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Two Steps Forward, One Step Back:� Updates in Family Planning

Jessika Ralph, MD MSCI FACOG

Grand Rounds for the Department of Obstetrics, Gynecology, and Women’s Health

April 19, 2022

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I have no financial disclosures.

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Objectives

Review the use of many new contraceptives
Discuss the use of anti-D immune globulin for the prevention of Rh sensitization in first trimester abortion
Highlight the improved availability of medication abortion
Discuss the legal challenges to abortion care in the US

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Goals

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Contraception

Legislation

Abortion

Annovera

Nexstellis

Slynd

Phexxi

Rh testing

SB8

https://pngtree.com/freepng/

doctor-cartoon-female_2991411.html

https://thenounproject.com/

term/bullhorn/8177/

Virtual Care

Twirla

Dobbs

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Contraception

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Contraception Update Highlights

A new estrogen!
A new progestin-only pill!
A low-dose combined hormonal patch!
A vaginal ring contraceptive that can be used for a year!
A new non-hormonal option!

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Slynd

Once daily pill containing 4mg drospirenone, taken in a 24/4 fashion

https://exeltisusa.com/our-womens-health-products/

Palacios S, Regidor PA, Colli E, et al.

Euro J of Contraception and Reproductive Health 2020.

Slynd is a new progestin only pill approved by the FDA in June 2019 and produced by Exeltis.

Remember that drospirenone is a newer (4^th generation) progestin, and has anti-mineralocorticoid and antiandrogenic activity, unlike the typical progestins used in progesterone-only contraceptives such as norethindrone (first generation), levonorgestrel (second generation), norgestimate (third generation), and medroxyprogesterone (a pregnane).

The main advantage to slynd is that drospirenone has a 30 hour half-life, so this pill formulation, unike micronor, has a 24h missed pill safety window. Also unlike older progestin-only pill formulations which do not have a hormone-free interval, Slynd has 4 placebo pills to induce a withdrawal bleed. The bleeding profile is improved compared to older progestin-only formulations; over time, patients had fewer or no scheduled bleeding days (during the 4 placebo pills), and about 40% of patients had unscheduled bleeding.

DRSP does not affect clotting factors or alter thromboembolic risk. Slynd has a Pearl Index of approximately 4.0, meaning if 100 people used Slynd for contraception for 1 year, 4 of them would experience a contraceptive failure (4 per 100 woman-years of use). This is a failure rate similar to combined hormonal contraceptives.

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Nextstellis

Once daily pill containing drospirenone 3mg and estetrol 14.2mg, taken in a 24/4 fashion

https://www.maynepharma.com/media/2654/mayne-pharma-annual-report-2021-web.pdf

Creinin MD, Westhoff CL, Bouchard C, et al. Contraception 2021.

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Estetrol

Produced by the human fetal liver
No effect on coagulation factors and limited effect on lipids

Fruzzetti F,, Fidecicchi T, Montt Guevara MM, Simoncini TJ Clinical Med 2021.

Ethinyl estradiol (EE) has been the primary estrogen used in combined oral contraceptives (COC) since the 1960s, primarily because of its high oral bioavailability, long half-life, and high potency, which allows small doses to be effective. As we all know, ethinyl estradiol has significant drawbacks, namely endothelial and hepatic effects that cause increased risks of blood clots, hypertension, and cardiovascular complications.

Estetrol, or E4, is a natural estrogen produced exclusively by the human fetal liver, though plant sources are used for clinical manufacturing. Unlike ethinyl estradiol, estetrol has little effect on lipid profiles, no effect on coagulation factors, and doesn’t interact with the cytochrome p450 system. Estetrol also has a much more limited effect on breast tissue, but the clinical data with regard to breast cancer risk remains limited at this time.

Its half life is approximately 30 hours.

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Twirla

Once weekly birth control patch containing 2.3mg ethinyl estradiol and 2.5mg levonorgestrel

Nelson AL, Kaunitz AM, Kroll R, et al. Contraception 2020.

https://www.twirla.com/hcp/

Twirla is a new weekly combined hormonal contraceptive patch, approved by the FDA in February 2020 and produced by Agile Therapeutics. Twirla was designed to address the need for a low-dose transdermal contraceptive. The current competitor contraceptive patch (xulane) exposes the user to 60% more ethinyl estradiol than a 35mcg EE contraceptive pill. Twirla is designed to administer approximately 30mcg EE and 120mcg LNG daily.

In the phase 3 SECURE trial, 2032 patients demonstrated that the Twirla patch had a pearl index of 5.8, or fewer than 6 failures per 100 people over 1 year of use. The failure rate did increase in participants with BMI > 30. Most common side effects were nausea and headache, and overall the patch demonstrated similar tolerability to other combined hormonal contraceptives of comparable dose.

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Phexxi

On-demand, non-hormonal vaginal gel containing lactic acid (1.8%), citric acid (1%), and potassium bitartrate (0.4%)

https://www.today.com/health/fda-approves-first-non-hormonal-contraceptive-gel-here-s-how-t185616

Thomas MA, Chappell BT, Maximos B, et al. Contraception 2020.

Phexxi is an on-demand, non-hormonal, pH-balanced vaginal gel, approved by the FDA in May 2020 and produced by evofem biosciences. The buffers in the gel maintain the vagina’s acidic pH and reduce sperm motility. Unlike previous non-hormonal spermicidal gels that contain surfactant which may increase infection risk of certain STIs, Phexxi may have microbicidal properties and be protective against sexually transmitted infections; studies evaluating this are onging.

In a Phase 3 study, a total of 1384 participants demonstrated that the use of Phexxi was associated with an 86% effectiveness at preventing pregnancy. Most common reported side effects were vaginal irritation.

Phexxi comes in individual single use applicators and can be inserted into the vagina up to an hour before intercourse. It is currently only available via prescription.

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Annovera

Silicone elastomer vaginal system containing 103mg segestrone acetate and 17.4mg ethinyl estradiol designed for cyclic monthly use up to 1 year

https://www.popcouncil.org/research/

one-year-contraceptive-vaginal-ring

Jensen JT, Edelman AB, Chen BA, et al. Contraception 2018.

2.25in

Created by the Pop Council, Annovera is the first year-long vaginal ring contraceptive, approved by the FDA In August 2018 and produced by TherapeuticsMD. It is a reusable, silicone, flexible ring containing segestrone acetate and ethinyl estradiol, designed for cyclic 3 weeks in/1 week out use. Unlike NuvaRing, it does not require refrigeration for storage when it is not in use. It is 56mm in total diameter, only 2mm larger than NuvaRing, and releases hormone at almost identical daily rates. Because it is made of silicone, it should not be used with silicone- or oil- based lubricants or vaginal medications.

Phase 3 clinical trials enrolled 2308 women across 27 sites in the US, Latin America, Europe, and Australia, demonstrating a Pearl Index of 2.98, or fewer than 3 contraceptive failures per 100 woman-years of use, demonstrating excellent contraceptive efficacy.

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Segestrone Acetate

(Nestorone®)

Next generation progestin
Derivative of 19-norprogesterone
No androgenic or anabolic activity

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https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/209627s000lbl.pdf

Kumar N, Koide SS, Tsong Y, Sundaram K. Steroids 2000.

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In the Works…�NES/T Contraceptive Gel

Created by the Pop Council
Currently in Phase 2 clinical trials

https://www.popcouncil.org/research/nestorone-testosterone-transdermal-gel-for-male-contraception

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Updates to Mirena 52mg LNG IUD

Now FDA-approved for contraception for 7 years of use!

https://www.mirena-us.com/about-mirena/mirena-effectiveness

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Abortion

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Abortion Update Highlights

Do we really need rhogam in the first trimester?
Medication abortion goes virtual, and gets popular

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No Rhogam if <8 Weeks Gestation

Clinical guidance in many countries, including the Denmark, the Netherlands, and Sweden, does not recommend Rhogam administration during first trimester abortion
Current evidence, though limited, suggests that during first trimester abortion feto-maternal hemorrhage does not reach the threshold for sensitization

It has long been the guidance of ACOG and the Society of Family Planning that any Rh negative woman receive rhogam if undergoing induced abortion. But do we really need to do that?

These recommendations were based on limited, old data which did demonstrate evidence of feto-maternal hemorrhage in first trimester abortion, but estimation of gestational age was unclear, outdated abortion methods such as sharp curettage were used, and Kleihauer-Betke testing was used to estimate the amount of hemorrhage, a test which has methodological limitations as it detects both maternal and fetal F cells and may overestimate hemorrhage volume. Furthermore, these studies were not powered to determine if the detected feto-maternal hemorrhage resulted in Rh sensitization.

In 2020, the National Abortion Federation changed their Clinical Policy Guidelines, stating that patients less than 56 days gestation may forgo Rh testing and rhogam administration, given their review of the evidence did not support a risk of Rh sensitization. This was based on the following evidence: first, a review of clinical guidance from many countries, including the Netherlands, Denmark, and Sweden, revealed that testing and treatment for Rh negative status is not routinely recommended at various points in the first trimester, either for pregnancy care in general or specifically in reference to induced abortion. Importantly, an epidemiologic study comparing rates of Rh sensitization in the Netherlands, where women having an induced abortion < 7 weeks and a spontaneous abortion < 10 weeks are not tested or treated, to Canada, where all patients with any first trimester abortion are tested and treated, did not find a difference in Rh sensitization between the countries. (The countries do have similar rates of fertility, abortion, and Rh negative status.)

Second, amongst a study of patients presenting with both spontaneous and induced abortion, no patients (of the 23 in the study) presenting below 8 weeks gestation had a feto-maternal hemorrhage of a volume sufficient for sensitization. Furthermore, in the most recent study to date, using flow cytometry, which is more accurate than traditional Kleihauer-Betke testing, amongst 28 patients experiencing abortion < 12 weeks, no participant reached the threshold for Rh sensitization.

Taking all of this together, the National Abortion Federation changed its recommendation, stating that “it is reasonable to forego Rh testing and anti-D immunoglobulin for patients undergoing any type of induced abortion before 8 weeks, as prior to this, this likelihood of fetal-maternal hemorrhage adequate to cause sensitization is negligible.”

Furthermore, given that medication abortion is more similar to spontaneous abortion with less risk of feto-maternal hemorrhage, forgoing Rh testing and anti-D immunoglobulin for medication abortion under 10 weeks may also be considered.

The Society of Family Planning is funding a larger, ongoing clinical trial investigating the volume of fetal-maternal hemorrhage in patients using medical abortion up to 10 weeks.

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Soooo… Virtual Abortion Care?

https://www.wholewomanshealth.com/abortion-care/abortion-medication-by-mail/

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The FDA Risk Evaluation and Mitigation Strategies

FDA restrictions “to ensure the benefits outweigh the risks of a particular drug”

mifepristone cannot be sold in retail pharmacies
prescribers must be certified
patients must sign the FDA-approved patient agreement

https://www.earlyoptionpill.com/wp-content/uploads/2016/03/Patient-Agreement-Form-March2016-1.pdf

Mifepristone is a drug specially regulated by the Food and Drug administration under a program called “Risk Evaluation and Mitigation Strategies,” or REMS. REMS ensures that drugs with known serious adverse events are handled and used safely. For example, clozapine, an antipsychotic, is under a REMS restriction because of the risk of severe neutropenia: pharmacists must verify that patients have had a recent neutrophil count prior to dispensing the drug.

The REMS restrictions for mifepristone include:

mifepristone may only be dispensed in clinics, medical offices, and hospitals under the supervision of a certified prescriber, and may not be sold in retail pharmacies
prescribers must become certified by verifying to the drug distributor that they are able to assess gestational age, rule out ectopic pregnancy, and provide or refer for surgical intervention as needed
women using mifepristone must sign the FDA-approved patient agreement that describes the use instructions and drug risks (ie, off-label use is completely restricted)

However, extensive clinical experience with mifepristone, as well as over 15 years of research, has demonstrated that mifepristone is not inherently toxic or harmful to the person who uses it. The risks the REMS are designed to mitigate are heavy vaginal bleeding and infection, are both rare complications of medical abortion, and are not unique risks to the condition or the treatment. Furthermore, the specific restriction on dispensing sites does not mitigate these risks.

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Advocacy and Research in Action

https://www.aclu.org/cases/american-college-obstetricians-and-gynecologists-v-us-food-and-drug-administration

https://www.aclu.org/press-releases/fda-announces-long-sought-after-review-harmful-restrictions-medication-abortion

nytimes.com/2021/12/16/health/abortion-pills-fda.html

May 2020

May 2021

December 2021

The COVID-19 pandemic highlighted how many services could safely be provided virtually, and sparked the mifepristone movement. In May 2020, the ACLU, on behalf of ACOG, CUCOG, the New York State Academy of Family Physicians, and Sistersong, sued the FDA over the in person dispensing requirement. In July, the federal judge ruled in favor of the plaintiffs and enjoined the dispensing requirement, allowing for mifepristone via mail-order pharmacy. The Trump administration did launch a series of appeals to these decisions, leading the case to the Supreme Court, who ruled in favor of the REMS requirements in January 2021.

However, in April 2021, the FDA themselves announced that they would not enforce the in-person dispensing requirement based on the safety data gathered during the COVID-19 pandemic which did not find an increase in adverse outcomes when patients received the medication by mail; the following month, in May, they announced they were officially reviewing the REMS requirements for mifepristone.

The overwhelming evidence, which we’ll take a closer look at in a moment, has shown that virtual dispensing of mifepristone did not increase adverse events convinced the FDA to remove the in-person dispensing requirement in December of 2021. However, the remaining REMS are still in effect, and guidelines on pharmacy access have not yet been developed.

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Patients Can Now Get Mifepristone By Mail… Unless

https://www.kff.org/policy-watch/medication-abortion-telemedicine-innovations-and-barriers-during-the-covid-19-emergency/

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Half of Abortions Are Accomplished with Mife/Miso

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But… is it safe?

Jan-Mar 2020

Traditional, in-person medication abortion

(22,158)

Apr-Jun 2020

Traditional and telemedicine medication abortion

(29,984)

Eligibility criteria for no-test medication abortion:

Known LMP
Regular menses
No use of hormonal contraceptives or breastfeeding in the last 3 months
History of ectopic
History of tubal surgery
Absence of pelvic pain and vaginal bleeding

Aiken ARA, Lohr PA, Lord J et al. BJOG 2021.

So now I have told you that virtual administration of medication abortion, meaning abortion without imaging or testing, is legal, available, and popular, you might be wondering… is it as safe and effective as in-person medication abortion? Well, let’s look at some data!

A retrospective cohort study from 2020 in Great Britain compared 22,158 patients that accessed medication abortion at less than 10 weeks gestation pre-pandemic to 29,984 patients that accessed medication abortion during the pandemic. Between April and June, in order to reduce the number of patients being seen in person, patients could receive a virtual consultation, and if they met the following eligibility criteria, they were able to receive their medications by mail without ultrasound or testing:

-known LMP in a person with regular menses who is not using contraceptives or currently breastfeeding, and without risk factors for ectopic pregnancy, such as a history of ectopic pregnancy, tubal surgery, or ongoing symptoms of ectopic pregnancy

Any patients that did not meet criteria for no-test abortion were referred for ultrasound. Of the 29,984 patients that sought medication abortion between April and June, 18,435 met criteria for telemedicine abortion.

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Aiken ARA, Lohr PA, Lord J et al. BJOG 2021.

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Aiken ARA, Lohr PA, Lord J et al. BJOG 2021.

Without ultrasound, providers appropriately worry that rates of ectopic pregnancy will be significantly higher, and patients may present too late for medication abortion to be efficacious. When comparing cohorts, again, rates of ectopic pregnancy were identical (and low, less than 1%, consistent with known rates of ectopic among patients seeking abortion care), and most were identified before receiving medication abortion. Amongst the hybrid cohort, less than 1% of patients were found to be > 10 weeks at the time of medication abortion. None of those patients had complications from using mife/miso at home.

Furthermore, acceptability of this model of care was high in the April-June cohort (96%).

Therefore, the authors concluded that a hybrid telemedicine model for medication abortion is effective, safe and acceptable.

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Upadhyay UD, Raymond EG, Koenig LR, et al. JAMA Internal Medicine 2022.

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Upadhyay UD, Raymond EG, Koenig LR, et al. JAMA Internal Medicine 2022.

75% of the cohort was identified for followup. (Multiple imputation was used to calculate the “adjusted imputed rate” - imputation aims to allow for the uncertainty about the missing data by creating several different plausible imputed data sets and appropriately combining results obtained from each of them)

95% of identified patients had a successful medication abortion without additional intervention. Approximately 1.5% required additional misoprostol, and the remaining 3.5% required an aspiration or other surgical procedure to complete their abortion. Again, true to prior studies of ectopic pregnancies in people seeking abortion care, only 4 participants in the study underwent treatment for ectopic pregnancy.

12 patients, <1% of the total, experienced an adverse event, most commonly a blood transfusion.

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Upadhyay UD, Raymond EG, Koenig LR, et al. JAMA Internal Medicine 2022.

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Easy, Safe, and Effective!

https://www.wholewomanshealth.com/abortion-care/abortion-medication-by-mail/

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Legislation

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Legislation Update Highlights

How Texas prevailed and banned abortion
Will SCOTUS overturn Roe?

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Texas SB8

As of September 1, 2021:

Abortions may not be performed if the pregnancy has detectable fetal cardiac activity
Providers of abortions or those that aid in a person obtaining an abortion suspected to be in violation of this statute may be sued in civil court by private citizens for up to $10,000

https://www.guttmacher.org/article/2021/11/new-evidence-texas-residents-have-obtained-abortions-least-12-states-do-not-border

Texas Senate Bill 8, a bill banning pre-viability abortions, was signed into law on May 19, 2021, and took effect on September 1. The key provisions of the law are:

Abortions are legal only if there is no detectable fetal cardiac activity. There is an exception for “medical emergencies” but what constitutes an emergency is not defined in the statute.
Any person who is NOT an agent of the state (ie, private citizens) may bring civil action against the physician or anyone that helps the pregnant person obtain an abortion, for up to $10,000.

This legal strategy is novel because previous abortion bans were enforceable by the state, so providers could sue the state on behalf of their patients to challenge the law’s constitutionality. However, because private citizens are now empowered to enforce the abortion ban in civil court, there is no clear route for providers to challenge the law, as they would be suing private citizens based on the threat that they might be sued' providers thus have no “standing,” ie, they haven’t been wronged in any way (yet), so there’s no reason for them to come to court.

https://reproductiverights.org/case/texas-abortion-ban-whole-womans-health-jackson/

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SB8 Challenge Timeline

SB8 signed into law

WWH v Jackson filed in US District Court for the Western District of Texas

Defendants’ “motion to dismiss” is denied

Defendants appeal to the Fifth Circuit Court

May 2021

July 2021

August 2021

On May 19 2021, SB8 was signed into law.

On July 13 2021, Whole Woman’s Health along with several other independent abortion clinics in the state, Texas abortion funds, and clergy members sued all of Texas’ state court trial judges and clerks, the Texas Medical Board, Nursing Board, and Pharmacy Board, and the Texas Attorney General in US District Court.

In August, the defendants filed a motion to dismiss the case based on the fact that they are not the enforcers of the law, so they feel the complaint is not legally valid. This was denied by the District Court. The defendants then appealed to the Fifth Circuit Court of Appeals.

I want to pause here to highlight that all of the remaining arguments we are going to discuss regarding SB8 are in regard to this appeal, meaning that the question each court is being asked is NOT whether the law SB8 is consititutional, but rather, whether the defendants are the proper defendants in the suit, meaning the question being asked of the court is, are the defendants bodies or persons who can enforce the law?

https://reproductiverights.org/case/texas-abortion-ban-whole-womans-health-jackson/

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SB8 Challenge Timeline

WWH et al file a petition for SCOTUS to hear the appeal

SCOTUS dismisses the case against Texas judges, clerks, and AG

Fifth Circuit Court hears appeal

Texas Supreme Court hears appeal

September 2021

December 2021

January 2022

February 2022

The 5^th Circuit scheduled the appeal hearing for “sometime in December.”

On September 23, WWH filed a petition with the Supreme Court to hear appeal on behalf of the 5^th Circuit in order to expedite the proceedings. This was granted October 22. Oral Arguments were heard on Nov 1.

On December 10 2021, the Supreme Court issued a ruling in favor of SB8, stating that WWH cannot sue the state judges, clerks, or Attorney General. It did state that the Medical Board and other licensing authorities were appropriate defendants in the case, and sent the case back to the lower courts for a decision.

In an attempt to continue delays, the 5^th Circuit Court chose to hear oral arguments as to whether the remaining defendants, the Medical Board/Nursing Board/Pharmacy Board, were appropriate enforcers of the law, rather than returning the actual case on the constitutionality of SB8, back to the original district court. It is clear this was a delay, as SCOTUS already ruled that these defendants were appropriately suited for the case. The oral arguments were held in January. The 5^th circuit then continued to delay the case by issuing a ruling that the Texas Supreme Court must decide if the defendants had a reason to stand trial.

https://reproductiverights.org/case/texas-abortion-ban-whole-womans-health-jackson/

The TX supreme court listened to arguments in February. A ruling has not yet been issued.

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SB8 Challenge Timeline

WWH et al file a petition for SCOTUS to hear the appeal

SCOTUS dismisses the case against Texas judges, clerks, and AG

Fifth Circuit Court hears appeal

Texas Supreme Court hears appeal

September 2021

December 2021

January 2022

February 2022

TO BE CONTINUED

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SB8 Copycats

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SB8 Copycats

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SB8 Copycats

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SB8 Copycats

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SB8 Copycats

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SB8 Copycats

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SB8 Copycats

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SB8 Copycats

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SB8 Copycats

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Deep Breath!

https://greatist.com/happiness/breathing-exercises-relax#Bottom-line

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Mississippi Gestational Age Act

MS Gov

Phil Bryant

https://en.wikipedia.org/wiki/Phil_Bryant

March 2018

https://www.newyorker.com/podcast/politics-and-more/the-last-abortion-clinic-in-mississippi

Jackson Women’s Health

Back in March 2018, Mississippi passed the ”Gestational Age Act,” a bill which would penalize a physician by revoking a physician’s medical license for any abortion performed after 15 weeks of pregnancy. It was signed into law by former Mississippi Governor Phil Bryant in the same month.

To be clear: this law is unconstitutional because abortion was confirmed by the Supreme Court in Roe in 1973, and the decision upheld in Casey in 1992, to be legal and the pregnant person’s choice, without undue burden by state interference, until viability.

Jackson Women’s Health Organization, affectionately known as ”The Pink House,” and the sole remaining abortion clinic in Mississippi, sued the state of Mississippi the same day the bill was signed in District Court.

https://reproductiverights.org/case/scotus-mississippi-abortion-ban/dobbs-jackson-womens-health/

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Jackson Women’s Health v Dobbs

District Court strikes down abortion ban

Mississippi appeals the decision to the Fifth Circuit Court

Fifth Circuit Court upholds the District Court’s ruling

Mississippi appeals to the Supreme Court

Oral arguments are presented at the Supreme Court

November 2018

December 2019

June 2020

December 2021

The Gestational Age Act was stayed (meaning it could not be enforced) by the district court, and was ultimately found unconstitutional by the same court in November of 2018, given that the previability abortion ban does not follow from the previous precedents of Roe and Casey.

The State of Mississippi (represented by Thomas Dobbs, the State Health Officer of MS Dept of Health, who would enforce the penalty of revoking a physician’s license), appealed the decision. The 5^th Circuit Court of Appeals heard the case, and in December of 2019, affirmed the District Court’s decision that the law is unconstitutional as it is a pre-viability abortion ban.

In June 2020, the State of Mississippi filed a request with SCOTUS to review the previous lower court’s decisions, and the Supreme Court agreed to hear the case in May 2021. Oral arguments occurred in December 2021. While there is no decision, many of the court’s conservative justices questioned the workability of the viability standard and discussed prior instances when the Supreme Court ruled against stare decisis (or rather, it’s prior rulings, ie the idea of precedent). It is certainly possible that SCOTUS could overturn Roe and Casey, or at least allow states to ban pre-viability abortions when they do not present an undue burden to a substantial number of citizens in a particular state.

https://reproductiverights.org/case/scotus-mississippi-abortion-ban/dobbs-jackson-womens-health/

https://www.kff.org/womens-health-policy/issue-brief/abortion-at-scotus-dobbs-v-jackson-womens-health/

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A Possible Outlook…

Myers C, Jones R, Upadhyay U. Contraception 2019.

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A Possible Outlook…

Myers C, Jones R, Upadhyay U. Contraception 2019.

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A Possible Outlook…

Myers C, Jones R, Upadhyay U. Contraception 2019.

Finally, and additional 6 states (Idaho, Utah, Georgia, South Carolina, Indiana, and Ohio) are considered high risk for banning all or most abortions if Roe were to fall, as they have a myriad of laws that are currently enjoined because of Roe (such as unconstitutional previability abortion bans).

Therefore, it is possible with the ruling in Dobbs that as many as 21 states would no longer have abortion available to their residents. Myers et al predicted that the average American would have an increase in travel of 250 miles.

Because of studies of previous clinic closures that forced folks to travel, we know that the farther a person has to travel for abortion, the less likely that person is to obtain one. Myers et al predict that if Roe were to fall, the abortion rate in the US would decline by a third.

As Myers said herself, “A post-Roe United States isn’t one in which abortion isn’t legal at all. It’s one in which there’s tremendous inequality in abortion access.”

https://www.nytimes.com/interactive/2021/05/18/upshot/abortion-laws-roe-wade-states.html

guttmacher.org/article/2021/10/26-states-are-certain-or-likely-ban-abortion-without-roe-heres-which-ones-and-why

https://www.mapchart.net/usa.html

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Minnesota Abortion Law

“We can think of few decisions more intimate, personal, and profound than a woman's decision between childbirth and abortion. Indeed, this decision is of such great import that it governs whether the woman will undergo extreme physical and psychological changes and whether she will create lifelong attachments and responsibilities. We therefore conclude that the right of privacy under the Minnesota Constitution encompasses a woman's right to decide to terminate her pregnancy.”

In the event SCOTUS overturns Roe, you might be wondering how this will apply to Minnesota.

Luckily, in 1995, the Minnesota Supreme Court ruled in Doe v Gomes that Minnesotans have the right to abortion. To provide you a light at the end of this talk, I’ll read you an excerpt of the decision (I have decided to include the original gendered language);

”In {a previous case} Jarvis v. Levine, we held that the "right [of privacy] begins with protecting the integrity of one's own body and includes the right not to have it altered or invaded without consent." We therefore found that the right to be free from intrusive medical treatment is a fundamental right encompassed by the right of privacy under the Minnesota Constitution. In making that decision, we acknowledged that "[n]o right is held more sacred, or is more carefully guarded, by the common law, than the right of every individual to the possession and control of his own person, free from all restraint or interference of others, unless by clear and unquestionable authority of law.

We find this characterization equally persuasive in the context of the present case. The right of procreation without state interference has long been recognized as "one of the basic civil rights of man, fundamental to the very existence and survival of the race." We can think of few decisions more intimate, personal, and profound than a woman's decision between childbirth and abortion. Indeed, this decision is of such great import that it governs whether the woman will undergo extreme physical and psychological changes and whether she will create lifelong attachments and responsibilities. We therefore conclude that the right of privacy under the Minnesota Constitution encompasses a woman's right to decide to terminate her pregnancy.”

https://unrestrictmn.org/faq/state-constitution-current-restrictions/

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Minnesota Abortion Law

“We can think of few decisions more intimate, personal, and profound than a woman's decision between childbirth and abortion. Indeed, this decision is of such great import that it governs whether the woman will undergo extreme physical and psychological changes and whether she will create lifelong attachments and responsibilities. We therefore conclude that the right of privacy under the Minnesota Constitution encompasses a woman's right to decide to terminate her pregnancy.”

In the event SCOTUS overturns Roe, meaning that each state will decide for itself the legality and availability of abortion care, you might be wondering how this will apply to Minnesota.

Luckily, in 1995, the Minnesota Supreme Court ruled in Doe v Gomes that Minnesotans have the right to abortion. To provide you a light at the end of this talk, I’ll read you an excerpt of the decision (I have decided to include the original gendered language);

”In {a previous case} Jarvis v. Levine, we held that the "right [of privacy] begins with protecting the integrity of one's own body and includes the right not to have it altered or invaded without consent." We therefore found that the right to be free from intrusive medical treatment is a fundamental right encompassed by the right of privacy under the Minnesota Constitution. In making that decision, we acknowledged that "[n]o right is held more sacred, or is more carefully guarded, by the common law, than the right of every individual to the possession and control of his own person, free from all restraint or interference of others, unless by clear and unquestionable authority of law.

We find this characterization equally persuasive in the context of the present case. The right of procreation without state interference has long been recognized as "one of the basic civil rights of man, fundamental to the very existence and survival of the race." We can think of few decisions more intimate, personal, and profound than a woman's decision between childbirth and abortion. Indeed, this decision is of such great import that it governs whether the woman will undergo extreme physical and psychological changes and whether she will create lifelong attachments and responsibilities. (Click) We therefore conclude that the right of privacy under the Minnesota Constitution encompasses a woman's right to decide to terminate her pregnancy.”

https://unrestrictmn.org/faq/state-constitution-current-restrictions/

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Conclusions

We have the following new contraceptives to offer patients:

Nextstellis
Slynd
Twirla
Phexxi
Annovera

Rhogam is safe to defer during first trimester abortion
Virtual medication abortion is safe
Abortion rights continue to be litigated on the national level

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Thank You!

Questions?

ralph044@umn.edu

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