An exploratory sequential mixed methods study on pregnancy loss care

Project Summary: Since the Dobbs v. Jackson Women’s Health Organization Supreme Court decision in June 2022, multiple states have implemented abortion bans. While not the intended target of abortion restrictions, care for pregnancy loss often overlaps with abortion care and can be affected by abortion policy. Given the dynamic

ongoing state policy changes, the lack of baseline monitoring of pregnancy loss and treatment trends, and the known socioeconomic and racial variation in pregnancy loss care, it is imperative to document clinician and patient experiences of navigating pregnancy loss care and to develop data collection systems that can be used

to monitor changes in practices and outcomes over time. The goals of the proposed study are to assess: 1) the extent to which pregnancy loss management practices are influenced by newly-enacted policies related to the Dobbs ruling; 2) the implications of these new policies and practice changes for patient-centered quality care;

and 3) which institutional factors may be influential in supporting patient-centered care despite restrictions. We will conduct an exploratory sequential mixed methods study with the following three aims: AIM 1 – Characterize clinician attitudes, knowledge, and decision-making related to clinical management protocols for pregnancy

loss in states with new abortion restrictions following the Dobbs decision. Using a combination of rapid qualitative analysis (RQA) and traditional thematic qualitative methods, we will conduct in-depth interviews with diverse clinicians (n=30-40) providing pregnancy loss care, recruiting across practice settings and state

abortion policy. In this analysis we will document real-time decision-making and understand practice changes and the barriers to and facilitators of evidence-based patient-centered care. AIM 2 – Document patient experiences with pregnancy loss management practices in states with and without new abortion restrictions

following the Dobbs decision. We will conduct in-depth qualitative interviews with patients (n=40-50) experiencing pregnancy loss, with representation across first and second trimester, state abortion policy, and demographic characteristics. Using a similar approach to Aim 1, we will explore patient understanding and

effects of policy changes and the barriers and facilitators of high-quality care. AIM 3 – Monitor and evaluate the impact of restrictive abortion policies implemented post-Dobbs on first and second trimester pregnancy loss management practices using EPIC and EPIC Cosmos electronic medical record data. We will first develop and

internally-validate a set of search filters to identify pregnancy losses, treatments, complications, and delays in care (Aim 3a).We will then validate filters externally at other institutions to confirm fidelity (Aim 3b), and then will use filters to collect data at four case study institutions in most and least restrictive policy environments to

assess changes in care related to state policy using a differences-in-differences analysis, and assess impact on disparities in care using a triple-differences analysis (Aim 3c). We will then apply filters to aggregate data in EPIC Cosmos to assess national trends and the impact of the Dobbs decision nationwide (Aim 3d).