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Historical evidence that fetal red blood cell (RBC) exposure during early spontaneous or induced abortion can cause maternal Rh sensitization is limited. A close reading of these studies indicates that forgoing Rh immunoglobulin administration before 12weeks gestation is highly unlikely to increase risk of Rh (D) antibody development, and recent studies indicate that fetal RBC exposure during aspiration abortion12 weeks gestation is below the calculated threshold to cause maternal Rh sensitization, and the amount of fetomaternal hemorrhage during dilation and evacuation procedures up to 18weeks gestation is adequately treated with 100mcg of Rh immunoglobulin. We provide updated recommendations for Rh immunoglobulin administration based on this new evidence.

Since abortion was legalized throughout the United States in 1973, states have passed restrictive abortion policies, including permitting only obstetrician-gynecologist physicians (OBGYNs) to provide abortions. We are unaware of any research that directly compares patient safety-related outcomes by physician specialty. In this study, we compared major and any abortion-related morbidity and adverse events in abortion care provided by physicians of other specialties versus OBGYNs.Using the IBM Watson Health MarketScan claims database, we identified privately insured individuals who had an induced abortion between January 1, 2011, and December 31, 2014. The primary outcome was major abortion-related morbidity or adverse events, and the secondary outcome was any abortion-related morbidity or adverse events occurring within 6 weeks of the abortion.The study cohort included 34,764 patients who had 35,407 abortions-4,843 (13.7%) abortions provided by physicians of other specialties and 30,564 (86.3%) abortions provided by OBGYNs. Major and any abortion-related morbidity or adverse event occurred in 115 (0.3%) and 1,271 (3.6%) of 35,407 of abortions, respectively. In adjusted analyses, there was no statistically significant difference in major abortion-related morbidity or adverse events comparing physicians of other specialties versus OBGYNs (adjusted odds ratio, 1.02; 95% confidence interval, 0.59-1.75), and no statistically significant difference in any abortion-related morbidity or adverse events comparing physicians of other specialties versus OBGYNs (adjusted odds ratio, 0.91; 95% confidence interval, 0.77-1.09).There were no differences in abortion-related morbidity or adverse events by physician specialty. Our findings do not support state laws limiting abortion care to OBGYN physicians.

Legal, institutional, and payer policies regulating reproductive healthcare lack a shared language with medicine, resulting in great confusion and consternation. This paper critically examines the implications and ramifications of unclear language related to abortion care. Using a case-based approach, we highlight the ways in which language and terminology may impact the quality and accessibility of care. We also address repercussions for providers and patients within their team, institutional, state, and payer landscapes. In particular, we explore the stigmatization of abortion as both a word and a process, the role of caregivers as gatekeepers, the implications of viability as a limit for access, and the hierarchy of deservedness and value. Recognizing the role of language in these discussions is critical to building systems that honor the complexities of patient-centered reproductive decision-making, ensure access to comprehensive reproductive healthcare including abortion, and center patient autonomy. Healthcare providers are uniquely positioned to facilitate institutional, state, and national landscapes in which pregnant patients are supported in their autonomy and provided with just and equitable reproductive healthcare.

Objectives To calculate the minimum fetal red blood cell concentration required to cause maternal Rh sensitization; validate the use of a flow cytometry protocol below that concentration; preliminarily assess the concentrations of fetal red blood cells in pregnant women before and after uterine aspiration. Study design Using pre-existing literature, we calculated the lowest concentration of fetal red blood cells found to cause sensitization within adult female circulation. We validated a two-color flow cytometry protocol using fluorescently labeled antibodies to Hemoglobin F (expressed by fetal red blood cells and adult F cells) and Carbonic Anhydrase (expressed in red blood cells during the third trimester and postnatally) by titrating second trimester cord blood into non-pregnant adult blood. We applied this flow cytometry protocol in a prospective cohort study of 42 pregnant women at 5–12 weeks gestational age undergoing uterine aspiration for induced or spontaneous abortion. Results The calculated threshold for causing Rh sensitization was 250 fetal red blood cells per 10 million total red blood cells. We showed a linear relationship between observed and expected fetal red blood cell fractions in titrated samples. Fetal red blood cell counts were more reliable when samples acquired by flow cytometry contained at least 1 million red blood cells. All 37 subjects with evaluable paired samples demonstrated fetal red blood cell concentrations below the calculated threshold for Rh sensitization both pre- and post-procedure. The fetal RBC concentrations increased from a mean of 4.5 (median 0, range 0–57) fetal RBCS pre- to a mean of 8.6 (median 2, range 0–32) fetal RBCs post- per 10 million total RBCs (p Conclusions Flow cytometry was capable of separately quantifying fetal red blood cells and maternal F cells to very dilute concentrations. Fetal red blood cell exposure in the first trimester was well below the calculated threshold for maternal Rh sensitization in our cohort. Larger studies are warranted to confirm our pilot study findings, fill this evidence gap and inform universal guidelines for administering Rh immunoglobulin after first trimester uterine aspiration. Implications Fetal red blood cell exposure following first trimester uterine aspiration is well below the calculated threshold for maternal Rh sensitization in our cohort.

To document the terminology patients hear during the treatment course for a nonviable pregnancy and to ask patients their perceived clarity and preference of terminology to identify a patient-centered lexicon.We performed a preplanned substudy survey of English-speaking participants in New York, Pennsylvania, and California at the time of enrollment in a randomized multisite trial of medical management of first-trimester early pregnancy loss. The six-item survey, administered on paper or an electronic tablet, was developed and piloted for internal and external validity. We used a visual analog scale and quantified tests of associations between participant characteristics and survey responses using risk ratios.We approached 155 English-speaking participants in the parent study, of whom 145 (93.5%) participated. In the process of receiving their diagnosis from a clinician, participants reported hearing the terms "miscarriage" (n=109 [75.2%]) and "early pregnancy loss" (n=73 [50.3%]) more than "early pregnancy failure" (n=31 [21.3%]) and "spontaneous abortion" (n=21 [14.4%]). The majority selected "miscarriage" (n=79 [54.5%]) followed by "early pregnancy loss" (n=49 [33.8%]) as their preferred term. In multivariable models controlling for study site, ethnicity, race, history of induced abortion, and whether the current pregnancy was planned, women indicated that "spontaneous abortion" and "early pregnancy failure" were significantly less clear than "early pregnancy loss" (53/145, adjusted risk ratio 0.12, 95% CI 0.07-0.19 and 92/145, adjusted risk ratio 0.38, 95% CI 0.24-0.61, respectively, as compared with 118/145 for "early pregnancy loss"). "Miscarriage" scored similarly to "early pregnancy loss" in clarity (119/145, adjusted risk ratio 1.05, 95% CI 0.62-1.77).The terminology used to communicate "nonviable pregnancy in the first trimester" is highly variable. In this cohort of women, most preferred the term "miscarriage" and classified both "miscarriage" and "early pregnancy loss" as clear labels for a nonviable pregnancy. Health care providers can use these terms to enhance patient-clinician communication.ClinicalTrials.gov, NCT02012491.

Following a collaborative workshop at the 39th Annual Pregnancy Meeting, the Society for Maternal-Fetal Medicine Reproductive Health Advisory Group identified a need to assess the attitudes of maternal-fetal medicine subspecialists about abortion services and the available resources at the local and regional levels. The purpose of this study was to identify trends in attitudes, beliefs, and behaviors of practicing maternal-fetal medicine subspecialists in the United States regarding abortion. An online survey was distributed to associate and regular members of the Society for Maternal-Fetal Medicine to assess their personal training experience, abortion practice patterns, factors that influence their decision to provide abortion care, and their responses to a series of scenarios about high-risk maternal or fetal medical conditions. Frequencies were analyzed and univariable and multivariable analyses were conducted on the survey responses. Of the 2751 members contacted, 546 Society for Maternal-Fetal Medicine members completed all (448 of 546, 82.1%) or some (98 of 546, 17.9%) of the survey. More than 80% of the respondents reported availability of abortion services in their state, 70% reported availability at their primary institution, and 44% reported provision as part of their personal medical practice. Ease of referral to family planning subspecialists or other abortion providers, institutional restrictions, and the lack of training or continuing education were identified as the most significant factors contributing to the respondents' limited scope of abortion services or lack of any abortion services offered. In the univariable analysis, exposure to formal family planning training programs, fewer years since the completion of residency, current practice setting not being religiously affiliated, and current state categorized as supportive by the Guttmacher Institute's abortion policy landscape were factors associated with abortion provision (all P values.01). After controlling for these factors in a multivariable regression, exposure to formal family planning training programs was no longer associated with current abortion provision (P=.20; adjusted odds ratio, 1.34; 95% confidence interval, 0.85-2.10), whereas a favorable state policy environment and fewer years since the completion of residency remained associated with abortion provision. The results of this survey suggest that factors at the individual, institutional, and state levels affect the provision of abortion care by maternal-fetal medicine subspecialists. The subspecialty of maternal-fetal medicine should be active in ensuring adequate training and education to create a community of maternal-fetal medicine physicians able to provide comprehensive reproductive healthcare services.

Medicaid, the state-federal health insurance program for individuals with low incomes, serves as a safety net for women throughout the life span. Historically, expansions of Medicaid have been associated with improved access to health care, less delay in obtaining health care, better self-reported health, and reductions in mortality. Compared with nonexpansion states, states that have participated in the Affordable Care Act's Medicaid expansion have experienced improvements in maternal and infant mortality and decreases in uninsured rates and have decreased racial inequities for these measures. In addition to supporting policies that expand access to Medicaid, the American College of Obstetricians and Gynecologists strongly supports education for its members, other obstetrician-gynecologists, and other health care practitioners regarding the complex system for regulation of Medicaid and encourages advocacy for policies that increase access to care for all women. This Committee Opinion has been revised to emphasize the importance of Medicaid to improving women's health, the history and growth of Medicaid, including the ACA's Medicaid expansion, and the mechanisms by which changes to the Medicaid program can occur, and it includes relevant examples for each.

The Long-Acting Reversible Contraception (LARC) Program at the American College of Obstetricians and Gynecologists (ACOG) celebrated its 10th anniversary in 2018. This Viewpoint article reviews opportunities, challenges, and lessons learned by the ACOG LARC Program throughout the last decade. Housed within the largest medical organization representing women’s health providers, the LARC Program supports change by developing resources for clinicians, healthcare systems, healthcare organizations, and policy makers. The Program’s Postpartum Contraceptive Access Initiative (PCAI) meets specific needs identified by an Expert Work Group using implementation science principles, including improved contraceptive counseling and clinician training, and institution-wide sustainable systems change in billing, coding, pharmacy, and electronic medical record integration. Key lessons learned include the importance of centering patient preferences and autonomy, developing foundational evidence-based guidance, supporting practice change through implementation tools and collaboration with local champions, advocating for insurance and payment policy, and partnering with other health care organizations to develop robust resources to improve patient access to the full range of contraceptive methods.

The early medical literature on mental health outcomes following abortion is fraught with methodological flaws that can improperly influence clinical practice. Our goal is to review the current medical literature on depression and other mental health outcomes for women obtaining abortions. The Turnaway Study prospectively enrolled 956 women seeking abortion in the USA and followed their mental health outcomes for 5 years. The control group was comprised of women denied abortions based on gestational age limits, thereby circumventing the major methodological flaw that had plagued earlier studies on the topic. Rates of depression are not significantly different between women obtaining abortion and those denied abortion. Rates of anxiety are initially higher in women denied abortion care. Counseling on decision-making for women with unintended pregnancies should reflect these findings.