Thread by @abbyliberty1

Next up: Is less more? A critical appraisal of medication abortion follow up with @VitalaGlobal @uoftobgyn @Stanford @Gynuity @UTAustin and Alamo Women's Health Clinic in Albuquerque

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Mifepristone approval/access has grown in so many ways:
- Globally access improved
- Indications for use expanded
- Methods of delivery expanding (telemedicine, meds by mail)

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In Europe, Germany had the lowest uptake of medication abortion. This might be due to low reimbursement for simple and safe care in Germany and medication abortion is so safe!

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COVID catapulted telemedicine services. This has helped with myth busting. Now we know:
- Availability of medication abortion did NOT increase abortion rates
- People WANT to have abortions at home
- Medication abortion is so SAFE it does not require physician CONTROL

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But do not be fooled: approval of mifepristone does not equal access. Access is limited by
- Governments (REMS, ultrasound req's)
- Providers (conscientious refusals, unnecessary tests/visits/ultrasounds
- Commercial entities (pricing, competition advertising)

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What do people need to have a safe medication abortion?
ONLY 3 THINGS:
1) The correct meds in the correct doses
2) The instructions for how to use the meds
3) Information on where to go/whom to contact if they have problems/concerns

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How can we increase access and use?
- No test medication abortion
- Telemedicine
- Access to the market for pills with no impediments
- Self led administration of drugs
- Self confirmation of success

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Dr. Blumenthal: I come from a long line of great worriers. No, not warriors - WORRIES!

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Is follow up from medication abortion for patients or for us as clinicians?

What are patients concerns, their wellbeing, risk reduction for themselves, guidelines compliance?

Do patients desire information/reassurance from us or can it be self attained?

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Over-medicalization of medication abortion contributes to cost and barriers to care. For example, there is no reimbursement for medication abortion provision in CA unless there is a follow up appointment.

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So what does this mean for follow up? We need to inform people to seek care for concerning SYMPTOMS such as hemorrhage, infection, pain.

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Medication abortion is victim to a dogma in medicine where there is resistance to de-escalate interventions. We use interventions as security blankets and this is not patient centered.

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Home pregnancy tests are not optimal for a variety of reasons and we should embrace and encourage efforts to improve upon this technology.

(Everyone just took out their phone to snap this slide, so I did too. Sharing notes via Twitter!)

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Barriers to accessing medication abortion in Texas even before #SB8:
- 24hr mandatory delay ("wait period") for care
- Both mifepristone and misoprostol had to be administered in clinic by a physician
- Mandatory follow up at 7 days (not evidence based timeline)

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Alamo Clinic moved from TX to NM and was able to practice evidence based care without government interference. Follow up for medication abortion is #patientcentered:
- Phone call in 1 week
- Possible ultrasound
- Home UPT
- Serum HCG

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In TX: Patients want to know as soon as possible if the medication abortion was not complete and if they need to travel out of state for care.

In NM: 65% did not answer follow up calls. Only 21% were reached by phone. 3% had gone to get an US for confirmation.

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People in TX have been seeking care after medication abortion at:
- Private physicians (maybe informants, may not "want" risk of post-abortion care)
- Planned Parenthood
- Crisis pregnancy centers (abundant but problematic for shaming and policing patients)

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While medication abortion failure is uncommon, if you live in TX and go to NM, failure could cost:
- 26 hr drive costing $240 in gas or 4 hour flight costing $420 in airfare
- Missed work/childcare
- DISTRESS

This cost is too much.

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Interstate abortion care is not set up to follow or trend beta HCG across institutions, let alone state lines. This shifts the "responsibility" to the patient and is a huge burden emotionally, financially and possibly legally.

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#DigitalHealth innovation and context-driven solutions to aid medication abortion from @VitalaGlobal.

The app they built with local communities is a source of information, expertise advice and elevating local resources.

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The program @AyaContigo is in Venezuela as a mobile abortion doula. Advantages include:
- Off line capability
- Live chat features from counselors from Venezuela
- Compatibility with @WhatsApp

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@AyaContigo is proof that there are local solutions which can offer user-centered community led design. Digital health reduces cost & accelerate distribution of trusted resources.

This is an example of a community in crisis leading the medical field.

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These lessons have impact in well resourced settings! @VitalaGlobal has created the resource mypostcare.ca which gives evidence based resources for medication abortion support for people in Canada.

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Audience: Monitoring outcomes if fundamental to ethical medical care. How can we monitor complications/outcomes as we embrace "less is more" with medication abortion?

Panel: What are real complications (ectopic) vs perceived complications? What matters to patients?

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Bottom line for medication abortion: We are beyond safety and effectiveness. We need to be asking how we provide a quality abortion experience for patients.

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