Outcomes and Safety of History-Based Screening for Medication Abortion: A Retrospective Multicenter Cohort Study

Ushma D Upadhyay, Elizabeth G Raymond, Leah R Koenig, Leah Coplon, Marji Gold, Bliss Kaneshiro, Christy M Boraas, Beverly Winikoff

Research output: Contribution to journalArticlepeer-review

38 Scopus citations


Importance: Screening for medication abortion eligibility typically includes ultrasonography or pelvic examination. To reduce physical contact during the COVID-19 pandemic, many clinicians stopped requiring tests before medication abortion and instead screened patients for pregnancy duration and ectopic pregnancy risk by history alone. However, few US-based studies have been conducted on the outcomes and safety of this novel model of care.

Objective: To evaluate the outcomes and safety of a history-based screening, no-test approach to medication abortion care.

Design, Setting, and Participants: This retrospective cohort study included patients obtaining a medication abortion without preabortion ultrasonography or pelvic examination between February 1, 2020, and January 31, 2021, at 14 independent, Planned Parenthood, academic-affiliated, and online-only clinics throughout the US.

Exposures: Medications for abortion provided without preabortion ultrasonography or pelvic examination and dispensed to patients in person or by mail.

Main Outcomes and Measures: Effectiveness, defined as complete abortion after 200 μg of mifepristone and up to 1600 μg of misoprostol without additional intervention, and major abortion-related adverse events, defined as hospital admission, major surgery, or blood transfusion.

Results: The study included data on 3779 patients with eligible abortions. The study participants were racially and ethnically diverse and included 870 (23.0%) Black patients, 533 (14.1%) Latinx/Hispanic patients, 1623 (42.9%) White patients, and 327 (8.7%) who identified as multiracial or with other racial or ethnic groups. For most (2626 [69.5%]), it was their first medication abortion. Patients lived in 34 states, and 2785 (73.7%) lived in urban areas. In 2511 (66.4%) abortions, the medications were dispensed in person; in the other 1268 (33.6%), they were mailed to the patient. Follow-up data were obtained for 2825 abortions (74.8%), and multiple imputation was used to account for missing data. Across the sample, 12 abortions (0.54%; 95% CI, 0.18%-0.90%) were followed by major abortion-related adverse events, and 4 patients (0.22%; 95% CI, 0.00%-0.45%) were treated for ectopic pregnancies. Follow-up identified 9 (0.40%; 95% CI, 0.00%-0.84%) patients who had pregnancy durations of greater than 70 days on the date the mifepristone was dispensed that were not identified at screening. The adjusted effectiveness rate was 94.8% (95% CI, 93.6%-95.9%). Effectiveness was similar when medications were dispensed in person (95.4%; 95% CI, 94.1%-96.7%) or mailed (93.3%; 95% CI, 90.7%-95.9%).

Conclusions and Relevance: In this cohort study, screening for medication abortion eligibility by history alone was effective and safe with either in-person dispensing or mailing of medications, resulting in outcomes similar to published rates of models involving ultrasonography or pelvic examination. This approach may facilitate more equitable access to this essential service by increasing the types of clinicians and locations offering abortion care.

Original languageEnglish (US)
Pages (from-to)482-491
Number of pages10
JournalJAMA internal medicine
Issue number5
StatePublished - May 2022

Bibliographical note

Funding Information:
Funding/Support: Dr Upadhyay and Ms Koenig are supported by research grants from the BaSe Family Fund. Funding to support data abstraction and cleaning was provided by the University of California Global Health Institute’s Center of Expertise on Women’s Health, Gender, and Empowerment.

Funding Information:
Additional Contributions: We are deeply grateful to the staff and clinics that contributed their data to this study, including Maine Family Planning, University of Hawaii, Planned Parenthood of the Rocky Mountains, carafem, Planned Parenthood of Montana, Planned Parenthood North Central States, Institute for Family Health, All Families, Cedar River Clinics, Long Beach Memorial Family Medicine, University of California Los Angeles Women’s Health, Just the Pill, and Choix. We appreciate medical record abstraction and data contributions from Cindy Adam, MS, FNP-C, Mark Adam, MSc, Julie Amaon, MD, Joey Banks, MD, Emory Bowen, BS, Elana Craemer, MD, Ryan Cummings, MD, Lauren Dubey, MS, FNP-C, Julia Eicher, DO, Lila Engelbrecht, BA, Ann Firstenberg, BS, Ana Garcia, MS, DO, Shay Gingras, BA, Deborah Glupczynski, MD, Melissa Grant, BA, Katherine Hartnett, BS, Karina Hernandez, CRA, Cecilia Huang, MD, Courtney Kerestes, MD, Lea Lacar, MD, Madeline Mahoney, Geeth Kavya Minama Reddy, MD, Sarah Murayama, BA, Deb Oyer, MD, Rajita Patil, MD, Marit Pearlman Shapiro, MD, MPH, Linda Prine, MD, Emily Rozema, MPH, Leyra Santiago Rivera, BSA, Laura Sawyer, RN, BSN, Amy Schlauch, DO, Julianne Scholes, BA, Elisabeth Seamon, MD, MPH, Meera Shah, MD, MPH, MS, Rose Swords, MD, Marcy Thomas, NP, WHNP-BC, Kristina Tocce, MD, MPH, Fiona Tubmen-Scovack, AAS, Jasmine Tyson, MS, Fari Valji, MD, Paige Varin, BA, Pam Wade, FNP, and Helen Weems, MSN, RN, APRN. We thank Rosalyn Schroeder, MPH, MSc, for financial administration of the study. We also thank Chris Ahlbach, BS, and Jennifer Ko, MLIS, for administrative support. We appreciate statistical consultation from John Boscardin, PhD, and David Glidden, PhD, MS. These individuals either received a stipend for their time spent on the study or received no additional compensation, outside of their usual salary. REDCap is supported by UL1 TR000445 from the National Center for Advancing Translational Sciences of the National Institutes of Health.

Publisher Copyright:
© 2022 American Medical Association. All rights reserved.

PubMed: MeSH publication types

  • Journal Article
  • Multicenter Study
  • Research Support, Non-U.S. Gov't


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