Attempts to purchase misoprostol online in Indonesia: a mystery client study design.

BACKGROUND: Abortion is highly restricted in Indonesia; self-administered misoprostol can safely induce an abortion. Brick and mortar pharmacies, a common place to purchase misoprostol off-label in other parts of the world, are monitored closely by the government authority in Indonesia which controls drugs so that they cannot function outside the law without risking arrest and prosecution. An online marketplace has sprung up in response that sells misoprostol through in-country distributors. Such procurement offers a level of safety and anonymity to the buyer and seller. So as to understand online access to misoprostol, we created a protocol to identify the most visible universe of sellers. METHODS: We carried out a mystery client methodology to replicate the experiences of women procuring misoprostol online. Our study consisted of five stages: (1) identify the universe of online sellers using the most common search terms, drawn from multiple platforms to capture diversity in interactions as well as products sold (2) remove duplicates across sites as determined by their telephone numbers (3) draw a roughly probability proportional to size sample (4) contact sellers as mystery clients through text/chat, depending on the platform, and engage with them and (5) attempt to purchase drugs offered by the seller. Descriptive statistics are presented. RESULTS: The listing generated 727 sites: 441 websites, 153 marketplace sellers, and 133 Instagram profiles. After removing duplicate listings, we identified 281 unique sellers. We selected all sellers with greater than 12 listings, 60% of sellers with 4-12 listings, 50% of sellers with 2-3 listings, and 40% of sellers with only one listing. Mystery clients were able to send initial messages to 110 sellers, of which 16 never responded. The interaction progressed to purchasing misoprostol with 76 sellers, 64 of whom sent drugs. CONCLUSIONS: As women seek to terminate unwanted pregnancies in legally restrictive settings, online sales of misoprostol must be considered. With the Covid pandemic constraining movement, the importance of this way of procuring misoprostol will likely become more appealing. Understanding this unregulated landscape is important if we are to try to improve women's ability to safely conduct an abortion in highly restrictive settings.

Women's experiences of a telemedicine abortion service (up to 12 weeks) implemented during the coronavirus (COVID-19) pandemic: a qualitative evaluation.

OBJECTIVE: To explore the experiences of women in Scotland who accessed medical abortion at home up to 12 weeks' gestation, delivered via a telemedicine abortion service implemented in response to the coronavirus (COVID-19) pandemic, to identify areas for improvement and inform service provision. DESIGN: Qualitative interview study. SETTING: Abortion service in one National Health Service health board in Scotland. POPULATION OR SAMPLE: Twenty women who accessed telemedicine abortion services and self-administered mifepristone and misoprostol at home up to 12 weeks' gestation. METHODS: Thematic analysis of semi-structured qualitative interviews, informed by the Framework analytic approach. MAIN OUTCOME MEASURES: Women's experiences of accessing telemedicine for medical abortion at home, specifically: acceptability of the telephone consultation and remote support; views on no pre-abortion ultrasound scan; and self-administration of abortion medications at home. RESULTS: Novel study findings were three-fold: (1) participants valued the option of accessing abortion care via telemedicine and emphasised the benefits of providing a choice of telephone and in-person consultation to suit those with different life circumstances; (2) the quality of abortion care was enhanced by the telemedicine service in relation to access, comfort and flexibility, and ongoing telephone support; (3) participants described being comfortable with, and in some cases a preference for, not having an ultrasound scan. CONCLUSIONS: This research demonstrates support for the continuation of telemedicine abortion services beyond the temporary arrangements in place during COVID-19, and lends weight to the argument that offering the option of telemedicine abortion care can enable women to access this essential health service. TWEETABLE ABSTRACT: #Telemedicine provision of medical #abortion at home up to 12 weeks' gestation is acceptable and highly valued by #women #Research #SRHR @nbw80 @doctorjjrw @jeniharden @cameronsharon @mrc_crh @edinuniusher.

Factors Associated With Use of an Online Telemedicine Service to Access Self-managed Medical Abortion in the US.

Importance: People in the US have been seeking self-managed abortions outside the formal health care system using medications obtained through online telemedicine. However, little is known about this practice, including potential motivating factors. Objective: To examine individual reasons for accessing medication abortion through an online telemedicine service as well as associations between state- and county-level factors and the rate of requests. Design, Setting, and Participants: This population-based cross-sectional study examined all requests for self-managed medication abortion through an online consultation form available from Aid Access, a telemedicine service in the US, between March 20, 2018, and March 20, 2020. Main Outcomes and Measures: Individual-level reasons for accessing the telemedicine service were examined as well as the rate of requests per 100 000 women of reproductive age by state. Zip code data provided by individuals making requests were used to examine county-level factors hypothesized to be associated with increased demand for self-managed abortion: distance to a clinic (calculated using location data for US abortion clinics) and the population proportion identifying as a member of a racial/ethnic minority group, living below the federal poverty level, and having broadband internet access (calculated using census data). Results: During the 2-year study period, 57 506 individuals in 2458 counties in 50 states requested self-managed medication abortion; 52.1% were aged 20 to 29 years (mean [SD] age, 25.9 [6.7] years), 50.0% had children, and 99.9% were 10 weeks' pregnant or less. The most common reasons cited by individuals making requests were the inability to afford in-clinic care (73.5%), privacy (49.3%), and clinic distance (40.4%). States with the highest rate of requests were Louisiana (202.7 per 100 000 women) and Mississippi (199.9 per 100 000 women). At the county level, an increase of 1 SD (47 miles) in distance to the nearest clinic was significantly associated with a 41% increase in requests (incidence rate ratio, 1.41; 95% CI, 1.31-1.51; P < .001), and a 10% increase in the population living below the federal poverty level was significantly associated with a 20% increase in requests (incidence rate ratio, 1.20; 95% CI, 1.13-1.28; P < .001). Conclusions and Relevance: In this cross-sectional study, clinic access barriers were the most commonly cited reason for requesting self-managed medication abortion using an online telemedicine service. At the county level, distance to an abortion clinic and living below the federal poverty level were associated with a higher rate of requests. State and federal legislation could address these access barriers.

Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic.

OBJECTIVE: To present updated evidence on the safety, efficacy and acceptability of a direct-to-patient telemedicine abortion service and describe how the service functioned during the COVID-19 pandemic. STUDY DESIGN: We offered the study at 10 sites that provided the service in 13 states and Washington DC. Interested individuals obtained any needed preabortion tests locally and had a videoconference with a study clinician. Sites sent study packages containing mifepristone and misoprostol by mail and had remote follow-up consultations within one month by telephone (or by online survey, if the participant could not be reached) to evaluate abortion completeness. The analysis was descriptive. RESULTS: We mailed 1390 packages between May 2016 and September 2020. Of the 83% (1157/1390) of abortions for which we obtained outcome information, 95% (1103/1157) were completed without a procedure. Participants made 70 unplanned visits to emergency rooms or urgent care centers for reasons related to the abortion (6%), and 10 serious adverse events occurred, including 5 transfusions (0.4%). Enrollment increased substantially with the onset of COVID-19. Although a screening ultrasound was required, sites determined in 52% (346/669) of abortions that occurred during COVID that those participants should not get the test to protect their health. Use of urine pregnancy test to confirm abortion completion increased from 67% (144/214) in the 6 months prior to COVID to 90% (602/669) in the 6 months during COVID. Nearly all satisfaction questionnaires (99%, 1013/1022) recorded that participants were satisfied with the service. CONCLUSIONS: This direct-to-patient telemedicine service was safe, effective, and acceptable, and supports the claim that there is no medical reason for mifepristone to be dispensed in clinics as required by the Food and Drug Administration. In some cases, participants did not need to visit any facilities to obtain the service, which was critical to protecting patient safety during the COVID-19 pandemic. IMPLICATIONS: Medical abortion using telemedicine and mail is effective and can be safely provided without a pretreatment ultrasound. This method of service delivery has the potential to greatly improve access to abortion care in the United States.

Successful management of three cases of interstitial pregnancies with local instillation of potassium chloride: avoiding a potential cornuostomy.

Here, we present three cases of women with interstitial pregnancy who were managed with local instillation of potassium chloride. These women were in their 20s-30s and presented in stable condition. Of them, two had a history of previous ectopic pregnancy. Interstitial pregnancy was diagnosed by transvaginal sonography which showed an empty uterine cavity with a gestational sac 1 cm away from the lateral edge of the uterine cavity, with <5 mm myometrium surrounding it in all planes. Two of the three cases failed to respond to methotrexate injection. Due to the presence of high-end ultrasound machine and technical expertise, local instillation of potassium chloride was offered as an alternative to surgical treatment, which is definitive, and all three patients had a successful outcome. One patient returned with pain in the abdomen, which required inpatient monitoring and was later diagnosed with urinary tract infection and was given appropriate antibiotics.

Increase rate of ruptured tubal ectopic pregnancy during the COVID-19 pandemic.

OBJECTIVE: During the 2020 COVID-19 pandemic there was a decrease in emergency room arrivals. There is limited evidence about the effect of this change in behavior on women's health. We aimed to evaluate the impact of the COVID-19 pandemic on the diagnosis, treatment and complications of women presenting with a tubal Ectopic Pregnancy (EP). STUDY DESIGN: This is a single centre retrospective cohort study. We compared the clinical presentation, treatment modalities and complications of all women presenting in our institution with a tubal EP during the COVID-19 pandemic between 15 March and 15 June 2020, with women who were treated in our institution with the same diagnosis in the corresponding period for the years 2018-2019. RESULTS: The study group included 19 cases of EP (N = 19) that were treated between the 15 March 2020 and 15 June 2020. The control group included 30 cases of EP (N = 30) that were admitted to in the corresponding period during 2018 and 2019. Maternal age, parity, gravity and mode of conception (natural vs. assisted) were similar between the two groups. There was no difference in the mean gestational age (GA) according to the last menstrual period. In the study group more women presented with sonographic evaluation of high fluid volume in the abdomen than in the control group (53 % vs 17 %, P value 0.01). This finding is correlated with a more advanced disease status. In the study group there was a highly statistically significant 3-fold increase in rupture among cases (P < 0.005) and a 4-fold larger volume of blood in the entrance to the abdomen (P < 0.002). We found that there were no cases of ruptured EP in the group of women who were pregnant after assisted reproduction. CONCLUSION: We found a higher rate of ruptured ectopic pregnancies in our institution during the COVID-19 pandemic. Health care providers should be alerted to this collateral damage in the non-infected population during the COVID-19 pandemic.

COVID-19 impact in abortions' practice, a regional French evaluation.

INTRODUCTION: On March 14, 2020, France has entered into stage 3 of the COVID-19 pandemic. The French National Health Agency (Haute Autorité de Santé) has urgently recommended the use of medical abortion at home between 7 and 9 weeks of gestation and telemedicine for medical abortion consultations. The main objective of this study was to assess whether the emergency measures undertaken for the management of abortions during the COVID-19 pandemic led to practice changes, and to obtain practitioners' opinions regarding the continuation of these measures. MATERIAL AND METHODS: This was a retrospective, quantitative, online self-administered survey from August 6, 2020 to October 2, 2020, aimed at health workers performing abortions (midwives, general practitioners, gynecologists obstetricians and medical gynecologists) in the South and Corse regions in France. RESULTS: Among the 124 practitioners included, 59/77 (76.6 %) offered medical abortion at home between 7 and 9 weeks of gestation and 61/89 (68.5 %) of them wished to carry on this practice. 55/123 (44.7 %) practitioners offered telemedicine for medical abortion at home and 71/115 (61.7 %) of them wished to carry on this practice. DISCUSSION: The emergency measures implemented by the the French National Health Agency (Haute Autorité de Santé) for medical abortion are approved and followed by the majority of health workers performing abortions in the South and Corse regions. This measure may be extended out of the COVID-19 epidemic.