Methodology and Participants Managing early pregnancy loss in primary care: Findings from mixed-method research with family physicians trained in uterine aspiration Lisa Maldonado, MPH, Diana Romero, PhD, MA, Gabrielle deFiebre, MPH, Linda Prine, MD Reproductive Health Access Project Background Results Training Many of the participants noted that they either got no training in the skills needed to provide miscarriage care (ultrasound, MVA, medication administration), or their training was inadequate. Even if a participant had received some training in MVA or ultrasounds, they reported feeling as though they would not be comfortable providing the service because of their level of competency in these skills. "I did get trained [in ultrasound] in residency and I don’t think to a level that would be kind of competent.” Comfort with expectant management, but referral for more treatment Almost all of the physicians reported managing miscarriage with expectant management, and expressed that they were comfortable providing this service. Those providing only one or two treatment options noted that if their patient needed further treatment beyond expectant or medication management, that they would refer their patients to another provider. Oftentimes the other providers were OB/GYN physicians with whom they had a professional relationship with, were affiliated with, or had a trusting, good relationship with. "I would say the truth is I think my OBGYN colleagues are really pretty fabulous...And so I do feel really lucky that my patients, I can hook them up with good people and they’ve had good experiences.” Materials needed The presence of an ultrasound seems to be important to physicians. Not having an ultrasound at all or for only some of the time was reported as a problem or something that physicians would need to have in order to provide more comprehensive miscarriage care. Without an ultrasound, physicians stated that they would have to send their patients elsewhere for that part of their care. Having to send a patient out for an ultrasound makes it easier to then send the patient outside of the clinical practice for their entire bout of care       Physicians answers also reflected the need for physical items, like materials and space, in order to provide MVA or medication. Without adequate space to perform procedures, physicians felt that providing MVAs was not possible. Blurred boundary between abortion and miscarriage care Miscarriage care is a valuable service Miscarriage is a common medical need 15% of all pregnancies end in miscarriage1 3 outpatient treatments exist for miscarriage2 Expectant management (“watch and wait”) Medication management (misoprostol) Uterine evacuation using manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA) Medication and MVA/EVA also used for early abortion Miscarriage management (MM) is within practice scope for family physicians (FPs)3 FPs provide comprehensive care for patients of all ages3 FPs often practice in underserved areas4 Table 1: Type of MM provided n (%) Expectant management (n=236) 184 (78.0) Medication management (n=235) 111 (47.2) MVA management (n=232) 26 (11.2) Objectives Investigate the factors that either facilitate or prevent family physicians (FPs) who were trained in early abortion to provide miscarriage management (MM) Table 2: [Bivariate Analysis] Provision of MM Type by Prenatal Care, Abortion Care, IUD Provision and On-site Ultrasound Provide Expectant Management Provide Medication Management Provide MVA Management Prenatal Care Yes 97.1*** 63.2*** 17.2** No 52.0 25.3 3.1 Abortion Care 95.1** 97.6*** 46.3*** 75.3 36.6 3.8 IUD 83.1*** 52.2*** 12.3 41.4 10.7 3.6 Ultrasound on-site 85.0** 56.7** 19.5*** 70.7 37.4 2.6 Methodology and Participants Mixed-methods study Study participants came from respondents of previous survey of family medicine residents who graduated between 2007-2012 from residency programs that offered training in early abortion care Qualitative portion Conducted in-depth telephone interviews with FPs (n=15) who stated on previous survey that they planned to provide MM but not abortion care post-residency Interviews were transcribed and then coded in Dedoose analysis software Quantitative portion Survey developed based on the themes found in qualitative interviews Survey sent via email and mail to entire pool of FPs who responded to post-residency survey (n = 505) 256 responded (RR = 50.7%) Excluded 12 participants from analysis who were not practicing at all or within field Survey question domains pertained to FPs’: Clinical practice Reproductive health care services provided MM practices, including barriers and enablers to care Univariate and Bivariate analyses conducted in SPSS Most FPs were providing expectant management, while almost half were providing medication management, and a small percentage were providing MVA management. Those providing prenatal care or abortion care, or those with on-site access to an ultrasound machine were significantly more likely to provide each management option. Respondents who provided IUDs were also significantly more likely to provide expectant management and medication management, but not MVA management. * p < 0.05; ** p < 0.01; *** p < 0.001 Conclusions and Recommendations MM is within the scope of practice for family physicians, but more treatment options could be provided if barriers are overcome Transitioning miscarriage care from the ER to primary care settings requires strengthening FP training in all three treatment options and addressing logistical requirements in clinical settings Need to ensure residency programs are adequately training their FPs in all skills necessary to provide MM Provide support to FPs post-residency to overcome barriers with integrating MM care Expand access to ultrasounds in community clinical practices. REFERENCES: (1)Hemminki E. Treatment of miscarriage: current practice and rationale. Obstet.Gynecol. 1998 Feb 1998;91(2):247-253; (2) Prine LW, MacNaughton H. Office management of early pregnancy loss. Am.Fam.Physician 2011 Jul 1, 2011;84(1):75-82; (3) Dehlendorf C, Brahmi D, Engel D, Grumbach K, Joffe C, Gold M. Integrating abortion training into family medicine residency programs. Fam.Med. 2007 May;39(5):337-342; (4) Fryer GE, Green LA, Dovey SM, Phillips RI,Jr. The United States relies on family physicians unlike any other specialty. Am.Fam.Physician 2001 May 1;63(9):1669.