OBJECTIVE: To assess young people\'s interest in advance provision (AP) of medication abortion- receiving mifepristone and misoprostol from a clinician in advance for their future use.
METHODS: From November 2022-August 2023 we administered an electronic survey regarding advance provision to patients assigned female at birth at four Bay Area youth-serving clinics.
RESULTS: Among 152 people ages 14-24 years (mean 17.9) surveyed, 73.7% (95% CI, 65.9%-80.5%) supported and 46.1% (95% CI, 65.9%-80.5%) were interested in the AP model. AP interest was higher among people who experienced three or more difficulties trying to access reproductive healthcare [70.6% (95% CI 44.0%, 89.7%)] and who experienced food or housing insecurity [60.3% (95% CI 46.6%, 73.0%)]. Most youth (81.6%) had a safe place to store the pills for later use; this proportion was significantly higher among people ages 18-24 years (88.5%) than teens ages 14-17 years (74.3%, p=.025). The most common perceived advantages of AP included being able to have the abortion earlier in pregnancy (61.8%), privacy (57.9%) and convenience (50.7%). Common disadvantages noted included concern that people might take the pills incorrectly (50.0%) or lose the pills (40.1%).
CONCLUSIONS: Young people have considerable interest in AP of medication abortion. Further research is needed to document the AP model\'s feasibility, clinical outcomes, and effect on access for adolescents.

OBJECTIVE: To assess willingness to provide medication abortion among North American Society for Pediatric and Adolescent Gynecology (NASPAG) clinicians caring for adolescents and young adults (AYA) following Dobbs v. Jackson Women\'s Health Organization DESIGN: Cross-sectional online survey METHODS: Potential participants received an e-mail invitation via the NASPAG listserv. A 43-item questionnaire queried demographics, practice setting, abortion training and practice, willingness to provide medication abortion, potential or real barriers to providing medication abortion, and sentiments of abortion. Descriptive statistics, χ2, and Fisher\'s exact tests were used.
RESULTS: Of the 70 participants, 51% were willing to provide a medication abortion for an adolescent who requested it in their clinical practice. The most common barriers to providing medication abortion were legislative restrictions (47%) and dispensing pills from clinic (33%). Participants\' willingness to provide a medication abortion differed by type of practice (p = .001), availability of mifepristone (p = .006), perception of state\'s abortion policy (p = .001), concern about legislative restrictions (p = .008), experience providing abortion (p = .04), and receipt of medication abortion training (p = .02). Willingness to provide medication abortion also differed based on various sentiments of abortion measured but not on opinion regarding legality of abortion for adolescents (p = .49).
CONCLUSIONS: Perception of state\'s abortion rights and concern about legislative restrictions influenced NASPAG clinicians\' willingness to provide medication abortion for adolescents. Interventions to minimize legislative interference with medical care, increase abortion training, and implement medication abortion in pediatric settings may expand AYA medication abortion access.

BACKGROUND: Telehealth abortion has taken on a vital role in maintaining abortion access since the Dobbs v. Jackson Women\'s Health Organization Supreme Court decision. However, little remains known about the landscape of new telehealth-only virtual clinic abortion providers that have expanded since telehealth abortion first became widely available in the United States in 2021.
OBJECTIVE: This study aimed to (1) document the landscape of telehealth-only virtual clinic abortion care in the United States, (2) describe changes in the presence of virtual clinic abortion services between September 2022, following the Dobbs decision, and June 2023, and (3) identify structural factors that may perpetuate inequities in access to virtual clinic abortion care.
METHODS: We conducted a repeated cross-sectional study by reviewing web search results and abortion directories to identify virtual abortion clinics in September 2022 and June 2023 and described changes in the presence of virtual clinics between these 2 periods. In June 2023, we also described each virtual clinic\'s policies, including states served, costs, patient age limits, insurance acceptance, financial assistance available, and gestational limits.
RESULTS: We documented 11 virtual clinics providing telehealth abortion care in 26 states and Washington DC in September 2022. By June 2023, 20 virtual clinics were providing services in 27 states and Washington DC. Most (n=16) offered care to minors, 8 provided care until 10 weeks of pregnancy, and median costs were US $259. In addition, 2 accepted private insurance and 1 accepted Medicaid, within a limited number of states. Most (n=16) had some form of financial assistance available.
CONCLUSIONS: Virtual clinic abortion providers have proliferated since the Dobbs decision. We documented inequities in the availability of telehealth abortion care from virtual clinics, including age restrictions that exclude minors, gestational limits for care, and limited insurance and Medicaid acceptance. Notably, virtual clinic abortion care was not permitted in 11 states where in-person abortion is available.

On January 30, 2024, over 300 researchers filed an amicus brief in FDA v. Alliance for Hippocratic Medicine, a United States (US) Supreme Court case concerning the regulatory status of mifepristone, one of two drugs used in medication abortion. In this Comment we summarize the legal challenge, responses from the FDA and drug manufacturer to these challenges, oral arguments presented before the Court, and the implications of the Court\'s decision on access to mifepristone in the US. We also summarize the content of the accompanying amicus brief.

OBJECTIVE: To compare medication abortion outcomes among people screened without or with ultrasound or pelvic examination.
METHODS: We used data collected from March 24, 2020 to September 27, 2021 at five TelAbortion Project sites that provided medication abortion with mifepristone and misoprostol by mail. Using logistic regression weighted on propensity scores, we compared outcomes in participants who had neither ultrasound nor exam before treatment (No-Test group) or had such tests (Test group). We analyzed outcomes separately for participants screened early in the analysis period (before September 15, 2020) or later. Outcomes included: procedural abortion completion or ongoing pregnancy, serious adverse events, and unplanned post-treatment abortion-related clinical visits.
RESULTS: Among 416 participants in the early period, the No-Test group had a significantly higher risk than the Test group of procedural abortion completion or ongoing pregnancy (5.6% vs. 0.9%, risk difference 4.6%, 95% CI 1.5%, 7.7%) and abortion-related clinical visits (13.3% vs. 6.3%; risk difference 7.0%; 95% CI 1.1%, 12.8%). Among 364 participants screened later, the risk of procedural abortion completion or ongoing pregnancy did not differ by group, while unplanned abortion-related clinical visits were less common in the No-Test group (9.9% vs. 20.5%; risk difference -10.6%; 95% CI -20.1%, -1.1%). Risk of serious adverse events did not differ by group in either period.
CONCLUSIONS: When providers first began omitting ultrasound or pelvic exam before medication abortion, the practice was associated with increased risks of failure of complete abortion and post-treatment clinical visits; however, these increased risks resolved over time.
CONCLUSIONS: Medication abortion without pretreatment ultrasound or examination is effective and safe. This model should be routinely offered to eligible patients.

Objective: Our objective was to evaluate the feasibility of a new protocol for telemedicine follow-up after medication management of early pregnancy loss. Study Design: The study was designed to assess the feasibility of planned telemedicine follow-up after medication management of early pregnancy loss. We compared these follow-up rates with those after planned in-person follow-up of medication management of early pregnancy loss and planned telemedicine follow-up after medication abortion. We conducted a retrospective cohort study, including patients initiating medication management of early pregnancy loss <13w0d gestation and medication abortion ≤10w0d with a combination of mifepristone and misoprostol between April 1, 2020, and March 28, 2021. As part of a new clinical protocol, patients could opt for telemedicine follow-up one week after treatment and a home urine pregnancy test 4 weeks after treatment. Our primary outcome was completed follow-up as per clinical protocol. We also examined outcomes related to complications across telemedicine and in-person follow-up groups. Results: Of patients reviewed, 181 were eligible for inclusion; 75 had medication management of early pregnancy loss, and 106 had medication abortion. Thirty-six out of 75 patients elected for telemedicine follow-up after early pregnancy loss. Of patients scheduled for telemedicine follow-up, 29/36 (81%, 95% CI: 64-92) with early pregnancy loss and 64/69 (93%, 95% CI: 84-98) undergoing medication abortion completed follow-up as per protocol (p = 0.06). Completed follow-up was also similar among patients undergoing medication management of early pregnancy loss who planned for in-person follow-up (p = 0.135). Complications were rare and did not differ across early pregnancy loss and medication abortion groups. Conclusions: Telemedicine follow-up is a feasible alternative to in-person assessment after medication management of early pregnancy loss.

BACKGROUND: Financial costs remain one of the greatest barriers to abortion, leading to delays in care and preventing some from getting a desired abortion. Medication abortion is available through in-person facilities and telehealth services. However, whether telehealth offers a more affordable option has not been well-documented.
METHODS: We used Advancing New Standards in Reproductive Health (ANSIRH)\'s Abortion Facility Database, which includes data on all publicly advertising abortion facilities and is updated annually. We describe facility out-of-pocket prices for medication abortion in 2021, 2022, and 2023, comparing in-person and telehealth provided by brick-and-mortar and virtual clinics, and by whether states allowed Medicaid coverage for abortion.
RESULTS: The national median price for medication abortion remained consistent at $568 in 2021 and $563 in 2023. However, medications provided by virtual clinics were notably lower in price than in-person care and this difference widened over time. The median cost of a medication abortion offered in-person increased from $580 in 2021 to $600 by 2023, while the median price of a medication abortion offered by virtual clinics decreased from $239 in 2021 to $150 in 2023. Among virtual clinics, few (7%) accepted Medicaid. Median prices in states that accept Medicaid were generally higher than in states that did not.
CONCLUSIONS: Medication abortion is offered at substantially lower prices by virtual clinics. However, not being able to use Medicaid or other insurance may make telehealth cost-prohibitive for some people, even if prices are lower. Additionally, many states do not allow telehealth for abortion, deepening inequities in healthcare.

BACKGROUND: This qualitative study aims to assess perspectives of clinicians and clinic staff on mail-order pharmacy dispensing for medication abortion.
METHODS: Participants included clinicians and staff involved in implementing a mail-order dispensing model for medication abortion at eleven clinics in seven states as part of a prospective cohort study, which began in January 2020 (before the FDA removed the in-person dispensing requirement for mifepristone). From June 2021 to July 2022, we invited participants at the participating clinics, including six primary care and five abortion clinics, to complete a semi-structured video interview about their experiences. We then conducted qualitative thematic analysis of interview data, summarizing themes related to perceived benefits and concerns about the mail-order model, perceived patient interest, and potential barriers to larger-scale implementation.
RESULTS: We conducted 24 interviews in total with clinicians (13 physicians and one nurse practitioner) and clinic staff (n = 10). Participants highlighted perceived benefits of the mail-order model, including its potential to expand abortion services into primary care, increase patient autonomy and privacy, and to normalize abortion services. They also highlighted key logistical, clinical, and feasibility concerns about the mail-order model, and specific challenges related to integrating abortion into primary care.
CONCLUSIONS: Clinicians and clinic staff working in primary care and abortion clinics were optimistic that mail-order dispensing of medication abortion can improve the ability of some providers to provide abortion and enable more patients to access services. The feasibility of mail-order pharmacy dispensing of medication abortion following the Supreme Court Dobbs decision is to be determined.
BACKGROUND: Registry: Clinicaltrials.gov.
BACKGROUND: NCT03913104. Date of registration: first submitted on April 3, 2019 and first posted on April 12, 2019.

OBJECTIVE: To compare the effectiveness and safety of medication abortion (MAB) via telemedicine versus in-person in pregnant people with less than 12 gestational weeks in Colombia.
METHODS: A retrospective cohort study was conducted with 23,362 pregnant people who requested MAB service from Profamilia (a Colombian non-governmental organization) in 2021-2022. The outcomes were success and safety of MAB. We performed a descriptive and a multivariate statistical analysis using the binary regression model to obtain an adjusted Odds Ratio (aOR) to identify factors associated with abortion success.
RESULTS: In comparison to in-person care (n = 20,289), individuals in telemedicine (n = 3073) were predominantly from urban areas, belonged to a lower socioeconomic stratum, single and did not identify with any ethnic group. In-person users tended to have higher levels of education and accessed the service through private insurance (p < 0,05). There were no differences in the odd of a successful abortion based on the modality of care (aOR 1.18; 95% CI=0.87-1.59). The results were also the same with sensitivity analysis stratified: pregnant people who were nine weeks gestation or less (aOR 0.86; 95% CI=0.63-1.17) or more (aOR 0.87; 95% CI=0.28-2.65).
CONCLUSIONS: Telemedicine is an effective and safe option for MAB, as in-person care. Telemedicine has the potential to increase abortion access by extending the availability of providers and offering people a new option for obtaining care conveniently and privately, especially for women with disadvantaged socioeconomic and educational background.
CONCLUSIONS: This study demonstrates that medication abortion (MAB) administered via telemedicine produces outcomes akin to those of in-person care, providing a compelling rationale for its adoption, particularly in underserved regions. This approach can be replicated in other countries in Latin America and the Caribbean.

In January 2023, the Food & Drug Administration modified the Risk Evaluation and Mitigation Strategy program regulating mifepristone to allow direct dispensation from retail pharmacies. In June 2023, we conducted a random, distributive survey of pharmacies in California using secret shopper methodology to investigate the feasibility of accessing mifepristone. One pharmacy had mifepristone immediately available (<24 hours), and misoprostol availability was limited. Accessibility to misoprostol varied by type of pharmacy (p < 0.01), but not by region. Even in a reproductive freedom state, access to mifepristone and misoprostol from outpatient retail pharmacies remains limited.