Title: Primary Care and Abortion Provider Perspectives on Mail-order Medication Abortion:
a qualitative study
Version: 7 Date: 10 May 2024
Reviewer's report:
This is a really informative paper showcasing the nuances of mail-order prescription, which
could guide implementation.
I have a few minor comments:
BACKGROUND
“Misoprostol, the second of the two medications used together to induce abortion, is not
restricted and is typically dispensed with mifepristone”
—whether misoprostol is dispensed with mifepristone varies widely since many clinics do not
operate as pharmacies. I suggest changing the words “typically dispensed” tor removing the
second part of the sentence: “Misoprostol, the second of the two medications used together to
induce abortion, is not restricted.”
“Medication abortion is a safe and effective treatment that can be provided in various clinical
settings, including via telemedicine, according to current guidelines”
Consider revising “current guidelines” as it may not be true at time of publication and in the
near future.
“Nevertheless, a case before the Supreme Court in 2024 challenges the FDA’s 2016 and 2021
actions with respect to mifepristone’s approved conditions of use, including the decision to
remove the in-person dispensing requirement.”
—this sentence is alluding to something that would be helpful to make explicit— please explain
why "nevertheless". A reader unaware of political motivation behind the SCOTUS case may
be confused. How about, “Nevertheless, a politically motivated case before the Supreme Court
in 2024 challenges the FDA’s 2016 and 2021 actions with respect to mifepristone’s approved
conditions of use, including the decision to remove the in-person dispensing requirement”
You discuss the political motivations in Results “Legal concerns” section and it would be helpful
to prepare the reader earlier on.
“The previous REMS’ in-person dispensing requirement for mifepristone meant that clinics had
to stock and monitor medications at their facilities, which was an impediment for providers,
particularly primary care providers, to offering medication abortions services. As a result, for
the last 20 years, medication abortion has been offered primarily by clinicians who were already
providing abortion procedures.”
I don’t fully follow this reasoning as written. Is it that it is easier implement medication abortion
services if you are already providing abortion services since you know you have a this treatment
demand? Id imagine other implementation challenges would be the same for the 2 different
practice settings?
“Additionally, restrictions on federal funding impedes the ability to provide abortion care for
primary care providers working in federally qualified health centers [9]”
—this is not always the case as FQHCs can provide abortion care using non-federal dollars.
How about instead of "impedes," “complicates” or “makes significantly more difficult”
may be more accurate?
Consider changing “provider” to “clinician” throughout the manuscript— I see clinicians almost
exclusively but when I see provider, I wonder if it’s a synonym or you mean a different group.
Is provider=clinicians+staff?. Ex p4
RESULTS
In this example, is the analysis correct? What do you mean by referral? If a referral is given,
then presumably it’s to a specific place? So why is the clinician confused about it? Perhaps you
mean patients were given a list of options and its wasn’t a more formal referral process? It is
possible to have a direct referral process and closed loop communication. It would be helpful
to explain what you mean as on p7 top, there’s a reference to the “referral process” which can
mean a lot of things.
“Another respondent expressed concern about patients not receiving the care they desired via
referral and her lack of ability to follow up with them,
“I would just keep thinking about how we’re doing 3 to 4 of these per month and where have
all these people been going for their care prior to this time? Are they just disappearing, are
they going to Planned Parenthood? Are they not getting care? Who knows?” (ID4, primary care
clinic). “
I found the “normalizing abortion” section of Results very powerful and succinct. I worry that
it may get lost in the results by being somewhere in the middle. Im wondering if it can be in
the beginning or end to really emphasize these points. Otherwise, the nuances of prescribing
mifepristone and using mail order pharmacy obscures the simple truth that the interviewees state
so clearly: its a drug like any other drug used to treat a condition and should be prescribed like
everything else.
DISCUSSION
“A study conducted during the COVID-19 pandemic in New Jersey, New York, and Washington
found that a single family physician could successfully provide medication abortion services
to the entire state using asynchronous online consultations and medications mailed directly to
patients [29].”
Would this single doctor have a team? It sounds reductive to give credit to one individual and
not realistic (and undermines importance of team based care)