Doctor in a white coat scrolling their phone

Research roundup: October 2022 edition

Trends in bHCG levels after medication abortion, a novel implant removal device, trends in IUD self-removal during the COVID-19 pandemic, and support for the patient-centeredness of telehealth birth control and abortion care.

by Colleen Denny, MD and Emma Gilmore, MD

published 10/31/22

1. Trend of serum beta-human chorionic gonadotropin levels after medical abortion in the early first trimester of pregnancy

Medication abortion using mifepristone and misoprostol is a safe and highly effective method for termination of pregnancies up to 12 weeks gestation. The complete abortion rate of this regimen is 92-97% within this gestational age range, which means that some patients will need further management. Repeat ultrasound after medication abortion may be used to ensure success, but this requires additional in-person assessment. Alternatively, measurements of beta-human chorionic gonadotropin (bHCG) can be used to ensure that a medical abortion is complete. In this prospective, observational study following 36 patients seeking medication abortion with viable pregnancies less than 64 days’ gestation, the researchers measured serum bHCG levels immediately pre-mifepristone administration, 48 hours later (after mifepristone and before misoprostol administration), one week after misoprostol administration, and then weekly until bHCG was negative. They noted a slight increase in serum bHCG values after mifepristone and before misoprostol (up to 5%), but a rapid decrease in the week after misoprostol use (98% from initial value), followed by a slower trend to negative bHCG, ranging from 2-7 weeks for a negative value. This data can help providers monitor patients electing for medication abortion, including interpretation of pregnancy testing in the period immediately following medication abortion.

2. Person-centered, high-quality care from a distance: A qualitative study of patient experiences of TelAbortion, a model for direct-to-patient medication abortion by mail in the United States

It is well-established that medication abortion is safe and highly effective, and medications are increasingly obtained by mail with remote consultation. When abortion medications are delivered via mail, without an in-person visit, its safety and efficacy remain high. However, less is known about the person-centeredness of this method, although this is an area that is emphasized by the World Health Organization. The person-centered framework for reproductive health equity features eight domains, which include dignity, autonomy, and supportive care. The authors of this study sought to evaluate the person-centeredness of the TelAbortion project, which was established before the COVID-19 pandemic to deliver medication abortion by mail. They conducted 45 patient interviews to evaluate the eight domains of a person-centered framework. Participants expressed that their TelAbortion experience was highly patient-centered and exceeded their expectations, fostering a sensation of autonomy and support. However, they did encounter stigma and other difficulties when trying to coordinate their care outside of TelAbortion. This study highlights the person-centeredness of medication abortion by mail and demonstrates that this care delivery method may lead to higher patient satisfaction and decreased difficulties in access when compared to in-person abortion services.

3. "I totally didn't need to be there in person": New York women's preferences for telehealth consultations for sexual and reproductive healthcare in primary care

Though relatively few sexual and reproductive health (SRH) providers heavily used telehealth prior to 2020, the COVID-19 pandemic expedited the transition to telehealth usage in many fields of medicine, including SRH. Providers, patients, and institutions continue to debate which kinds of patient encounters may be best served with telehealth. In this study involving five focus groups of 30 participants, the authors queried patients about their experiences and preferences regarding telehealth encounters. While participants reported that they preferred telehealth for perceived “basic” topics such as contraceptive counseling and valued the convenience of not physically going to a health center, they preferred in-person consultation for more “complex” topics such as preconception counseling. The authors concluded that telehealth practitioners should focus on building rapport with patients on more “complex” topics and create a warm remote environment to facilitate these more difficult conversations.

4. Who Accesses Birth Control Online? An Analysis of Requests for Contraception Submitted to an Online Prescribing Platform in the United States

Telehealth is increasingly emerging as a way to bring services, such as birth control, to patients who face barriers to accessing in-person care. While numerous online platforms exist for this purpose, little is known about the people who are using them to obtain birth control. The authors of this study sought to find out more about the population using a single prescribing platform by analyzing their demographics and other characteristics, whether they had contraindications to hormonal birth control, and whether telehealth is helping to fill gaps in access. The research team was able to identify more than 38,000 queries in a single platform between 2015 and 2017. Most patients were seeking birth control pills, and only an estimated 8.9% had a contraindication to hormonal methods containing estrogen. Fewer requests came from rural or uninsured individuals, and only a small number of patients were younger than 18. While this initial analysis suggests that telehealth is a safe method of providing birth control, outreach may be needed to involve people who are young, live outside urban areas, or are under-insured.

5. Effectiveness of fertility awareness-based methods for pregnancy prevention during the postpartum period

Although all hormonal contraception methods are generally safe for postpartum patients starting six weeks after delivery, some postpartum individuals may wish to avoid hormonal methods for personal or medical reasons and instead consider fertility awareness-based methods. In this systematic review, the authors aggregated research looking at pregnancy risk for patients using fertility-based awareness methods prior to three cycles after childbirth. They identified four studies and concluded that none were high-quality, and most were low-quality. The individual studies used different fertility awareness methods, including calendar-based, cervical mucus-based, and/or urinary hormone-based. Aggregated reported pregnancy probability in the first six cycles postpartum ranged from 8.1 to 26.8 depending on the method used and breastfeeding status. However, the authors highlight that breastfeeding status, which often changes in the postpartum period, affects fertility, and that fertility-awareness methods may rely on tracking menses that are less reliable in the postpartum period. Providers discussing this option with their postpartum patients should caution on the dearth of evidence on the effectiveness and on limitations of these methods in the postpartum period.

6. Removal of a well-palpable one-rod subdermal contraceptive implant using a dedicated hand-held device or standard technique: a randomized, open-label, non-inferiority trial

Subdermal contraceptive implants such as Nexplanon and, previously, Implanon, offer long-acting and highly effective forms of reversal contraception and are becoming more popular choices among patients throughout the world. While implant placement is relatively straightforward, implant removals may be slightly more complicated and the lack of skilled providers able to remove an implant safely may present a barrier to timely removal. In response to this need, a mechanical hand-held device, RemovAid, has been recently developed to facilitate implant removal in areas with fewer skilled practitioners. In this three-arm, open-label non-inferiority randomized trial, researchers recruited 225 patients with easily palpable subdermal implants desiring removal and randomized them to standard removal technique, RemovAid with injectable lidocaine, and RemovAid with lidocaine patch. Regarding efficacy in removal, 100% of the implants were removed using the standard technique, compared to 85% in the RemovAid and lidocaine patch group and 73% in the RemovAid and injectable lidocaine group. Efficacy in the RemovAid groups increased to 96% and 91%, respectively, if removals including breakage of the implant and/or use of forceps were included. Regarding safety, no primary complications occurred in any group, and one secondary complication (arm trauma) occurred in each of the groups. The authors conclude that while RemovAid’s removal efficacy was not as high as the standard removal technique, it could represent a safe and highly effective alternative to removal where skilled providers are not readily available.

7. Intrauterine device self-removal practices during the COVID-19 pandemic among family planning clinics

Requiring in-office intrauterine device (IUD) removal can be burdensome for some patients, due to scheduling, insurance, or logistical issues. The COVID-19 pandemic changed care delivery in many areas, including sexual and reproductive health care, and led to increased use of remote or virtual care. Existing data suggests that patients are open to self-removal of IUDs, but little is known about the way that this has been incorporated into family planning care since the start of the pandemic. The authors of this paper used a survey-based study to assess family planning clinic practices around IUD self-removal at three time points in 2020, including adaptations to the way that care was provided during the pandemic. They found that 7.9% of clinical sites provided information on IUD self-removal in early 2020, and this had increased to 25.4% of sites by the end of the study period. This increase was associated with being at an academic center and seeing a smaller number of patients. Overall, these results do show that family planning clinics modified their counseling during the pandemic, but there is still room to grow in the area of IUD self-removal.

8. Trends in US Emergency Department Use After Sexual Assault, 2006-2019

Sexual assault (SA) is a disturbingly common phenomenon in the United States, with complex medical and legal implications for survivors. While research estimates that only one-fifth of adult sexual assault (SA) survivors will seek any kind of care, those who do typically present to Emergency Departments (ED) for assessment and treatment. In this cross-sectional study using two national databases, the authors determined that ED visits for sexual assault increased an astonishing 1,533% between 2006 and 2019, far outpacing the smaller increases seen in sexual assault reporting to law enforcement. They found that female, younger, and lower-income individuals were more likely to present to the ED after SA, and that older and Medicaid-insured patients were more likely to be admitted. The authors discuss that changes in societal attitudes towards SA in the last two decades may influence the likelihood of SA survivors seeking medical care. They also argue for increased institutional support for populations most likely to be affected by SA, especially given that most patients will not be admitted to the hospital and may benefit from closer outpatient support.

9. Novel Shared Decision-Making Tool Improves Contraceptive Screening and Right Care during Pregnancy in a Military Hospital: A Quality Improvement Report

Rates of unintended pregnancy in the military remain higher than those for the general United States population, at 54-60% vs 45-50%. However, there is a lack of recommendations regarding best practices for pregnancy and contraception counseling in the military population. The authors of this study created a quality improvement project within a military health system clinic to improve screening and patient-centered contraception counseling for individuals in the third trimester of pregnancy. Their project included four elements: a screening process, a checklist, a team engagement plan, and a shared decision-making toolkit that provided interested patients with resources and information about postpartum contraception options. This multi-pronged approach ensured that all clinic staff and patients were involved in discussions around contraception care and clinic staff were rewarded for participating in the quality improvement project. Screening rates increased from 37% to 79% over the course of the study, and 92% of patients had a contraceptive plan documented in their chart prior to delivery. This study demonstrates the utility of a shared decision-making contraceptive toolkit for the military setting and provides a starting point for future study with this population.

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.
read more about:research,abortion,telehealth
read our commenting policy »