Special Section: Reproductive Health and Rights
SFMMS INTERVIEW Daniel Grossman, MD, FACOG Steve Heilig, MPH to access that seem to be possible with the advent of medication abortion here.
Daniel Grossman MD is a leading researcher in and advocate for improving reproductive health, widely known for his work in numerous aspects of that field. He is Professor, UCSF Department of Obstetrics, Gynecology & Reproductive Sciences and Director, Advancing New Standards in Reproductive Health (ANSIRH). He earned his MD at Stanford and did his residency at UCSF. A list of his extensive public and professional publications can be found at: https://bixbycenter.ucsf.edu/daniel-grossman-md-facog How did you first decide to devote much of your career to working in the reproductive health and abortion arena? When I was an undergrad at Yale, I got a fellowship to go to what was then called Zaire for the summer, at a very rural missionary hospital, and then in residency I did some work in Indonesia, and after I finished residency in OB/Gyn at UCSF I did some work with other organizations there. I was first interested in global health, and some of my first experiences in places like subSaharan Africa where I saw firsthand how challenges in maternal and child health caused so much morbidity and mortality and saw so many people suffering from the consequences of unsafe abortion. I was just really shocked how many were having very serious medical complications and even dying, not because we didn’t know how to diagnose or treat their problem, but because of bad policy. That really got me very interested in working at this intersection of medical care and public policy. You’ve been very focused on medication abortion, and we’re now almost 22 years since the first approval of that by the FDA. How do you see that as having played out thus far? There were immediately regulatory requirements applied to mifepristone that were codified in the REMS – Regulatory Evaluation Mitigation Strategy – and that in addition to various state laws and regulations have really limited the number of providers who can provide it and patients that can use it. That said, at least there’s been some progress at the FDA level in recent years – in 2016 the label for mifepristone was updated to be more in line with medical evidence, in particular the component concerning a requirement for in-person dispensing in a clinic, medical office, or hospital, and couldn’t be dispensed from a pharmacy or mailed to a patient. That was then suspended in 2020 due to the COVID epidemic, and in 2021 the FDA announced they would permanently get rid of the in-person requirement. That said, they added another requirement that pharmacies would have to be certified to dispense, and we’re still waiting to see the details of that policy, and how easy it will be for clinicians to sign up and start providing. So the progress has been very slow and we have not seen the hoped-for reduction in barriers 12
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Just last year it was reported that just over half of all abortions are now being provided via medication. Do you think that it would be significantly higher without these restrictions? I don’t know if it would be a lot more but do think that there would be some increase, and that there would be more clinicians who provide it. It just can be challenging and cumbersome for some clinicians who do not have a lot of these patients to order it and have it on hand.
So one improvement would be to make it available on a regular prescription basis? Yes, it should be possible to just transmit a prescription to a local pharmacy, or a mail-order pharmacy for mailing to patients. That would make a big difference.
You’ve also written about the possibility of “advance provision” of these pills; how would that work? This was something we did back when emergency contraception was only available via prescription – we would give patients a prescription or the actual pills so they could take them in advance of need so they could take it as soon as possible, and that is still done. This could theoretically be done with medication abortion as well, considering the common delays and difficulties in getting to a clinic given geographic and financial barriers. People could take them as soon as they learned they were pregnant and it's likely they could get the abortion earlier in pregnancy. This might not comply with laws in every state now, but from a medical perspective it seems it would be very reasonable to screen for some of the contraindications for medication abortions that are unlikely to change in advance when medications are given to the patient, and encourage them to call right before they are about to use it to confirm it is appropriate for them to use, and of course there could be appropriate follow-up as well. Do you think the awareness of the availability of medication abortion has altered the epidemiology of abortion, such as making more abortions occurring earlier in pregnancy to take advantage of the option? We do have some evidence that expended access to medication abortion that there was a decrease in second-trimester abortion, with some people reporting that having access to the pills was a factor. So a concerted effort to medication abortion can help people access abortion early in pregnancy. That said there will always be many who for various reasons will need to acquire an abortion after the first trimester. You mentioned telemedicine – how does that figure into this picture going forward? We now have a lot of evidence from the US and UK in particular demonstrating that telehealth provision of abortion is a model that reaches people in their homes and other places where we WWW.SFMMS.ORG
