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD) [Project #K23HD093839]. Dr. Barral's time was supported by the NIH-funded KL2 program at the University of Kansas Clinical and Translation Science Institute [5KL2TR002367-05, subaward GR13074]. Dr. Svetaz's time was supported by the Eliminating Health Disparities Initiative Grant from the Minnesota Department of Health.

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