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Abstract
Objectives The primary objective of this study was to assess the feasibility of initiating medical abortions in a large, academic emergency department (ED) in the United States.
Methods A retrospective case series analysis was conducted to evaluate a protocol for initiating medical abortion in the ED implemented from January 2020 to October 2023 at an academic, tertiary care hospital in California, USA. Participants included ED patients diagnosed with pregnancies in the first trimester that were undesired and who opted for medical abortion. The medical abortion protocol was collaboratively designed by a multidisciplinary team and follow-up was conducted by our institution’s gynaecology department. Data were sourced from a data repository of electronic health records and subjected to descriptive statistical analysis.
Results A total of 27 eligible patients initiated medical abortions in the ED during the study period. The cohort was diverse in terms of racial and ethnic backgrounds and almost evenly split between private and public insurance. No patients had significant complications identified in the medical record. Two patients required uterine aspiration by the gynaecology team; one patient in clinic and one during a return visit to the ED.
Conclusions Data from this case series suggest that initiating medical abortion in the ED is feasible. The ED may be considered as an additional access point for abortion care services, especially in areas where other care options are not readily available. Educational, legal and regulatory frameworks that allow emergency physicians to take a greater role in providing this care should be considered.
- abortion, induced
- family planning services
- Reproductive Health Services
Data availability statement
Data are available upon reasonable request. Data are available upon reasonable request to the corresponding author.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Emergency departments (EDs) routinely provide care for early pregnancy loss, ectopic pregnancy and complications of normal pregnancy. However, due to rising abortion restrictions in the United States and a lack of comprehensive training in emergency medicine curricula, EDs have historically not been utilised for initiating medical abortion services. This gap underscores the need for integrated abortion care within ED settings to address potential healthcare disparities.
WHAT THIS STUDY ADDS
This study demonstrates the feasibility of initiating medical abortions within an ED in the United States, showing that such services can be integrated into emergency care with no significant complications. It also reveals that a considerable proportion of patients seeking this service belong to underrepresented racial backgrounds and are insured publicly, suggesting EDs can play a pivotal role in mitigating disparities in reproductive healthcare access.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The findings encourage further research into ED-based medical abortion as a safe and effective care model, potentially reshaping practice by offering an additional access point for abortion services, particularly in restrictive environments. This model could influence policy by providing evidence to support the expansion of comprehensive reproductive health services in EDs across different regions and healthcare systems.
Introduction
In the United States (US), emergency departments (EDs) are a key source of healthcare for a substantial number of pregnant individuals, with an estimated 2.77 million pregnant patients seeking care annually.1 Among women of reproductive age visiting EDs, 6% are found to be newly pregnant, highlighting the ED’s crucial role in early pregnancy detection for both planned and unplanned pregnancies.2 However, with the increasing restrictions on abortion in the US, the ED is becoming an increasingly vital venue for family planning services.3 4 Despite the American College of Emergency Physicians (ACEP) advocating for accessible reproductive healthcare nationwide, emergency medicine training often lacks in-depth education on pregnancy disclosure and options counselling.4–6 Consequently, these services are seldom provided in EDs.4
For patients who learn of their pregnancies in the ED, the current standard of care often leads to dissatisfaction, a lack of alternatives for undesired pregnancies, and a failure to address the diverse emotional responses experienced in these situations.7 These issues are particularly pronounced among pregnant patients between the ages of 18–44 years who visit the ED, as they are disproportionately Black, Hispanic and/or of lower socioeconomic status compared with non-pregnant women.1 These groups already face significant challenges in accessing reproductive healthcare, a situation exacerbated by recent legal developments, including the Dobbs decision.8–10 Historical data indicate that half of these pregnancies are unplanned, and before the Dobbs ruling, half of these unplanned pregnancies ended in abortion.11
Medical abortion, particularly using mifepristone and misoprostol in the first trimester, is the most prevalent form of abortion in the US.12 The Food and Drug Administration (FDA) regulates mifepristone through the Risk Evaluation and Mitigation Strategy (REMS), which mandates special certification for prescribing providers and the completion of specific agreement forms.13 Before January 2023, in-person dispensing of mifepristone was required, often necessitating a clinic visit. Although dispensing has now been extended to include retail pharmacies and mail services, challenges in accessing mifepristone persist.14 Furthermore, there is a growing trend of patients, particularly those with limited access to traditional healthcare services, seeking care in EDs and urgent care clinics. The success of providing contraception in these settings underscores the potential for EDs to play a greater role in reproductive healthcare. In this context, the ED becomes a critical space for timely abortion care, given the urgent nature of these services and the potential to avoid procedural abortion. Offering medical abortion in the ED may mitigate disparities, reduce the need for subsequent outpatient visits, and facilitate timely access. Despite these potential advantages, the practicality of ED-based abortion has not yet been rigorously examined.
To meet this need, we developed a protocol for initiating medical abortion in our ED. This study is a preliminary examination of patients who received abortions through this protocol.
Methods
Study design and setting
This protocol was developed and implemented in our ED at a quaternary care hospital with more than 100 000 visits annually in California. To study the feasibility of our protocol, we completed a retrospective case series analysis from the time implementation in January 2020 to October 2023. Compliance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines was maintained.15 Ethical approval was secured from the Stanford Institutional Review Board (#67720).
Protocol development
A multidisciplinary team, comprising the ED’s clinical operations staff, hospital legal advisors, and members of the Department of Obstetrics and Gynecology with subspeciality training in abortion care (Complex Family Planning), collaboratively developed a medical abortion protocol. This protocol was rooted in clinical practice guidelines provided by the American College of Obstetricians and Gynecologists (ACOG).16 A more conservative gestational age cut-off of 9 weeks was requested by our hospital’s legal team. Additionally, we specified that a transvaginal ultrasound, quantitative human chorionic gonadotropin (hCG) and Rhesus (Rh) typing be performed as part of the protocol. Though these elements are not universally required for medical abortion, these are ordered as part of standard practice for first-trimester patients without a confirmed intrauterine pregnancy in our ED. A decision-making flowchart was created to assist clinicians in initiating medical abortion (figure 1).
Flowchart detailing the steps of the Stanford emergency department medical abortion protocol. ED, emergency department; hCG, human chorionic gonadotropin.
An educational didactic for ED faculty and residents was developed, focusing on options for counselling, medical abortion specifics and procedural flowcharts (online supplemental appendix 1). Prior to the study, only 10.3% of ED physicians reported discussing pregnancy options with patients.17 Clinicians were encouraged to probe into patients’ attitudes toward their pregnancies. Consultations with gynaecologists were initiated for patients interested in abortion. After obtaining informed consent for medication administration, mifepristone was prescribed by a REMS certified gynaecologist. A prescription and instructions for misoprostol administration was provided. Follow-up was coordinated by the Complex Family Planning service, which consists of gyneacologists at our institution with subspeciality training in abortion.
Supplemental material
Selection of participants
To evaluate protocol implementation, we identified and examined ED patients who received mifepristone for medical abortion during the study period. We did not include patients who received abortifacient medications for other clinical purposes, such as the medical management of miscarriages.
Measurements
Data were sourced from the Stanford Medicine Research Data Repository (STARR), containing records from Stanford Healthcare.18 Using STARR, we identified patients who were administered mifepristone in the ED within the study timeframe and excluded those with other indications. A structured abstraction form was developed to capture relevant variables from the electronic health record data. These included self-reported race, ethnicity and gender of patients; the primary insurance type associated with the ED visit as noted in the medical record; obstetric history, the reason for the visit, and the patient’s awareness of their pregnancy as recorded by the ED or gynaecologic provider. Gestational age, determined either by ultrasound or the date of the last menstrual period, and any follow-up care detailed in later clinical notes were also included. Data abstraction was performed by one author (CP) and cross-verified by another author (MS) for accuracy. Reviewers were aware of the study aims. A third author (AH) independently reviewed charts for gestational age, obstetric history, previous abortions and cases of representation to the ED to evaluate inter-rater reliability. Agreement was substantial to perfect (κ=0.76–1).
Outcomes
We examined the number of ED-initiated medical abortions and any complications noted during follow-up. We also collected data on prior awareness of pregnancy and post-abortion contraception initiation. Data extraction relied on medical records, including provider and nursing notes, telephonic communications, and laboratory results. Post-ED visit documentation was scrutinised for insights into abortion completion or complications. Cases with no subsequent entries in our healthcare system were treated as lost to follow-up, and any missing data were explicitly documented.
Analysis
Data collected through the structured abstraction forms were compiled using Microsoft Excel for Mac version 16.78. Descriptive statistical analyses were conducted using R version 4.3.0 (R Foundation for Statistical Computing, Vienna, Austria).
Patient and public involvement
The research question and outcome measures of this study were developed with the recognition of the ED’s role as a critical setting for identifying new pregnancies and the need for accessible reproductive healthcare, especially in the context of rising national abortion restrictions. As this study was retrospective, patients were not directly involved in the design or recruitment process beyond their consent for medical abortions.
Results
Patient characteristics
During the study period, 27 patients initiated medical abortions in the ED as detailed in table 1. The median age of the cohort was 24 years, with an age range spanning from 15 to 41 years. Gestational duration at the time of the ED visit had a median of 5 weeks and 6 days, with a range extending from 4 weeks and 3 days to 8 weeks and 5 days. In terms of racial and ethnic demographics, the majority of patients identified with a racial category not classifiable as White, Black or Asian (13/27, 48%), while a significant portion identified as Hispanic/Latino (12/27, 44%). Insurance status among participants was nearly evenly divided: 52% (14/27) were privately insured whereas 48% (13/27) were publicly insured.
Characteristics of patients (N=27) who initiated medical abortion in the emergency department 2020–2023
Clinical presentation and diagnosis
Of the total, 48% (13/27) were diagnosed with a new pregnancy during their ED visit. Among the others, 33% (9/27) came to the ED following a positive at-home pregnancy test, which was subsequently confirmed in the ED. A total of 52% (14/27) of the participants were primigravida and 37% (10/27) participants previously had an abortion. The predominant reasons for seeking ED care included abdominal pain (10/27, 37%), issues directly related to pregnancy, which were most commonly a positive home pregnancy test, (8/27, 30%) and nausea or vomiting (6/27, 22%). An ultrasound to confirm intrauterine pregnancy was obtained in 26/27 (96%) of patients. The patient who did not receive an ultrasound in the ED had a previously confirmed intrauterine pregnancy from another facility.
Follow-up and clinical outcomes
Follow-up data were available for at least 3 months following medical abortion for all patients. Post-discharge, 89% (24/27) of patients were successfully contacted for follow-up. Subsequent care involved an ultrasound examination in 41% (11/27) of cases. Additionally, 30% (8/27) of patients underwent repeated laboratory testing and 19% (5/27) verified pregnancy status with a home pregnancy test. Notably, two patients required a uterine aspiration procedure after medical abortion. The first patient returned to the ED due to significant pain following misoprostol administration and underwent a uterine aspiration in the ED. The second patient was evaluated in the gynaecology clinic 2 months post-medical abortion for persistent minor vaginal bleeding and was found to have retained products of conception via diagnostic uterine aspiration. No instances of significant bleeding or infectious complications related to medical abortion were observed in our study cohort. Long-acting reversible contraceptives (LARCs) (six intrauterine devices and one implant) were placed at follow-up appointments for 26% (7/27) of patients.
Limitations
This pilot study has several limitations. We report on a small number of patients and use a retrospective design. Our patient population and the resources available in our tertiary academic healthcare system with an on-call Complex Family Planning section may limit the generalisability of this pilot programme and results. Although our health record allows us to view encounters with many facilities in our region, we cannot exclude the possibility that patients presented with complications from abortion at other hospital systems. Finally, we practise in a state where abortion is protected and covered by state Medicaid, a government-funded programme designed to provide healthcare coverage to low-income individuals; alternative interventions would need to be developed for EDs in states with abortion restrictions.
Discussion
The findings of this pilot study demonstrate that initiating medical abortion in the ED is feasible. This aligns with the growing recognition of EDs as pivotal access points for reproductive healthcare, especially for populations disproportionately impacted by healthcare disparities. Moreover, in this cohort initiating medical abortion in the ED, 48% of the pregnancies were first identified during the ED visit, further emphasising the ED’s role in early pregnancy management.
Our pilot programme successfully initiated medical abortion in 27 patients, with a majority coming from underrepresented racial backgrounds and a near-even distribution between public and private insurance. These demographics suggest that the programme reached a diverse patient population. Notably, none of the patients re-presented with significant bleeding or infectious complications. Although our study was not powered to detect complications, our findings align with the reported low complication rate of medical abortions in the literature.19 Our follow-up rate was high at 89%, reinforcing the feasibility of ED-initiated medical abortion care.
Given the recent policy changes and legal restrictions affecting access to abortion services, the potential for EDs to offer medical abortion could have substantial public health implications. The initiative is particularly impactful for Black and Hispanic patients and those of lower socioeconomic status, who face systemic barriers to reproductive healthcare access. Further, the convenience of initiating abortion care in the ED potentially eliminates the need for multiple outpatient visits, thereby expediting access to this time-sensitive intervention. Finally, although we did not encounter any known cases of pregnancy as a result of sexual assault in our pilot, medical abortion through the ED could be included in our institution’s Sexual Assault Forensic Examination (SAFE) pathway for instances when emergency contraception may not be effective.20
From a policy perspective, the current study offers an alternative healthcare delivery model that could be more widely adopted. Given the nationwide shift toward restricting abortion access, offering such services in emergency settings can be an important step toward mitigating healthcare disparities. It also supports the stance of organisations like the American College of Emergency Physicians, which advocates for comprehensive reproductive healthcare services in emergency settings.6
Future research should focus on broader implementation to validate the safety and efficacy of ED-initiated medical abortions. Although we did not rigorously examine provider, staff and patient perspectives on initiating abortion in the ED, we did not encounter any instances of negative emotional reactions to the protocol. As our institution broadly supports access to abortion as essential healthcare, our providers views or their willingness to express negative sentiment towards abortion may not be typical of other institutions. Qualitative studies could provide valuable insights into patient and provider experiences and satisfaction, thereby helping to further refine the model. Moreover, research should explore the adaptability of this approach in different types of healthcare systems, including those in states with restrictive abortion laws.
In our pilot programme, ED physicians were assisted by on-call gynaecologists to administer medical abortions. However, this support structure is not commonly found in many EDs, particularly in less well-resourced departments. As mifepristone becomes increasingly utilised for early pregnancy loss management and medical abortions, it is important to consider the development of training programmes. These programmes would aim to enable ED physicians to independently and safely administer these medications, facilitating broader implementation across various settings.
Initiating medical abortion in the ED appears to be feasible, with the potential to address significant healthcare disparities. This pilot study provides preliminary data that could guide further research and policy formulation aimed at making reproductive healthcare more equitable and accessible.
Data availability statement
Data are available upon reasonable request. Data are available upon reasonable request to the corresponding author.
Ethics statements
Patient consent for publication
Ethics approval
This study involved human participants and was approved by Stanford University IRB: #67720. This was a retrospective chart review.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @dochenkel
Contributors CP, MS, and AH conceived of the study and designed the study protocol. CP performed data collection, which was verified by MS and AH. CP completed data analysis. All authors participated in the drafting of the manuscript, contributed substantially to its revision, approved the final version of the manuscript, and agree to be accountable for their contributed work. CP takes responsibility for the paper as a whole.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.