Editorial BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2020-200945 on 27 January 2021. Downloaded from Addressing the urgent global need for later care during COVID-19 and beyond

Nathalie Kapp ‍ ‍ ,1 Alison Edelman,2 Rebecca Gomperts,3 Karthik Srinivasan,4 Rasha Dabash1

1Ipas, Chapel Hill, North Carolina, beyond 12 weeks’ gestation Planned Parenthood Federation (IPPF) USA comprise the minority of cases globally, have for years worked to address these 2Oregon Health & Science University, Portland, Oregon, USA namely 10%–40% of all services, depending challenges and implement an experience-­ 3Women on Web International on country.1 2 Later abortions are critical to based response to meet the need for early Foundation, Amsterdam, The facilitate as their safe provision can mitigate abortion while simultaneously expanding Netherlands 4International Planned significant abortion-related­ mortality and access to later care using common 1 Parenthood Federation, London, morbidity. People seeking later abortions resources (providers, platforms, commod- UK often face financial and logistical barriers, ities and methods). These examples high- are more likely to have experienced violence, light innovative models for expanding Correspondence to and be young.1 2 access to later abortion care to meet an Dr Nathalie Kapp, Ipas, Chapel Hill, North Carolina, USA; ​ In March 2020, the World Health Orga- increased demand for services. nathaliek@gmail.​ ​com nization (WHO) declared COVID-19 a The pandemic has burdened staff and pandemic. Since then, we have witnessed supply chains at referral centres that were Received 3 November 2020 3 Revised 5 January 2021 strains on health services, travel restric- previously critical abortion providers. Task-­ Accepted 13 January 2021 tions, stay-at-­ ­home orders and physical sharing among outpatient clinics already distancing measures to curtail disease offering early abortion services could play a copyright. spread.3 The resulting disruptions in role in expanding the gestational age range supply chains, economic instability, inter- for services without requiring referral, ruptions in health services, and fear of as demonstrated by IPPF. IPPF piloted a seeking treatment have impacted both programme to leverage existing staff and the need for and access to abortion care, resources to reduce referrals for later abor- which is considered an essential service by tion from sites offering early services. The WHO.3 4 While all abortion services are pilot implemented a midwife-­led medical essential, ensuring access to later care is and MVA outpatient service for abortion crucial given the numerous barriers and beyond 12 weeks’ gestation at 18 clinics in http://jfprhc.bmj.com/ delays women face which may be exacer- six African and Asian countries. The clinics bated by the pandemic, particularly among have subsequently served 700 outpatient the most vulnerable and underserved.3 clients needing later abortion care (mean In many settings, particularly low-­ gestation 14.9 weeks) that would have other- resource and legally restricted countries, wise been referred to distant, higher-level­ accessing facility-based­ later abortion care facilities. IPPF is now incorporating addi- on September 29, 2021 by guest. Protected was challenging prior to the pandemic.1 tional innovations to reduce women’s in-fa­ - It has become even more difficult during cility time, including home-administered­ lockdowns, public transportation stop- or , cervical prepa- pages and travel restrictions.3 Strategies ration, and optional home-­administration © Author(s) (or their to mitigate the COVID-19 impact and of mailed medical abortion pills. Expanding employer(s)) 2021. Re-­use permitted under CC BY-­NC. No maintain or expand access to later abor- access to telemedicine abortion may reduce commercial re-­use. See rights tion care must draw on key innovations, in-clinic­ demand, allowing other staff time and permissions. Published by including task-sharing­ (both provider and procedure space for later in-­clinic proce- BMJ. cadre and facility level), expansion of dures while maintaining physical distancing. To cite: Kapp N, Edelman A, manual (MVA) appli- Addressing commodity supply includes Gomperts R, et al. BMJ Sex cation, use of telemedicine and accompa- in-country­ and regional partnerships with Reprod Health Published Online First: [please include niment models, and addressing challenges manufacturers and marketing organisations 5–9 Day Month Year]. doi:10.1136/ to commodity supply. Ipas and part- to offset disruptions of centralised supply bmjsrh-2020-200945 ners Women on Web and International chains.

Kapp N, et al. BMJ Sex Reprod Health 2021;0:1–3. doi:10.1136/bmjsrh-2020-200945 1 Editorial BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2020-200945 on 27 January 2021. Downloaded from Experience offering services beyond 12 weeks in abortion are generally present where early care is avail- humanitarian settings, where barriers are signifi- able, and that impact on women’s lives and health is cant, provides strategies to expand access during the greater as gestational age increases. The integration pandemic.10 Ipas and partners coordinating reproduc- of later abortion care into early services is critical for tive health services during the Rohingya humanitarian ensuring needed care both during and following the crisis found many clients seeking menstrual regulation pandemic. Incremental expansion through telemed- (missed menses treatment without confirming preg- icine, expanding cadres of providers at lower-­level nancy) or emergency services presented with uterine facilities, and providing evidence-­based methods while size beyond 12 weeks.10 Ipas trained and supported gradually increasing the gestational age range have the physicians to provide post-­abortion and indicated potential to significantly reduce barriers to essential abortion care with mifepristone and misoprostol and abortion care and decrease the stigma associated with taught MVA-expansion­ skills to treat retained placenta abortion services later in pregnancy. and aspiration abortion up to 12 weeks’ gestation. Improving the referral network and ensuring providers Acknowledgements The authors wish to acknowledge the contribution of Brittany Moore and Hilary Bracken their note-­ within and near the camps offered safe, evidence-­ taking and outline of the webinar. based care ensured that women had greater access Funding The authors have not declared a specific grant for this to care. The intervention built provider comfort by research from any funding agency in the public, commercial or expanding the gestational age limit up to 14 weeks not-­for-­profit sectors. for MVA services incrementally, 1 week at a time, Competing interests None declared. for example, from 10 to 11 weeks. The incremental Patient and public involvement Patients and/or the public expansion improved provider confidence and ensured were not involved in the design, or conduct, or reporting, or sustainability. Training, mentoring and piloting proved dissemination plans of this research. critical for provider confidence and reducing stigma Patient consent for publication Not required. 10 with expansion. As the skillset needed for medical Provenance and peer review Not commissioned; externally management of later abortion and possible complica- peer reviewed. tions is similar to obstetrical care, providers already Open access This is an open access article distributed in trained in emergency obstetrics gained confidence accordance with the Creative Commons Attribution Non Commercial (CC BY-NC­ 4.0) license, which permits others quickly. During COVID-19, the creation of a virtual copyright. to distribute, remix, adapt, build upon this work non-­ provider network may be important for supporting commercially, and license their derivative works on different providers unable to meet in person. This work demon- terms, provided the original work is properly cited, appropriate strated that experienced, early abortion providers can credit is given, any changes made indicated, and the use is non-­ efficiently transition to later gestational ages using commercial. See: http://​creativecommons.​org/​licenses/by​ -​nc/​4.​ 0/. resources already at their disposal. These providers often need support only for the logistical, legal and ORCID iD structural challenges faced when expanding services. Nathalie Kapp http://​orcid.​org/​0000-​0002-​9602-​3674 Telemedicine, as implemented for 15 years through

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