Abstract
Introduction: Providing abortion in primary care expands access and alleviates delays. The 2020 COVID-19 public health emergency (PHE) led to the expansion of telehealth, including medication abortion (MAB). This study evaluates the accessibility of novel telehealth MAB (teleMAB) initiated during the PHE, with the lifting of mifepristone restrictions, compared with traditional in-clinic MAB offered before the PHE at a Massachusetts safety-net primary care organization.
Methods: We conducted a retrospective electronic medical record review of 267 MABs. We describe sociodemographic, care access, and complete abortion characteristics and compare differences between teleMAB and in-clinic MABs using Chi-squared test, fisher’s exact test, independent t test, and Wilcoxon rank sum. We conducted logistic regression to examine differences in time to care (6 days or less vs 7 days or more).
Results: 184 MABs were eligible for analysis (137 in-clinic, 47 teleMAB). Patients were not significantly more likely to receive teleMAB versus in-clinic MAB based on race, ethnicity, language, or payment. Completed abortion did not significantly differ between groups (P = .187). Patients received care more quickly when accessing teleMAB compared with usual in-clinic MAB (median 3 days, range 0 to 20 vs median 6 days, range 0 to 32; P < . 001). TeleMAB patients had 2.29 times the odds of having their abortion appointment within 6 days compared with in-clinic (95% CI: 1.13, 4.86).
Conclusion: TeleMAB in primary care is as effective, timelier, and potentially more accessible than in-clinic MAB when in-person mifepristone regulations were enforced. TeleMAB is feasible and can promote patient-centered and timely access to abortion care.
- Abortion-Induced
- Access to Health Care
- Logistic Regression
- Mifepristone
- Patient-Centered Care
- Primary Health Care
- Quantitative Research
- Reproductive Health
- Retrospective Studies
- Telehealth
- Women's Health
Introduction
The Dobbs v Jackson Women’s Health Organization US Supreme Court decision (Dobbs) ended the federal protection to abortion, curtailing access for more than 35 million women and pregnancy-capable people who now live in 18 states that have banned or severely restricted provision.1,2 Decades of research demonstrates that when abortion is restricted, those seeking care experience significant delays due to challenges navigating limited appointment availability and increased travel distances.3⇓–5 Medication abortion (MAB) in primary care has the potential to meaningfully increase access to care.6⇓–8 Early abortion is within the scope of primary care, and family physicians routinely provide safe and effective medication and aspiration abortion in outpatient settings.9⇓⇓⇓–13 Some patients prefer obtaining abortion care with primary care because of the trust, privacy, and continuity of care it affords and are highly satisfied with this care.14,15 Yet, as of 2018 only 3% of family physicians reported providing abortion, although before its Food and Drug Administration (FDA) approval, 45% of family physicians anticipated offering MAB in their practices.16,17 Despite its proven safety, since its approval the FDA has restricted mifepristone, the first of a 2-drug MAB regimen, under a “Risk Evaluation and Mitigation Strategy” (REMS), requiring clinicians to physically assess patients’ pregnancies and dispense the medication in-clinic, until the COVID-19 Public Health Emergency (PHE).18
The PHE led to sustained changes in health care delivery, expanding telehealth services, including in primary care.19 A temporary injunction on the FDA REMS and dissemination of evidence-based protocols supporting remote clinical assessment of patients allowed for telehealth MAB (teleMAB).18,20,21 Although some clinics successfully adapted to the changing environment, few safety-net primary care clinics transitioned from in-clinic MAB to teleMAB with medication delivery. Barriers to novel abortion provision include unsupportive leadership, community or professional stigma, and burdensome systems, federal, and state regulations, including pre-Dobbs restrictions on teleMAB in 19 states.22⇓–24
Although teleMAB can alleviate geographic barriers to abortion, medically underserved communities are impacted by harmful economic and social policies and conditions—poor broadband infrastructure, low access to education and job opportunities, residential segregation, and more—that impede their abilities to use telehealth, resulting in further inequities.7,25 The extent to which primary care settings can meet the needs of diverse populations by offering teleMAB compared with usual in-clinic MAB is unclear. This study evaluates the accessibility of novel primary care teleMAB, initiated during the PHE with the lifting of mifepristone FDA restrictions, compared with traditional in-clinic MAB offered before the PHE.
Methods
Study Design and Setting
We conducted a retrospective electronic medical record (EMR) review at a large primary care safety-net health system in Massachusetts. This organization serves an economically and culturally diverse population of 120,000 patients across 15 primary care clinics. Many identify as immigrants, the majority hold public or subsidized insurance, and 42% have limited English proficiency requiring professional interpretation in more than 60 languages. The organization has routinely provided MAB since 2003, providing on average 14 MABs per month (2019) and does not publicly advertise their abortion services.
In response to the PHE and temporary lifting of FDA restrictions, the organization expanded MAB to offer synchronous telehealth consultations, remote consent signing, and medications delivered to patients via courier from July 28, 2020 to present, except from January to April 2021 when the Supreme Court reinstated FDA enforcement of the in-person requirements (Figure 1).18 Patients up to 11 weeks’ gestation could choose between in-person and teleMAB appointments, though access to in-person appointments was severely curtailed during the PHE due to temporary clinic closures, staffing changes, and backlogs of appointments leading to health care delays for an extended time. Still, in-clinic visits were required for patients with contraindications to remote care, like symptoms of potential ectopic pregnancy. The in-clinic pre-PHE sample best represents the organization’s abortion-seeking patient population during the same months as examined for teleMAB to account for seasonal tendencies in abortion.26,27 MAB protocols changed in March 2020; first requiring ultrasound and recommending lab work, then only requiring ultrasound and labs when indicated, consistent with published standards of care.21
Total medication abortions per month at Massachusetts primary care health system before and during public health emergency (April 2019–December 2021).
We extracted EMR data for eligible patients (n = 267): in-clinic MAB (April 12, 2019-January 12, 2020) and teleMAB (July 28, 2020-December 31, 2021). Figure 2 illustrates exclusion criteria.
Flow diagram of inclusion criteria into study.
Data Collection
DN, HM, and AT developed an encrypted Google Forms chart abstraction tool to systematically summarize sociodemographic, care access, and relevant medical information in a deidentified dataset. Sociodemographics included race (self-report, predetermined categories), ethnicity (self-report, open-ended), form of payment (private, public, missing), language of care, and whether a patient was an established patient at time of MAB. Race, ethnicity, payment, and language were included to explore racial, ethnic, and income-related differences in teleMAB access and serve as proxy measurements for systemic social, economic, and political barriers to accessing care.28
Care access measures included gestational age at time of MAB appointment and time to MAB appointment, calculated in days from when a patient first requested MAB (phone call or visit) to their MAB appointment date. We dichotomized time to MAB appointment as 6 days or less versus seven days or more based on an analysis of the 2014 Abortion Patient Survey, which found an average abortion appointment delay of 7.6 days.29 Complete abortion was dichotomized to describe MAB completions per protocol 1 to 28 days after abortion.
Data Analysis
We reported sociodemographic, care access, and complete abortion measures using descriptive statistics and compare differences between in-clinic and telehealth groups using c2, fisher’s exact test, independent t test, and Wilcoxon rank sum. We conducted logistic regression to examine time to care differences. We used R (4.1.1, R Core Team 2022) to conduct analyses. We set significance at P = .05; unknown responses were assigned missing. This study was approved by the two organizations’ institutional review boards.
Results
Of 267 medical records extracted, 184 were eligible for analysis, of which 137 (74.5%) MABs occurred in-clinic pre-PHE and 47 (25.5%) were teleMAB encounters during the PHE (Table 1). The vast majority in both groups (91%) were established patients. Patients were not significantly more likely to receive teleMAB versus in-clinic MAB based on race, ethnicity, language, or form of payment. Completed abortion did not significantly differ between teleMAB and in-clinic MABs (P = .187).
Sociodemographic and Access Characteristics of Patients Receiving Medication Abortion in a Primary Care Health System Before and During the COVID-19 Public Health Emergency
In-clinic visits had a mean gestational age at time of appointment of 48.1 days compared with 45.3 days for teleMAB (P = .049). Patients received care more quickly when accessing teleMAB compared with in-clinic services (median 3 days to teleMAB, range 0 to 20 days vs median 6 days to in-clinic, range 0 to 32; P < .001, Figure 3). TeleMAB patients had 2.29 times the odds of having their abortion appointment within 6 days compared with in-clinic (95% CI: 1.13, 4.86).
Days between first contact for medication abortion and appointment between in-clinic pre-PHE visits and teleMAB visits during the PHE. Abbreviation: PHE, public health emergency.
Discussion
In a safety-net primary care system we found that teleMAB was as effective, timelier, and potentially more accessible than in-clinic care (when the FDA enforced in-person assessment and medication acquisition). This demonstrates the feasibility of primary care organizations to integrate novel abortion services to meet their patients’ needs. In addition, timely clinical visits is an important indicator of quality abortion care.30,31 Reducing delays enhances patient-centeredness, reflecting a health system’s responsiveness to patients’ preferences, needs, and values.30 Increasing access in primary care is critical as Dobbs and other abortion restrictions have increased demand at remaining facilities, contributing to delays and prolonged care.4,32⇓⇓–35
We found no differences in sociodemographic characteristics or complete abortion between in-clinic and teleMAB patients. Although we cannot draw conclusions regarding MAB safety due to the study’s small sample, our findings are within the range of other studies evaluating complete abortion after MAB in primary care.36⇓–38 And, although not statistically significant, we found a smaller percentage of teleMAB patients were Black, Haitian, and non-English speaking. Studies during the PHE have found racial, ethnic, and language inequities in broad telehealth utilization.39⇓⇓–42 Structural barriers drive these inequities, including challenges integrating interpretation into video visits, reimbursement for audio-only visits, and systematic disinvestment in predominantly Black and/or low-income communities and consequences on access to and comfort using digital health infrastructure.41 Like other telehealth services, teleMAB may not be as accessible due to this digital divide.25,42 Employing strategies to increase abortion access in community-based settings where and how underserved communities obtain their usual health care is critical. Beyond telehealth, primary care organizations should prioritize access to timely in-person appointments for patients who cannot or do not want to use telehealth. Research is needed to ensure introducing teleMAB does not exacerbate access disparities.
This study has limitations. We sought to collect comprehensive demographics but were limited by IRB requirements that restricted collecting age, parity, and other clinical data. Although time-related factors comparing in-clinic pre-PHE MAB with teleMAB during the PHE may have created systematic differences in the study’s abortion-seeking population, this comparison is appropriate given the reduced in-person appointment and staff availability during the PHE, and the need to compare newly introduced teleMAB to usual in-clinic care. As the FDA permanently revised the mifepristone REMS in December 2021 by removing in-person requirements and allowing a pharmacy certification process, future research should compare access to and timeliness of primary care teleMAB to in-clinic MAB, as both are now similarly available in unrestricted states. Further study of the feasibility and effectiveness of primary care teleMAB may motivate more clinics to offer this care, thus reducing delays and improving access. And although the Supreme Court prepares to hear Alliance for Hippocratic Medicine v FDA, which may reverse the FDA’s REMS modifications that enabled remote mifepristone dispensing, misoprostol-only teleMAB protocols will still be available.43,44
Novel teleMAB was comparable to in-clinic services historically provided in a primary care safety-net health care system. TeleMAB seems feasible and can promote timely access to abortion care. Primary care settings should consider implementing teleMAB provision to facilitate timely, patient-centered access to care.
Notes
This article was externally peer reviewed.
Funding: This project was funded by the Society of Family Planning Research Fund (SFPRF15-MSD4, PI: Srinivasulu).
Conflict of interest: Emily Godfrey is an Organon Nexplanon Trainer, but this interest is outside the scope of the submitted work. None of the other authors have conflicting and competing interests to disclose.
To see this article online, please go to: http://jabfm.org/content/37/2/295.full.
- Received for publication May 5, 2023.
- Revision received August 21, 2023.
- Accepted for publication November 13, 2023.
