No-Test Screening Protocols May Disproportionately Exclude Structurally Oppressed Communities Who Could Benefit from Accessing Medication Abortion.

Objective: To explore disparities in ineligibility for medication abortion using no-test screening criteria compared with assessment with testing including ultrasound.

Methods: From June 2021 to December 2022, we surveyed patients ages ≥15 seeking abortion at nine recruitment facilities in eight U.S. states before ultrasound; clinicians assessed patients' eligibility for medication abortion with ultrasound and other testing. Using clinical guidelines and the no-test protocol criteria, we estimated (1) the proportion ineligible by no-test assessment (pregnancy duration and ectopic pregnancy risk factors as reported in patient surveys and clinician-reported assessment of other contraindications) and (2) the proportion ineligible using no-test criteria yet eligible with testing (false positives). We assessed associations between participant characteristics and ineligibility for medication abortion and reasons for ineligibility.

Results: We approached 2,846 people, of whom 1,591 were eligible for the study. Of the 1,386 who consented and had complete clinician data, 21.1% (306/1,386) were ineligible with testing, 71.5% (n = 991/1,386) were ineligible using no-test criteria, and 51.4% (n = 713/1,386) screened false positive. In adjusted analyses, ineligibility using no-test criteria was significantly greater among people ages 15-19 (86.8% [105/121] vs. 71.5% for full sample, p < 0.001) and experiencing food or housing insecurity (75.8% [525/690] vs. 67.2%[464/693], p < 0.01); people ages 20-24 were more likely to screen false positive (56.1% [263/469] vs. 51.4% for full sample [713/1,386], p = 0.03). Moderate/severe pelvic pain was the most common (614/1,386) patient-reported reason for ineligibility and reported significantly more by people ages 15-19, who were nulliparous, and experienced food or housing insecurity.

Conclusions: Screening criteria for no-test medication abortion may exclude many people who are eligible, disproportionately excluding certain population groups from getting the care they seek. More research is needed to improve screening criteria to ensure equitable access to no-test medication abortion.