Abortion restriction and early pregnancy loss care

Abortion restriction and early pregnancy loss care | Image Credit: © mikumistock - © mikumistock - stock.adobe.com.

According to a recent study published in the American Journal of Obstetrics & Gynecology, hostile state policies toward abortion are associated with reduced odds of patient-centered care for early pregnancy loss.

Over 1 million cases of early pregnancy loss are recorded in the United States annually, with 10% to 20% of recorded pregnancies affected. Miscarriage may lead to medical complications such as infection, bleeding, and unscheduled surgery or hospitalization. The risks of mental health conditions such as anxiety, depression, and posttraumatic stress disorder also increase.

Very early visible pregnancy is associated with early pregnancy loss, but many clinicians continue to employ highly conservative imaging criteria. This may lead to improper diagnosing.

Conservative imaging criteria is more common in states with increased abortion regulation and scrutiny. Evidence-based medicine may be provided through ob-gyn residence programs, but there is little data on providing care for early pregnancy loss available at training locations. 

Routine abortion training has been associated with increased comfort with miscarriage management, but legislative restrictions on abortion care have been enacted in over 50% of US states.Following the Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization, states are able to ban abortion in early pregnancy.

To determine the association between legislative abortion restrictions and early pregnancy loss management, investigators conducted a cross-sectional survey. Participants included ob-gyn residency programs registered in the American Medical Association FREIDA database in September 2021.

Online surveys on early pregnancy loss management were sent to participating program faculty members, with responses anonymized. Questions on early pregnancy loss management, institutional abortion restrictions, and program information were included in the survey. 

Survey responses were collected from November 8, 2021, to January 12, 2022, using the Qualtrics online survey platform. Programs were grouped by program characteristics included in the survey, geographic region, and state abortion regulations. 

State regulations were categorized based on designations from the Guttmacher Institute in December 2020. Categories of very hostile, hostile, and leans hostile were grouped as hostile, while neutral, leans supportive, supportive, and very supportive were grouped as supportive or neutral.

Adherence to ultrasound diagnostic guidelines was the primary outcome of the study, recorded based on state abortion policies. The most common location of first early pregnancy loss evaluation and available treatments were recorded as secondary outcomes.

There were 149 program memberswho responded to the survey, of which over half were residency program directors or Ryan Program or Complex Family Planning Fellowship directors. The populations of programs were similar to the overall population based on state legislative climates and geographic distribution.

Restrictions to abortion access were seen in 38.2% of institutions, no restrictions in 38.2%, and total bans except for maternal life endangerment in 22.8%. Strict adherence to imaging guidelines from the Society of Radiologists in Ultrasound were reported by 49.7% of programs, while the remainder, “reported more holistic incorporation of guidelines with clinical judgment.”

Rigid guideline adherence was reported by 12% of programs with unrestricted abortion access, 67% with restricted access, and 82% with banned access. Early pregnancy loss was treated using mifepristone by 86% of programs with unrestricted access, 31% with restricted access, and 26% with banned access, while outpatient uterine aspiration was used by 81%, 48%, and 26% respectively.

An association was found between abortion restriction by indication and adherence to imaging guidelines. This indicated reduced efficacy for managing early pregnancy loss in programs with restricted or banned abortion. Investigators concluded patients seeking care for early pregnancy loss will find improved quality of care at institutions with unrestricted abortion access.

Reference

Phillips AM, Rachad S, Flink-Bochacki R. The association between abortion restrictions and patient-centered care for early pregnancy loss at US obstetrics-gynecology residency programs. American Journal of Obstetrics & Gynecology. 2023;229(1). doi:10.1016/j.ajog.2023.03.038