Medication Abortion is Safe and Effective without Physical Examination

Ushma Upadhyay, PhD, MPH

With nearly 1 million people in the US seeking an induced abortion each year, investigators including Ushma Upadhyay, PhD, MPH, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, were compelled to examine the outcomes and safety of medication abortion care. Specifically, this study focused on instances where patients were screened by a history assessment and without ultrasonography or pelvic examination.

While it was routine to perform an ultrasonography or pelvic examination before administering the treatment, when the COVID-19 pandemic began and the country relied heavily on telehealth, some clinics used only patients' history to determine if they were eligible for treatment.

Accessing Abortion Medications in 2020

The objective of the retrospective cohort study was to evaluate the outcomes and safety of a history-based screening, no-test approach to medication abortion care. Investigators included patients who were obtaining a medication abortion between February 2020-January 2021at Planned Parenthood, academic-affiliated, and online-only clinics throughout the US.

Mifepristone and misoprostol are approved medications for inducing abortion up to 70 days of pregnancy, according to the US Food and Drug Administion (FDA), which temporarily relaxed the requirement of in-person prescribing of the medications in 2020. Patients received medication for abortion either in person or by mail without any preabortion ultrasonography or pelvic examinations taking place.

The primary endpoint was measured by effectiveness, which was defined by complete abortion after 200 μg of mifepristone and up to 1600 μg of misoprostol and no additional intervention.The safety was determined by major abortion-related adverse events: hospital admission, major surgery, or blood transfusion.

History-Based Screening is Safe & Effective

Data from 3779 patients with eligible abortions were included in the research. In 66.4% of the abortions, medication was dispensed in person and the remaining 33.6% received medication in the mail. The population was racially and ethnically diverse, and for most (69.5%) it was their first medication abortion.

For 74.8% (2825) of patients, follow-up data were obtained and in order to account for missing information, multiple imputation was used. Major abortion-related adverse events occured in only 12 abortions (0.54%; 95% CI, 0.18%-0.90%), with 4 patients (0.22%; 95% CI, 0.00%-0.45%) requiring treatment for ectopic preganancies.

During follow-up, investigators discovered that 9 patients had a duration of pregnancy that exceeded 70 days at the date that mifepristone was dispensed (which was not identified at screening). The adjusted effectiveness rate was 94.8% (95% CI, 93.6%-95.9%).

Investigators found that the method in which the medications were received by the patients resulted in similar effectiveness. Instances where the medications were dispensed via mail (93.3%; 95% CI, 90.7%-95.9%), were compared with dispensing the medications in person (95.4%; 95% CI, 94.1%-96.7%).

“In this cohort study, screening for medication abortion eligibility by history alone was effective and safe with either in-person dispensing or mailing of medications, resulting in outcomes similar to published rates of models involving ultrasonography or pelvic examination,” investigators wrote. “This approach may facilitate more equitable access to this essential service by increasing the types of clinicians and locations offering abortion care.”

The study “Outcomes and Safety of History-Based Screening for Medication Abortion: A Retrospective Multicenter Cohort Study” was published in JAMA Internal Medicine.