Title: Primary Care and Abortion Provider Perspectives on Mail-order Medication Abortion:
a qualitative study
Version: 2 Date: 13 Feb 2024
Reviewer's report:
This is a qualitative study evaluating the benefits and challenges of dispensing medication
abortion drugs via a mail-order pharmacy.
Abstract:
Methods- please add context about location of the study (United States, various states)
In this sentence, “We then conducted qualitative thematic analysis of interview data,
summarizing themes related to perceived benefits and concerns about the mail-order model,
patient interest, and barriers to larger-scale implementation.” Since patients were not interviewed
for this study, it feels a bit of a stretch to include “patient interest” without more context.
Consider removing or qualifying.
Results: Authors make an effort to quantify number and types of clinicians and staff. Since the
analysis does not note any relevant findings based on these distinctions, consider removing. If
you found differences that are relevant to the findings, please describe.
Manuscript Background
Please provide additional detail for readers less knowledgeable in the politics and logistics of
medication abortion to understand how this study contributes to existing body of knowledge.
The subtext here is that mail order-prescribed mifepristone allows an entirely virtual medication
abortion process to happen; however that is really beyond the scope of this manuscript which
focuses on describing an in-clinic model with a mail order drug delivery.
1. Where does prescribing to a retail pharmacy fit in with all the ways that abortion drugs can be
given to a patient? It seems like there are a number of options: provider dispenses mifepristone
and patient swallows it, provider dispenses mifepristone and patient takes it home for later use,
provider sends prescription of mifepristone to retail pharmacy for patient to pick up and take
drug later, provider sends prescription to a mail-order pharmacy and patient receives drug by
mail. I imagine all these have their pros and cons that are clinic, patient, pharmacy and state
specific. Please be more explicit how the delivery model studied here is relevant for medication
abortion in current sociopolitical environment.
2. Where does misoprostol, the other abortion drug fit in? Is it typically prescribed via retail
pharmacy or mail-order pharmacy? Dispensed? How does that impact the workflow for the staff
and the patients?
3. Is there a precedence for dispensing other medications used in primary care settings via a mail-
order pharmacy? When is this approach  preferred to in-person clinic dispensing or prescription
sent to retail pharmacy by providers, clinic administrators or patients?
4. How prevalent are retail pharmacies and how comfortable are they participating in dispensing
of abortion drugs?
5. It would helpful to the reader if the authors could explain the required steps of medication
abortion process. Many of the quotes imply that it’s simple, can be virtual, performed by any type
of provider, yet many people are used to an in-person care model and may feel like something
important may be omitted while the participants/authors are blasé about it. Various steps are
mentioned throughout the manuscript without a simple explanation such as:confirmation of
intent to have an abortion —>eligibility determination (including gestational age determination)
—> explanation of process—>informed consent—>dispensing drugs—>ingestion of drugs
and expulsion of pregnancy—>confirmation of pregnancy resolution. Then the reader can
understand where the innovation is, namely in dispensing of drugs.
Please provide rationale for including abortion clinics in this study since their barriers for giving
patients mifepristone (and misoprostol) are quite different from those in primary care settings. In
my read, much of the focus of the manuscript is on primary care that has unique and significant
barriers: lack of support from clinic administrators, federal funding restrictions, low volume
doesn’t justify stocking/monitoring expiration, lack of training, busy providing other types of
primary care. I imagine abortion clinics are less impacted by these barriers and may still want
to offer mail order drugs, but for different reasons (efficiency, greater access, etc).
Methods:
How were clinics selected? Were there any inclusions or exclusions? Were their geographical
locations taken into account? How many of these clinics were connected to academic institutions
and research? This information would be helpful to understand real world application of
findings.
Please explain if the mail-order pharmacy was specific to this research study (and hence operated
at its best) to extrapolate findings to real world settings. Was there any consideration to work
with existing mail-order pharmacies to test real world application? A bit of context either in
Methods or in Background would be helpful.
How were the interviews with the participants conducted (in-person, video, telephone;one-on-
one, focus groups)? Do you mean perceived patient interest? How was this ascertained? Was
there an interview guide for conducting interviews? Was there iteration in the interview process?
Please clarify: “2 authors coded all the transcripts”- does it mean that each transcript was coded
by 2 people?
Results: please explain relevance of the types of participants (where they worked their roles) as it
pertains to findings. I noticed that the quotes don’t specify provider vs staff and role, participants
are sometimes referred to as person, provider, respondent, etc. implying it wasn’t remarkable.
Did the interviewer explore the practice of requiring in-person mifepristone dispensing and
swallowing the drug, when it hadn’t been a requirement? There’s an undertone of critique from
the authors when this point is made and reasons for this practice would be helpful to understand.
(Example “Increased patient autonomy and privacy", 1st paragraph).
Discussion: It would be helpful for the authors to emphasize the point that mail order dispensing
of abortion drugs expands abortion care delivery options, which in an ideal world, would co-exist
with in-person dispensing, retail pharmacy prescribing and tailored to the health care institution
and patients served. (Obviously requirement of swallowing the drug doesn’t serve anyone). This
is true for many prescription drugs!
Unfortunately, REMS/federal politics, state politics, institutional politics pose significant
restrictions to what’s possible for medication abortion specifically.
Conclusion:
"From the perspective of clinic staff and clinicians, mail-order dispensing of mifepristone
enhanced the quality of patient care experiences."
This conclusion feels too broad and glosses over a lot of the nuance presented (mail-ordering is
not for every patient or every clinical scenario). Maybe something like: From the perspective of
clinic staff and clinicians, mail order dispensing enabled clinic staff and clinicians to serve the
needs of more patients compared to their existing models of care.