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THE SAFETY AND QUALITY OF ABORTION CARE IN THE UNITED STATES Committee on Reproductive Health Services: Assessing the Safety and Quality of Abortion Care in the U.S. Board on Population Health and Public Health Practice Board on Health Care Services Health and Medicine Division A Consensus Study Report of PREPUBLICATION COPY: UNCORRECTED PROOFS
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by contracts between the National Academy of Sciences and the David and Lucile Packard Foundation, Grove Foundation, JPB Foundation, Susan Thompson Buffett Foundation, Tara Health Foundation, and William and Flora Hewlett Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/24950 Library of Congress Control Number: Additional copies of this publication are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2018 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. The safety and quality of abortion care in the United States. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24950. PREPUBLICATION COPY: UNCORRECTED PROOFS
The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY: UNCORRECTED PROOFS
Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the studyâs statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committeeâs deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY: UNCORRECTED PROOFS
COMMITTEE ON REPRODUCTIVE HEALTH SERVICES: ASSESSING THE SAFETY AND QUALITY OF ABORTION CARE IN THE U.S. B. NED CALONGE (Co-Chair), University of Colorado HELENE D. GAYLE (Co-Chair), Chicago Community Trust WENDY R. BREWSTER, University of North Carolina at Chapel Hill School of Medicine LEE A. FLEISHER, University of Pennsylvania Perelman School of Medicine CAROL J. ROWLAND HOGUE, Emory University Rollins School of Public Health JODY RAE LORI, University of Michigan School of Nursing JEANNE MIRANDA, University of California, Los Angeles RUTH MURPHEY PARKER, Emory University School of Medicine DEBORAH E. POWELL, University of Minnesota Medical School EVA K. PRESSMAN, University of Rochester Medical Center ALINA SALGANICOFF, Kaiser Family Foundation PAUL G. SHEKELLE, The RAND Corporation SUSAN M. WOLF, University of Minnesota Study Staff JILL EDEN, Study Director KATYE MAGEE, Research Associate MATTHEW MASIELLO, Research Assistant ANNA MARTIN, Senior Program Assistant ROSE MARIE MARTINEZ, Senior Board Director, Board on Population Health and Public Health Practice SHARYL NASS, Board Director, Board on Health Care Services HOPE HARE, Administrative Assistant PATRICK BURKE, Senior Financial Officer MISRAK DABI, Financial Associate (from June 2017) PREPUBLICATION COPY: UNCORRECTED PROOFS v
Reviewers This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: REBECCA H. ALLEN, Brown University DONALD M. BERWICK, Institute for Healthcare Improvement CLAIRE BRINDIS, University of California, San Francisco PONJOLA CONEY, Virginia Commonwealth University VANESSA K. DALTON, University of Michigan C. NEILL EPPERSON, University of Pennsylvania Perelman School of Medicine DANIEL GROSSMAN, University of California, San Francisco AMY LEVI, University of New Mexico College of Nursing HEIDI D. NELSON, Oregon Health & Science University WILLIE J. PARKER, Physicians for Reproductive Health ROBERT L. PHILLIPS, JR., American Board of Family Medicine SARA ROSENBAUM, The George Washington University Milken Institute School of Public Health MICHAEL W. VARNER, University of Utah School of Medicine GAIL R. WILENSKY, Project HOPE SUSAN F. WOOD, The George Washington University Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by ALFRED O. BERG, University of Washington, and ENRIQUETA C. BOND, Burroughs Wellcome Fund. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. PREPUBLICATION COPY: UNCORRECTED PROOFS vii
Acknowledgments The committee and staff are indebted to a number of individuals and organizations for their contributions to this report. We extend special thanks to all the individuals who were essential sources of information, generously giving their time and knowledge to further the committeeâs efforts. Thank you to Elizabeth Brown, Sidney Callahan, Olivia Cappello, Nancy Chescheir, Mitch Creinin, Carrie Cwiak, Ann Davis, Diana Greene Foster, Marji Gold, Alisa Goldberg, Kristy Goodman, Jane Henney, Susan Higginbotham, Elizabeth Janiak, Tara Jatlaoui, Rachel Jones, Uta Landy, Amy Levi, Steve Lichtenberg, Abigail Long, Ana McKee, Michael Raggio, Matthew Reeves, Debra Stulberg, Diana Taylor, Stephanie Teal, Ushma Upadhyay, Carl Weiner, Kari White, Beverly Winikoff, and Susan Wood. Thank you as well to the following individuals, who provided testimony to the committee: BONNIE SCOTT JONES, Senior Policy Advisor, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco; SARAH ROBERTS, Associate Professor, Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco; and JULIET ROGERS, Assistant Professor, Health Management and Policy, University of Michigan. Funding for this study was provided by the David and Lucile Packard Foundation, Grove Foundation, JPB Foundation, Susan Thompson Buffett Foundation, Tara Health Foundation, and William and Flora Hewlett Foundation. The committee appreciates the opportunity and support extended by the sponsors for the development of this report. Many within the Health and Medicine Division (HMD) of the National Academies of Sciences, Engineering, and Medicine were helpful to the study staff. The committee would like to thank Rebecca Morgan and the National Academies Research Center staff for their assistance in the committeeâs research efforts. We would also like to thank Patrick Burke and Misrak Dabi (HMD Offices of Finance and Administration); Chelsea Frakes, Lauren Shern, and Taryn Young (Health and Medicine Division Executive Office); and Greta Gorman, Nicole Joy, and Bettina Ritter (HMD Office of Communications). PREPUBLICATION COPY: UNCORRECTED PROOFS ix
Contents SUMMARY S-1 1 INTRODUCTION 1-1 Abortion Care Today, 1-2 Study Approach, 1-17 Organization of the Report, 1-22 References, 1-23 2 THE SAFETY AND QUALITY OF CURRENT ABORTION METHODS 2-1 Preabortion Care, 2-3 Initial Clinical Assessment, 2-5 Safety and Effectiveness of Current Abortion Methods, 2-5 Postabortion Care, 2-18 Use of Analgesia, Sedation, and Anesthesia in Abortion Care, 2-19 Mortality, 2-24 State Regulation of Abortion Care, 2-25 Summary, 2-26 References, 2-28 3 ESSENTIAL CLINICAL COMPETENCIES FOR ABORTION 3-1 PROVIDERS Required Clinical Competencies, 3-2 Which Providers Have the Clinical Skills to Perform Abortions?, 3-7 Training of Physicians and Advanced Practice Clinicians, 3-9 Availability of Trained Clinicians, 3-16 Summary, 3-19 References, 3-20 4 LONG-TERM HEALTH EFFECTS 4-1 Limitations of the Literature, 4-2 Future Childbearing and Pregnancy Outcomes, 4-4 Risk of Breast Cancer, 4-16 Mental Health Disorders, 4-17 Premature Death, 4-19 Summary, 4-19 References, 4-20 5 CONCLUSIONS 5-1 APPENDIXES A Biographical Sketches of Committee Members A-1 B Acronyms and Glossary B-1 PREPUBLICATION COPY: UNCORRECTED PROOFS xi
C Public Meeting Agenda C-1 D Literature Search Strategy D-1 PREPUBLICATION COPY: UNCORRECTED PROOFS xii
Boxes, Figures, and Tables BOXES 1-1 Charge to the Committee on Reproductive Health Services: Assessing the Safety and Quality of Abortion Care, 1-2 1-2 Current Abortion Methods, 1-4 1-3 The Six Dimensions of Health Care Quality, 1-19 1-4 Types of Research Reviewed for This Study, 1-22 2-1 FDA Risk Evaluation and Mitigation Strategy (REMS) Program for Mifeprex, 2-7 FIGURES 1-1 Continuum of abortion care, 1-5 1-2 Abortion rate, United States, 1973 to 2014, 1-11 1-3 Percentage and cumulative percentage of outpatient abortions by weeksâ gestation, 2014â2015, 1-12 1-4 Percentage of abortion-providing facilities accounted for by each facility type and percentage of abortions performed in each type of facility, 2014 (N = 1,671), 1-16 1-5 Median distance to the nearest abortion-providing facility by county, 2014, 1-17 1-6 The committeeâs analytic framework for assessing the quality of abortion care, 1-20 3-1 Selected residencies and fellowships offering abortion training in the United States, 3- 12 3-2 Regulations defining the level of provider credentialing required to provide abortions, by state and abortion method, 3-19 TABLES 1-1 Overview of State Abortion-Specific Regulations That May Impact Safety and Quality, as of September 1, 2017, 1-7 1-2 Characteristics of Women Who Had an Abortion in an Outpatient Setting in 2014, by Percent, 1-14 2-1 Selected Organizations That Issue Clinical Guidelines on Abortion Care, 2-2 2-2 Levels and Effects of Analgesia, Sedation, and Anesthesia, 2-20 2-3 Minimum Facility Requirements Related to Level of Sedation for Medication, Aspiration, and Dilation and Evacuation (D&E) Abortions, 2-21 2-4 Comparison of Mortality Rates for Abortion, Childbirth, Colonoscopy, Dental Procedures, Plastic Surgery, and Tonsillectomy, United States, 2-24 3-1 Required Competencies by Type of Abortion Procedure, 3-3 PREPUBLICATION COPY: UNCORRECTED PROOFS xiii
4-1 Studies Assessing the Association Between Abortion and Subsequent Pregnancy Complications Using Record-Linkage Methods, 4-8 4-2 Studies Assessing the Association between Abortion and Preterm Birth (PTB), Low Birthweight (LBW), and Small-for-Gestational Age (SGA) Using Record-Linkage Methods, 4-13 5-1 Does Abortion Care in the United States Meet the Six Attributes of Quality Health Care?, 5-5 PREPUBLICATION COPY: UNCORRECTED PROOFS xiv
