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Implications of the Dobbs Decision: Role of Medications in Self-Managed Abortions

In a special issue on healthcare access and reproductive rights, JAMA publishes research and several opinion articles that examine the effects on healthcare of the U.S. Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision overturning abortion rights. A major thread running in several articles is the role of the abortafacients mifepristone and misoprostol when obtained and used without medical supervision.

“FDA permits medication abortion through 10 weeks’ gestation,” note authors of a Viewpoint article. “Yet state abortion bans are written broadly and prohibit many medication abortions. Fifteen states with gestational limits of 6 weeks or less would effectively prohibit all medication abortions. Although the FDA allows remote dispensing of mifepristone, telehealth for abortion medication varies by state, with 7 states explicitly prohibiting the practice. Additional states curtail access to medication abortion, including 19 states that require the prescribing clinician to be physically present.… Clinicians could face legal jeopardy even in states that permit abortions. Although out-of-state enforcement of abortion bans has practical barriers, bills in some states would prohibit out-of-state abortion assistance. Clinicians who counsel their patients about out-of-state abortion facilities or directly contact out-of-state clinicians to transfer patient information could be subject to legal penalties.”

Authors of a second Viewpoint write: “Rarely, patients may present to the hospital with serious complications related to a self-managed abortion attempt, such as uterine perforation, active hemorrhage, or sepsis. These patients should be evaluated and promptly treated using the best available evidence-based care. More commonly, after self-managed abortion with medications, patients will present with symptoms such as mild bleeding or cramping that require minimal treatment. It is helpful for clinicians who may be caring for these patients in emergency or urgent care settings to be familiar with the normal course of a medication abortion (eg, expected intensity and length of bleeding and discomfort) to avoid unnecessary interventions. For example, it is appropriate to avoid intervention and have patients monitor their symptoms if they report only minimal bleeding and pain after passing pregnancy tissue. Such patients should be instructed to take a pregnancy test in 4 weeks, at which time the test should be negative. In addition, clinicians should be aware that a thickened endometrium shown on ultrasound is normal after a complete medication abortion, and that this finding, in isolation, should not dictate intervention in an asymptomatic patient.”

“These articles in this issue of JAMA provide information about how abortion restrictions interfere with the autonomy of clinicians to provide evidence-based medical care and to engage in shared decision-making with their patients in accordance with their professional responsibilities,” the editors write in an editorial. “The evolving patchwork of restrictive abortion laws in the US does not align with modern medical care, poses risks to multiple groups of patients, and exacerbates injustices in health care. Legal interference between patients and their clinicians who are providing evidence-based care is unacceptable and ultimately harms patients, clinicians, and society at large.”

Source: JAMA