1. 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 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 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 Feb 1998;91(2): ; (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 May;39(5): ; (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.