Effectiveness and safety of medication abortion with vs. without screening ultrasonography or pelvic exam.

Background: Before the COVID-19 pandemic, clinicians in the United States (U.S.) routinely required in-person screening tests such as ultrasonography or pelvic examination for medication abortion care. To minimize physical contact during the pandemic, clinicians began providing "no-test" medication abortion care, which can improve access by facilitating care from a broader range of clinicians, lowering costs, and reducing wait times. Despite evidence that medication abortion without in-person screening tests is safe and effective, screening ultrasound and pelvic examination remain common when medication abortion care is provided in person.

Objectives: In this cohort study, we compared the effectiveness and safety of medication abortion provided with and without in-person screening tests, specifically ultrasonography or pelvic examination.

Study design: We conducted a retrospective cohort study of medication abortions provided as a part of regular clinical practice by 3 U.S. clinics from February 2020-January 2021. Clinics abstracted medical record data for all patients with gestations <77 days who had neither screening ultrasonography nor pelvic examination ("no-test" group) and a random sample who had either test ("screening test" group). Participating clinics provided medication abortion care both with and without screening tests during the study period, and patients were screened either in person or via telehealth in both study groups. We imputed missing data and used inverse-probability-of-treatment-weighted logistic regression to compare abortion effectiveness (complete abortion without additional treatment), safety (abortions not involving major adverse events), emergency department visits, and abortions inadvertently provided beyond 77 days (a commonly used pregnancy duration limit for medication abortion) between study groups.

Results: We included 649 abortions with and 1,727 abortions without screening tests. Patients who obtained medication abortion without screening ultrasonography or pelvic examination had lower average pregnancy durations (48 vs. 50 days, p<0.001), were more likely to be White (43% vs. 32%, p<0.001), were less likely to reside in urban areas (78% vs. 83%, p=0.004), were more likely to receive abortion medications by mail (35% vs. 1%, p<0.001) and were more likely to pay out-of-pocket for abortion costs (62% vs. 55%, p=0.002). Abortion outcomes were documented for 72% of the screening test group and 58% of the no-test group (p<0.001). After imputing missing outcome data, we found similar effectiveness (95.3% vs. 93.4%, Risk Difference [RD]: -1.9% [95% CI: -6.9%, 3.1%]) and safety (99.8% vs. 98.7%, RD: -1.1% [95% CI: -2.9%, 0.7%]) between the screening test and no-test groups. Complete case analyses also found similar effectiveness (95.8% vs. 94.1%, RD: -1.7% [-4.4%, 1.1%]) and safety (100.0% vs. 99.2%, RD: -0.81% [-1.74%, 0.11%]) between study groups. Across both groups, 0.59% of abortions were found at follow-up to have been inadvertently provided at >77 days of gestation, and 4.0% involved an emergency department visit; these proportions did not differ by study group. Emergency department visits involving treatment were more common in the no-test group (2.1% vs. 0.39%, RD: 1.7% [95% CI: 0.1%, 3.3%]).

Conclusions: This study indicates that medication abortion care provided without screening ultrasonography or pelvic exam is comparably safe and effective to care with these screening tests. Although loss to follow-up was high, results are consistent with previous studies. Medication abortion should be routinely offered without screening ultrasonography or pelvic examination to eligible patients, including those screened in person.