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Research roundup: March 2023 edition

by Colleen Denny, MD and Emma Gilmore, MD

published 03/31/23

1. Medication Abortion with Misoprostol-Only: A Sample Protocol

Medication abortion is a safe and effective and is currently used by more than half of all patients seeking abortion in the US. The combination of mifepristone followed by misoprostol is FDA-approved for patients up to 70 days’ of gestation. However, as recent anti-choice lawsuits have the potential to significantly decrease access to mifepristone, this summary article describes protocol options and data supporting the use of misoprostol alone for effective and safe medication abortion. While the authors discuss that misoprostol-only regimens may be slightly less effective overall than regimens that also use mifepristone, success rates remain quite high, with successful abortion in 87-93% of patients in several large trials. Data also showed a low likelihood of ongoing pregnancy, at 3-6%, and <1% risk of bleeding requiring transfusion. Based on these findings, the authors provide a sample protocol for providing misoprostol-only medication abortion, including dosing and recommended follow-up. While ongoing political battles continue to unjustly threaten patients’ access to reproductive health care, providers can use this data to counsel patients, support their decision-making, and continue to offer high-quality alternatives in a changing political landscape.

2. Travel for later abortion in the USA: lived experiences, structural contributors and abortion fund support

Recent changes in the political landscape have limited abortion access in many regions across the US, forcing some patients in those areas to travel to seek abortion care. Patients at later gestational ages are more likely to have to travel for abortion care. In this qualitative interview-based study, the authors identified 19 patients who traveled to seek abortion care after 12 weeks of gestation. In semi-structured interviews, the researchers identified several themes, including the difficulty of arranging logistics at home and work to be away, the uncertainty and stress of time-sensitive travel, the physical discomfort and stress of managing post-abortion symptoms when traveling back home, and the financial stresses of all aspects of the experience. While slightly more than half of interviewed patients had some support from an abortion fund, they discussed that such support, while appreciated, could be difficult to ensure in advance and did not cover any expenses associated with a support person traveling with them. The authors recommend greater financial and logistical support for abortion funds, and encourage further research on the phenomenon of abortion travel.

3. Infectious outcomes following immediate postplacental intrauterine device placement in the setting of chorioamnionitis: An exploratory, retrospective study

Patients who desire highly effective postpartum contraception may choose IUD placement immediately after delivery (PPIUD). However, a diagnosis of chorioamnionitis during labor is considered a contraindication for PPIUD placement, given the theoretical risk of worsening or prolonging infection, although there is little data about the actual risk of this practice. In this retrospective cohort study, the authors identified 55 patients who desired PPIUD but were diagnosed with chorioamnionitis during their admission for delivery; 22 of these patients had PPIUD placed and 33 had their placement deferred. The authors found that none of these patients had any postpartum endometritis, sepsis, or additional antibiotic administration, and there were no differences between the groups for IUD-related complaints. The authors suggest that the lack of differences in infectious outcomes may be partially related to overdiagnosis of chorioamnionitis, and note that delaying postpartum placement of IUDs may lead to postpartum patients not receiving their desired form of contraception long-term. Providers should feel supported in using the new stricter chorioamnionitis guidelines in offering PPIUD to patients who desire it.

4. Switching and discontinuation of participant-masked randomization to a copper or levonorgestrel intrauterine device when presenting for emergency contraception

Recent research indicates that both the copper IUD and the 52mg LNG IUD can be used as highly effective forms of emergency contraception (EC). However, different patient populations may have varying preferences for the two types of IUD, based on known bleeding profiles and side effects, and it is not clear how frequently patients randomized to an IUD for EC would later opt to remove their IUD or switch to the other type. In this secondary analysis of the original randomized control trial, the authors determined that IUD removal was similar in the two groups at six months, with approximately 10% of patients in each group electing to remove their IUDs. Switching IUD type was rarer, but more common in the group switching from copper to LNG (5.5%) than from LNG to copper (2.1%). Approximately half of the users in both groups indicated that they were satisfied or highly satisfied with their IUD. These data suggest that patients receiving IUDs of either type for EC generally continue with their IUDs for at least several months after initial placement. Providers offering IUDs for EC can discuss that both IUDs seem to have similar acceptance and satisfaction among patients both in the short-term need for EC and longer-term indication for ongoing contraception.

5. Safety and efficacy of a suction cervical stabilizer for IUD insertion: results from a randomized, controlled study

IUDs are well known to be highly effective, safe choices for contraception. However, when considering birth control options, some patients are deterred by concerns about pain, in particular at time of placement. To safely place an IUD, the cervical canal needs to be stabilized, which is typically performed with the assistance of a sharp-toothed tenaculum or similar tool. Tenaculum placement is one of the major contributors to pain during IUD insertion and may also cause additional bleeding. In the hopes of reducing the pain of IUD placement, the authors of this study performed a randomized controlled trial comparing the tenaculum to the Aspivix cervical stabilizer, which uses suction to grasp the anterior lip of the cervix. They found that the experimental device led to significantly lower pain scores during the procedure, particularly in nulliparous patients. While this device is still under development, these results suggest that there may be a less painful alternative to tenaculum use, creating the potential to expand access to IUDs for patients concerned about pain during placement.

6. People still want a face and that's where we can fill in': a qualitative study of community pharmacists' experiences of providing healthcare advice about preconception and pregnancy

For many pregnancy-capable individuals, access to preconception counseling is limited, particularly in areas that already suffer from inequalities such as limited public transportation or a lack of health care facilities. These disparities persist even in early pregnancy, and patients without easy access to providers may lack important information about dietary intake or the risks associated with certain lifestyle behaviors, such as smoking. The authors of this study hypothesized that community pharmacists could address these gaps in access by providing health care advice to individuals, both preconception and during pregnancy. They conducted a qualitative study and used focus groups to assess community pharmacists’ attitudes about these practices. Participants reported that they were already providing information about reproductive health, but that their workload and time pressures made it difficult to give in-depth advice to customers. They also identified a need for further education about preconception and pregnancy topics. This study adds to existing evidence that pharmacists are willing to provide such advice, and are well-positioned to do so, but barriers still exist. Future public health initiatives should consider focusing on community pharmacies to better utilize this untapped resource.

7. Assessment of Adolescent Decision-Making Capacity for Pharmacy Access to Hormonal Contraception

To improve access to contraception, 24 states have passed legislation that allows pharmacists to provide birth control directly to customers. These initiatives may be important steps in expanding access to contraception, as they reduce barriers associated with clinic appointments such as scheduling and transportation. However, minors have been intentionally excluded by some of these changes, partially due to concerns about whether adolescents can provide informed consent in the pharmacy setting. To better understand adolescents’ decision-making capacity around contraception, the authors of this study recruited patients aged 14-21 to use a decision-aid tool within a simulated pharmacy setting. Participants were scored and their scores were plotted and compared. Overall, adolescents demonstrated extensive capacity to make decisions about contraception and demonstrated scores similar to adults’. Factors such as health literacy and family affluence did not affect scores. These results suggest that adolescents are fully capable of making independent decisions about contraception. Legislation should be expanded to include this age group, who may face significant barriers when exploring options for birth control. Read more about how pharmacists can increase access to birth control.

8. Educational Intervention Among Adolescents and Young Adults on Emergency Contraception Options

EC options include two types of pills—over-the-counter levonorgestrel EC pills (Plan B and generics) and ulipristal acetate EC pills (ella)—and two types of IUDs—copper IUD (Paragard) and levonorgestrel 52mg IUDs (Mirena and Lilleta). Familiarity with EC is increasingly crucial in this post-Dobbs era, but studies suggest that most young people are unfamiliar with the range of options available to them and don’t know basic details about EC. Information about EC could be profoundly impactful for young sexually active individuals, and it should be available in the community, outside of clinical settings. The authors of this study conducted a brief educational intervention for college students aged 18-25, using visual aids, to assess the effect of these aids on EC knowledge. More than 1,000 students participated in the intervention. Pre- and post-intervention surveys revealed that this time-efficient teaching aid had a significant effect on participants’ knowledge, teaching them key points about all EC methods. This study suggests that brief, effective educational interventions can have a large impact on young adults’ knowledge about EC and should be prioritized in both community and clinical settings. You can find this material on the Power to Decide store and start using it in your practice today!

Colleen Denny, MD, is an attending ObGyn at Bellevue Hospital in New York City, where she is the Medical Director of the Women's Clinic, and a clinical assistant professor with the NYU School of Medicine. She enjoys providing care for patients in all phases of life and is especially interested in issues related to contraception access and public health. Outside of work, she’s a runner, a dancer, and a bit of a crossword puzzle nerd.
Emma Gilmore is a fellow in Complex Family Planning at the University of Pennsylvania. She completed her residency in Obstetrics and Gynecology at New York University. She's passionate about reproductive rights, medical education, and combating health care disparities, particularly in sexual and reproductive health. In her free time, she can be found taking her dog on walks around the beautiful parks in and around Philadelphia.
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