Abstract
Early pregnancy loss (EPL) is common, but patients face barriers to the most effective medication (mifepristone followed by misoprostol) and procedural (uterine aspiration) management options. This cross-sectional geospatial analysis evaluated access to mifepristone/misoprostol and uterine aspiration in emergency departments (comprehensive) and uterine aspiration anywhere in a hospital (aspiration) for early pregnancy loss (EPL) in New Mexico. Access was a 60-minute car commute. We collected data from hospital key informants and public databases and performed logistical regression to evaluate associations between access and rurality, area deprivation, race and ethnicity. Thirty-five of 42 (83.3%) hospitals responded between October 2020 and August 2021. Two hospitals (5.7%) provided comprehensive management; 24 (68.6%) provided aspiration. Rural and higher deprivation areas had statistically significant lower adjusted odds ratios of comprehensive management (0.03–0.07 and 0.3–0.4, respectively) and aspiration (0.03–0.06 and 0.1–0.3, respectively) access. Mifepristone and uterine aspiration implementation would address disparate access to EPL treatment.
PRÉCIS:
Residents of rural or lower socioeconomic areas have lower access to mifepristone and misoprostol and uterine aspiration for early pregnancy loss in New Mexico.
Introduction
Early pregnancy loss (EPL)is common, but patients face barriers to the most effective management.1 Management options include expectant, medication (mifepristone followed by misoprostol), or procedural (uterine aspiration); patients receiving their preferred option report the highest satisfaction.1,2 However, FDA administrative hurdles limit mifepristone access,1,3 and uterine aspiration requires trained clinicians and equipment.4 We lack knowledge regarding patient access to the most effective medication and procedural management in the face of these barriers.
Our objectives were to evaluate geographic access in New Mexico to 1) mifepristone/misoprostol and uterine aspiration in emergency departments (ED’s), where patients often first present (comprehensive), and 2) uterine aspiration in the ED or operating room, in case of clinical instability (aspiration).
Methods
We performed a cross-sectional geospatial analysis to evaluate access to mifepristone/misoprostol and uterine aspiration in emergency departments (comprehensive) and uterine aspiration anywhere in a hospital (aspiration) for early pregnancy loss (EPL) in New Mexico. We compared geographic access by race and ethnicity as social constructs, rurality, and social deprivation. The University of New Mexico’s Human Research Protections Program deemed the study exempt from human subject research.
Research team members approached ED or Labor and Delivery clinical directors from all New Mexican hospitals via telephone and email for up to five attempts. Unit directors entered data on available medication and procedural options through an emailed REDCap link; research team members entered data into REDCap during telephone surveys.5 We used U.S. American Community Survey (ACS) 2019 at the census block level for the percentages of reproductive-age women in the five most prevalent demographic groups in New Mexico and a “None of the above,” separating out Hispanic self-identification from race categories.6 The ACS data and underlying census questions used the term “women,” which we also use for consistency. We utilized the Federal Office of Rural Health Policy’s definition of rural with non-metropolitan Rural-Urban Commuting Area (RUCA) codes, and obtained area deprivation index (ADI) scores from the Neighborhood Atlas.7,8
We recoded each variable into four categories. We categorized census block group by metropolitan, micropolitan, and small town RUCA codes. We divided ADI by census block group decile—least (1,2), less (3,4,5), more (6,7,8) and most deprived (9,10). For and American Indian or Alaska Native reproductive-age women—the two largest distinct historically marginalized groups in the New Mexico Census—we categorized census block groups by population quartiles. The first quartile includes the 25% of census block groups with the fewest reproductive-age women in the specified group.
We used Geographic Information System (GIS, ArcGIS 10.8.1) to calculate travel time by car from census block group population-weighted centroids to the nearest hospital using ESRI StreetMap Premium data. We defined 60 minutes travel time as geographic access in case of clinical instability, consistent with the trauma literature.9 We performed descriptive analysis of access to comprehensive management and aspiration and used SAS 9.4 for logistic regression modeling of adjusted odds ratios (aOR’s) for four independent variables: rurality, ADI, race, and ethnicity (SAS Institute, Cary, NC). We chose these potential confounding variables because of their associations with disparities in other maternal health outcomes.10
Results
Thirty-five of 42 hospitals (83.3%) responded between October 2020 and August 2021: 22/29 (75.8%) rural and 13/13 (100%) urban hospitals. Two (5.7%) hospitals offered comprehensive management, and 24 (68.6%) offered aspiration (Figure 1).
Figure 1.
Geographic access to early pregnancy loss management in New Mexico. The map shows census block groups with geographic access to mifepristone/misoprostol and uterine aspiration in the emergency department (a) and to uterine aspiration in the hospital (b) in blue. Darker shades of blue indicate shorter travel times. Red dots are hospitals that provided care.
Approximately half of reproductive-age women lived in a census block group with access to comprehensive management and 89.7% to aspiration (Table 1). More women had access to aspiration than comprehensive management across all geographic, socioeconomic and racial and ethnic categories. The largest absolute difference was access to comprehensive management in the ED between metropolitan and rural residents: 70% versus 8–11%, respectively.
Table 1.
Rurality, socioeconomics, demographics, and access to early pregnancy loss management by census block group residence among New Mexican reproductive-age women, 2020-2021
| Descriptive | Logistic regression | |||||||
|---|---|---|---|---|---|---|---|---|
| Comprehensive EPL management in ED | Uterine aspiration in hospital | |||||||
| All | Comprehensive EPL management in ED | Uterine aspiration in hospital | Unadjusted | Adjusted* | Unadjusted | Adjusted* | ||
| Characteristic | n (%) | n (%) | n (%) | Characteristic | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) |
|
| ||||||||
| Total | 461,561 (100.0) | 238,186 (51.6) | 414,129 (89.7) | |||||
|
| ||||||||
| RUCA† | ||||||||
| Metropolitan | 321,459 (69.6) | 226,403 (70.4) | 318,030 (98.9) | Metropolitan | Ref | Ref | ||
| Micropolitan | 94,355 (20.4) | 7,099 (7.5) | 62,347 (66.1) | Micropolitan | 0.03 (0.02–0.05) | 0.05 (0.03–0.07) | 0.02 (0.01–0.05) | 0.05 (0.03–0.1) |
| Small Town | 23,044 (5.0) | 2,252 (9.8) | 19,138 (83.0) | Small Town | 0.03 (0.01–0.07) | 0.03 (0.01–0.07) | 0.04 (0.02–0.09) | 0.06 (0.03–0.1) |
| Rural Area | 22,700 (4.9) | 2,432 (10.7) | 14,614 (64.4) | Rural Area | 0.04 (0.02–0.09) | 0.07 (0.03–0.1) | 0.02 (0.01–0.04) | 0.03 (0.01–0.06) |
|
| ||||||||
| ADIठ| ||||||||
| Least deprivation | 79,698 (17.3) | 56,741 (71.2) | 77,240 (96.9) | Least deprivation | Ref | Ref | ||
| Less deprivation | 145,096 (31.4) | 87,963 (60.6) | 135,701 (93.5) | Less deprivation | 0.6 (0.4–0.8) | 0.4 (0.3–0.6) | 0.3 (0.2–0.6) | 0.3 (0.1–0.7) |
| More deprivation | 144,728 (31.4) | 68,618 (47.4) | 127,674 (88.2) | More deprivation | 0.3 (0.2–0.4) | 0.3 (0.2–0.5) | 0.2 (0.08–0.4) | 0.2 (0.08–0.5) |
| Most deprivation | 83,790 (18.2) | 23,427 (28.0) | 68,218 (81.4) | Most deprivation | 0.2 (0.1–0.2) | 0.3 (0.2–0.5) | 0.1 (0.06–0.2) | 0.1 (0.05–0.3) |
|
| ||||||||
| Race and ethnicity§ | ||||||||
| American Indian or Alaska Native | 38,973 (8.4) | 18,893 (48.5) | 35,609 (91.4) | American Indian or Alaska Native∥ | ||||
| Asian | 7,054 (1.5) | 4,839 (68.6) | 6,664 (94.5) | Quartile 1 | Ref | Ref | ||
| Black | 8,092 (1.8) | 4,802 (59.3) | 6,832 (84.4) | Quartile 2 | 2.9 (2.1–4.1) | 2.6 (1.7–3.9) | 1.8 (1.2–2.6) | 1.4 (0.9–2.1) |
| Hispanic | 203,889 (44.2) | 104,158 (51.1) | 184,185 (90.3) | Quartile 3 | 11.0 (7.7–15.7) | 7.3 (4.7–11.2) | 8.4 (4.7–15.1) | 3.5 (1.8–6.8) |
| White | 133,737 (29.0) | 69,261 (51.8 | 118,062 (88.3) | Quartile 4 | 5.3 (3.8–7.5) | 5.5 (3.4–8.7) | 6.5 (3.8–11.0) | 10.1 (4.8–21.0) |
| None of the above | 69,813 (15.1) | 36,233 (51.9) | 62,777 (89.9) | Hispanic∥ | ||||
| Quartile 1 | Ref | Ref | ||||||
| Quartile 2 | 2.2 (1.6–2.9) | 2.9 (1.9–4.5) | 0.8 (0.5–1.2) | 1.03 (0.6–1.9) | ||||
| Quartile 3 | 1.3 (0.95–1.7) | 1.7 (1.1–2.6) | 0.9 (0.6–1.4) | 1.98 (1.1–3.7) | ||||
| Quartile 4 | 1.03 (0.8–1.4) | 1.3 (0.8–2.1) | 1.2 (0.8–2.0) | 2.9 (1.5–5.7) | ||||
Comprehensive management = mifepristone pretreatment to misoprostol and uterine aspiration, EPL = early pregnancy loss, ED = Emergency department, OR = odds ratio, aOR = adjusted odds ratio, CI = confidence interval, RUCA = Rural Urban Commuting Area, ADI= Area Deprivation Index. 28 observations were removed from each model because of missing ADI values.
Based on a model with independent variables: American Indian or Native Alaskan, Hispanic, RUCA and ADI.
Census block groups with given designation 1–3 = Metropolitan, 4–6 = Micropolitan, 7–9 = Small town, and 10 = Rural area. The Federal Office of Rural Health Policy considers micropolitan, small town and rural area as rural.
Census block groups with given designation. Least = ADI deciles 1 and 2; less = 3–5; more = 6–8; most = 9 and 10.
Hispanic identification separated as a group. All listed racial categories include people who identified as non-Hispanic. We use the term women to be consistent with United States Census measurement terminology.
Quartiles represent 25% of census block groups with the least (1) through most (4) numbers of reproductive-age women belonging to specified race or ethnic group. We use the term women to be consistent with United States Census measurement terminology.
Compared to metropolitan census block groups, aOR’s for comprehensive access were lower for micropolitan, aOR 0.05 (95% confidence interval [CI] 0.03–0.07); small town, aOR 0.03 (95% CI 0.01–0.07); and rural areas, aOR 0.07 (95% CI 0.03–0.1). Aspiration geographic access was similar—micropolitan, aOR 0.05 (95% CI 0.03–0.1); small town, aOR 0.06 (95% CI 0.03–0.11); and rural, aOR 0.3 (95% CI 0.01–0.06, rural area) compared to metropolitan. Compared to the least deprived (i.e., most socioeconomically advantaged) census block groups, aOR’s for comprehensive access were lower for the less deprived, aOR 0.4 (95% CI 0.3–0.6); more deprived, aOR (95% CI 0.2–0.5), and most deprived, aOR 0.3 (95% CI 0.2–0.5) census block groups. Aspiration access was similar—less deprived, aOR 0.3 (95% CI 0.1–0.7); more deprived, aOR 0.2 (95% CI 0.08–0.5), and most deprived, aOR 0.1 (95% CI 0.05–0.3).
Census block groups in the three highest quartiles for American Indian or Alaska Native reproductive-age women had higher odds of comprehensive access—Quartile 2, aOR 2.6 (95% CI 1.7–3.9); Quartile 3, aOR 7.3 (95% CI 4.7–11.2), and Quartile 4, aOR 5.5 (95% CI 3.4–8.7). For aspiration access, only the two highest quartiles had higher aOR’s—Quartile 3, aOR 3.5 (95% CI 1.8–6.8) and Quartile 4, aOR 10.1 (95% CI 4.8–21.0). Adjusted OR’s for both outcomes by Hispanic identification were smaller and not always statistically significant: increased for comprehensive access in Quartile 2, aOR 2.9 (95% CI 1.9–4.5) and Quartile 3, aOR 1.7 (95% CI 1.1–2.6), and increased for aspiration in Quartiles 3, aOR 1.98 (95% CI 1.1–3.7) and Quartile 4, aOR 2.9 (95% CI 1.5–5.7).
Discussion
Rurality and higher socioeconomic deprivation are risk factors for decreased access to the most effective comprehensive EPL management and uterine aspiration. The study was strengthened by adjusting comparisons by risks factors for other poor maternal health outcomes. However, we did not adjust for availability of abortion care provision or obstetrician-gynecologists, regional variations in preferences for expectant or procedural management, or facility type (e.g., community, academic, Indian Health Services). Potential reporting bias regarding mifepristone’s use in abortion care could lead to decreased reporting of mifepristone availability, more likely in rural and socially conservative areas. Interestingly, a few clinicians erroneously reported mifepristone availability, confusing it with misoprostol, and necessitating verification; we collected data before recent laws and court cases brought increased attention to the medication. Additionally, New Mexico is a state with relatively low population density and high poverty. However, many of the issues patients and hospitals in rural and high deprivation areas experience in New Mexico are likely generalizable to other states; national data similarly shows rural and socioeconomic disparities in other maternal health outcomes.10 Focused implementation of uterine aspiration and mifepristone/misoprostol would address these disparities. Family physicians and advanced practice clinicians can fill the access gap for aspiration.4,11 Mifepristone followed by misoprostol has few contraindications, is safe, does not require equipment or proceduralists, and is relatively inexpensive.3 To provide EPL care, we first need to determine barriers and facilitators in hospitals serving rural and socioeconomically deprived communities and then identify, understand, and evaluate implementation strategies for mifepristone/misoprostol and uterine aspiration suited for these settings.
Supplementary Material
ACKNOWLEDGEMENT:
The authors thank Cassandra Darley at University of New Mexico for logistical and regulatory guidance during the study.
DISCLOSURE OF FUNDING:
This work was supported by a grant from the University of New Mexico Department of Obstetrics & Gynecology’s Curet Grant. At the time of the study, Dr. Krashin was supported by a grant from the Society of Family Planning Research Fund (FSS19–06) and through the University of New Mexico (UNM) Center for Translational Science Center’s KL2 program under grant number TR001448. Dr. Krashin is also supported by a grant to the UNM Department of Obstetrics and Gynecology’s Curet fund. Dr. Lin receives support from the National Cancer Institutes and the Cancer Center Support Grant through Grant Number P30CA118100, and the National Institute on Minority Health and Health Disparities (NIMHD) of the NIH under award number P50MD015706. This work was also conducted as part of the University of New Mexico Women in STEM Faculty Development Fund. REDcap was provided through an award from the National Center for Advancing Translational Sciences, National Institutes of Health under grant number UL1TR001449.
Footnotes
Financial Disclosure
Jamie W. Krashin indicated that this article discusses off-label use of mifepristone, which does not have an FDA indication for management of early pregnancy loss. Eric Brannen received stipends from Dr. Yan Lin as her doctoral student. Courtney A Schreiber reports receiving payment from UptoDate. Her institution received funding from Athenium and IBX. The other authors did not report any potential conflicts of interest.
Each author has confirmed compliance with the journal’s requirements for authorship.
Presented at the ACOG’s Annual Clinical & Scientific Meeting in Baltimore, MD on May 19, 2023.
Contributor Information
Jamie W Krashin, Department of Obstetrics & Gynecology, University of New Mexico, Albuquerque, New Mexico.
Patricia Black, Department of Obstetrics & Gynecology, University of New Mexico; Lovelace Medical Center.
Eric Brannen, Department of Geography & Environmental Studies, University of New Mexico..
Charlotte Gard, Department of Economics, Applied Statistics, and International Business, New Mexico State University..
Yan Lin, Department of Geography & Environmental Studies, University of New Mexico..
Margaret Greenwood-Ericksen, Department of Emergency Medicine, University of New Mexico.
Victoria Y Trujillo, Department of Obstetrics & Gynecology, University of New Mexico.
Gillian Burkhardt, Department of Obstetrics & Gynecology, University of New Mexico.
Courtney A. Schreiber, Department of Obstetrics & Gynecology, University of Pennsylvania.
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