Early Abortion in Family Medicine: Clinical Outcomes

Ian M. Bennett; Margaret Baylson; Karin Kalkstein; Ginger Gillespie; Scarlett L. Bellamy; Joan Fleischman

doi:10.1370/afm.1051

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Table 1.

Patient Characteristics

Characteristic	Medication (n=1,309) No. (%)	Aspiration (n=1,149^a) No. (%)	Ineligible^b(n=92) No. (%)
^a The number of procedures may not add to 1,149 because of missing data.
^b Ineligible because of advanced gestational age, miscarriage, not pregnant, referred out, sonogram only, chose not to have an abortion.
^c Significant difference between choice of aspiration or medication abortion (P <.05).
^d Total pregnancies.
Age, y^c
15–20	123 (43.6)	138 (48.9)	21 (7.5)
20–24	383 (54.5)	292 (41.5)	28 (4.0)
25–29	379 (53.8)	308 (43.8)	17 (2.4)
≥30	410 (50.0)	384 (46.9)	25 (3.1)
Payment^c
Cash	427 (47.7)	457 (51.1)	11 (1.2)
Private insurance	417 (52.9)	357 (45.2)	15 (1.9)
Medicaid	448 (57.0)	320 (40.7)	18 (2.3)
Other	3 (7.5)	5 (12.5)	32 (80)
Gravidity^d
1	326 (46.6)	321 (45.9)	53 (7.5)
2	274 (53.7)	231 (45.3)	5 (1.0)
≥3	707 (53.6)	593 (45.0)	18 (1.4)
Prior medication abortion^c
0	1,075 (49.1)	1,027 (46.9)	89 (4.0)
1	172 (62.6)	101 (36.7)	2 (0.7)
2	42 (76.4)	12 (21.8)	1 (1.8)
≥3	19 (67.9)	9 (32.1)	0 (0.0)
Prior aspiration abortion
0	705 (50.5)	615 (44.0)	77 (5.5)
1	348 (51.8)	315 (46.9)	9 (1.3)
2	162 (54.7)	131 (44.3)	3 (1.0)
≥3	94 (51.1)	87 (47.3)	3 (1.6)
Estimated gestational age, wk
<6	256 (61.8)	156 (37.7)	2 (0.5)
6–9	941 (53.7)	801 (45.7)	10 (0.6)
10–12	2 (2.9)	65 (92.8)	3 (4.3)
>12	0	10 (30.3)	23 (69.7)
Practice type
Residency	348 (75.1)	97 (21.0)	18 (3.9)
Private office	961 (46.4)	1,052 (50.8)	58 (2.8)

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Table 2.

Early Abortion Outcomes (Encountered vs Published Rates)

Outcome	No.	Rate	95% CI	Published Rates Per 100 Cases
NA=Information not available.
^a After aspiration (initial medication) or re-aspiration (initial aspiration), these patients had successful terminations without need for outside referral or hospitalization.
^b Sonographic-documented progression of pregnancy.
^c More than 250-cc blood loss (none required transfusion).
^d Required hospitalization: published rates of hospitalization for medication abortion = 0.02–0.26,²⁵^,³¹^,⁴⁷ and aspiration abortion=0.0071–0.3.¹^,²⁹
Initial evaluation	2,550
Diagnosed molar pregnancy	1	0.04	0.00–0.13	0.01–0.012²⁶^,²⁷
Diagnosed ectopic pregnancy	3	0.12	0.00–0.13	0.03–0.33²⁸^–³⁰
Medication abortion	1,309
Successful, uncomplicated	1,263	96.49	95.49–96.99	92.0–98.0³¹^–³⁴
Adverse events and complications
Continuing pregnancy^a,b	19	1.45	0.80–1.78	0.39–4.5¹⁶^,¹⁷
Incomplete abortion^a	16	1.22	0.63–1.53	2.4–4.5¹⁶^,¹⁷
Patient request for aspiration^a	1	0.08	0.00–0.15	0.12–0.3³³^,³⁵
Hemorrhage^a,c	9	0.69	0.24–0.92	0.0–2.0³⁶
Infection	0	0.00	–	0.09–0.5³⁶
Missed ectopic pregnancy^d	1	0.08	0.00–0.15	0.0–0.26²⁷^,³²^,³⁷
Aspiration abortion	1,149
Successful, uncomplicated	1,109	96.52	95.46–97.06	95.9–99.095¹^,⁶^,²⁶^,³⁸^–⁴⁰
Adverse events and complications (immediate)
Unable to dilate cervix	10	0.87	0.27–1.04	NA
Hemorrhage^a	4	0.35	0.01–0.52	0.007–0.8¹^,²⁶^,³⁸^,⁴⁰^–⁴²
Perforation	0	0.00	–	0.0009–0.195¹^,²⁶
Cervical injury	0	0.00	–	0.13–3.9²⁶^,³⁸^,⁴³^,⁴⁴
Delayed complication (3 h to 21 d)
Continuing pregnancy^a,b	1	0.09	0.00–0.17	0.036–2.3²⁶^,³⁸^,³⁹
Incomplete evacuation^*	21	1.83	1.05–2.22	0.85–4.7¹^,³⁸^,⁴⁵
Hematometra (postabortal syndrome)^a	2	0.17	0.00–0.30	0.1–1.4²⁶^,³⁹^,⁴¹^,⁴⁶
Endometritis (received antibiotic treatment)	1	0.09	0.00–0.17	0.1–0.6²⁶^,³⁹
Hemorrhage^a,c	0	0.00	–	0.007–0.28¹^,²⁶
Missed ectopic pregnancy^d	3	0.26	0.00–0.41	0.00–0.3²⁶^,²⁸^–³⁰^,³⁸^,³⁹

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Table 3.

Complication Rates of Abortion for Physicians by Previous Procedures Completed and Practice Type

Characteristic	Uncomplicated Procedures No. (%)	Complications No. (%)	χ²(df)	PValue
df=degrees of freedom.
Note: Attribution of physician was determined based on the initial physician assignment and not to a supervising/training physician even if a supervisor intervened in the course of a procedure.
Physician experience
Aspiration (n=1,149)
<50	420 (96.8)	14 (3.2)	0.946 (3)	.814
50–99	235 (95.9)	10 (4.2)
100–999	266 (96.7)	9 (3.3)
≥1,000	188 (96.4)	7 (3.6)
Medication (n=1,309)
<50	704 (96.3)	27 (3.7)	2.337 (3)	.505
50–99	246 (98.0)	5 (2.0)
100–999	290 (95.7)	13 (4.3)
≥1,000	23 (95.8)	1 (4.2)
Practice type
Aspiration (n=1,149)
Residency	93 (95.9)	4 (4.1)	0.072 (1)	.782
Private office	1,012 (96.2)	40 (3.8)
Medication (n=1,309)
Residency	336 (96.6)	12 (3.4)	0.006 (1)	.940
Private office	927 (96.5)	34 (3.5)

Additional Files

Tables

Supplemental Figure

Supplemental Figure 1. Kaplan Meier Analysis of �Complication-Free Survival Probabilities� Comparing More Experienced Providers to Less Experienced Providers for MED and ASP Procedures.

Files in this Data Supplement:

Supplemental data: Figure - PDF file, 1 page, 108 KB
The Article in Brief

Early Abortion in Family Medicine: Clinical Outcomes

Ian M. Bennett , and colleagues

Background There has been little research assessing early abortion outcomes in family medicine. This study aims to determine success rates of abortion procedures by family physicians, identify the nature and severity of adverse outcomes/complications, and assess the ability to manage complications on site.

What This Study Found The rates of complications of first-trimester abortion care in family medicine clinical sites are very low and within the range of outcomes published for obstetric-gynecology and specialty abortion sites. Assessing the outcomes of 1,309 medication and 1,149 aspiration abortion procedures among family physicians in four residency training programs and one private practice, researchers found 96.5 percent of the medication and 99.1 percent of the aspiration abortions were successful. Less than 4 percent of either the medication or aspiration abortions had any related complications, and most complications were minor and managed within the family medicine practices without reliance on emergency services or those of specialists.

Implications

The authors suggest that family physicians who provide early abortion care can promote continuity of care within the context of the medical home and may help to ameliorate abortion provider shortages across the United States.
The study calls for initiatives to bring first-trimester abortion training into family medicine settings.
Correction

The rate of successful uncomplicated aspiration abortion reported in the abstract was inadvertently switched with the rate of successful aspiration abortion (including complications). The correct rate should be 96.5% (95.5%-97.1%) as listed in Table 2. In addition, in the Results section of the text the rate of successful uncomplicated abortion should be 96.5% and not 96.2%.