Barriers to D&E practice among family planning subspecialists

Providers' experiences with abortion care: A scoping review

BACKGROUND

Induced abortion is one of the most common gynecological procedures in the world, with as many as three in every ten pregnancies ending in abortion. It, however, remains controversial. The objective of this scoping review was to explore and map existing literature on the experiences of those who provide abortion care.

METHODS AND FINDINGS

This exploratory review followed the Levac et al. guidelines and was reported in accordance with the PRISMA-ScR checklist. CINAHL, Cochrane, EMBASE, PsycInfo, PubMed, and Web of Science were used to identify peer-reviewed, original research articles published on providers' experience of abortion. We identified 106 relevant studies, which include a total sample of 4,250 providers from 28 countries and six continents. Most of the studies were qualitative (n = 83), though quantitative (n = 15) and mixed methods (n = 8) studies were also included. We identified two overarching themes: (1) Providers' experiences with abortion stigma and (2) Providers' reflections on their abortion work. Our findings suggest that providers from around the world experience challenges within society and their communities and workplaces which reinforce the stigmatization and marginalization of abortion and pose questions about the morality of this work. Most, however, are proud of their work, believe abortion care to be socially important and necessary, and remain committed to the provision of care.

CONCLUSIONS

The findings of this review provide a comprehensive overview on the known experiences of providing abortion care. It is a key point of reference for international providers, researchers, and advocates to further this area of research or discussion in their own territories. The findings of this review will inform future work on how to support providers against stigmatization and will offer providers the chance to reflect on their own experiences.

Collaboration between maternal-fetal medicine and family planning: a survey of Northeast US academic medical centers

OBJECTIVES

To explore how complex family planning (CFP) and maternal-fetal medicine (MFM) in Northeast academic medical centers work together to provide abortion care.

METHODS

We distributed an exploratory cross-sectional online survey to CFP and MFM faculty and fellows at academic medical centers in the Northeast between July and September of 2020. The survey included demographic information, assessment of practice patterns, hospital/administration support and assessment of collaboration. Likert scale questions examined opinions about collaboration and an open-ended question solicited ideas for improvement. We performed bivariate analysis to examine the association between subspecialty and practice location regarding provision of abortion care and perceived barriers to care.

RESULTS

The response rate was 31 % and was similar by specialty. Of the 69 respondents, 83 % were MFMs, 75 % were faculty, and 54 % practiced in New York. More than 85 % reported personal participation in some portion of abortion care. The two most common perceived barriers to care were "lack or reluctance of physicians/staff" and state laws prohibiting termination. Nearly all (95 %) stated there was a good working relationship between CFP and MFM divisions; however, almost one-third agreed with or were neutral to the statements "MFM and CFP are siloed in terms of work/patient care."

CONCLUSIONS

Academic MFM and CFP providers in the Northeast collaborate well in providing abortion care, though our findings highlight areas that would benefit from improvement. Optimizing collaboration in the Northeast is important given its regional role for ensuring abortion access in the current national landscape. Improved education of all members of the patient care team on the importance of abortion access may also help provide optimal patient care where abortion services still legally exist.

The integration of abortion into obstetrician-gynecologists' practice after comprehensive family planning resident training

OBJECTIVES

To explore the impacts of routine family planning and abortion training during residency on abortion practice between three and ten years after residency.

METHODS

In 2018, we surveyed 771 graduated obstetrician-gynecologists at least three years after residency about their current abortion practice. Respondents consented to join a prospective cohort as part of routine, post-rotation evaluation of the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning. We matched and then de-identified post-rotation and post-residency surveys, and conducted bivariate and multivariable analyses.

RESULTS

Of 463 respondents (60% response rate), 188 (41%) reported that they provide abortions (median of eight abortions per month) in their current practice. Eighty-eight (19%) do not provide abortions but would if not restricted by their practice. One hundred-fifty respondents (32%) reported abortions are out of their practice scope or that someone else in their practice provides abortions, and 38 (8%) do not desire to provide abortion care. Two hundred twenty-six (54%) reported practice or hospital group restrictions to abortion care. In multivariable analyses controlling for demographics, training, attitude and practice factors; geographic location, practice restrictions and logistical barriers, among other variables, correlated with abortion practice (practice in the West: odds ratio (OR) 2.3; 95% confidence interval [CI], 1.3-4.2; p = 0.01; logistical barriers: OR 0.3, CI 0.1 to 0.7, p = 0.01; and practice restrictions OR 0.5, CI 0.3 to 0.8, p = 0.01).

CONCLUSIONS

Nearly half of Ryan Program-trained obstetrician-gynecologists provide abortions. However, many barriers prevent the integration of abortion into practice. Healthcare providers and leaders should work to eliminate barriers to the provision of abortion care.

IMPLICATIONS

Regardless of their intentions at the time of training, nearly half of Ryan Program-trained obstetrician-gynecologists provide abortions in practice, and another 19% would if not restricted by their practice. Integrated training is critical to abortion care, and efforts to overcome practice barriers could improve access to comprehensive health care.

Interprofessional Abortion Opposition: A National Survey and Qualitative Interviews with Abortion Training Program Directors at U.S. Teaching Hospitals

CONTEXT

Hospital policies and culture affect abortion provision. The prevalence and nature of colleague opposition to abortion and how this opposition limits abortion care in U.S. teaching hospitals have not been investigated.

METHODS

As part of a mixed-methods study, a nationwide survey of residency and site directors at 169 accredited obstetrics-gynecology training programs was conducted in 2015-2016, and 18 in-depth interviews with program directors were conducted in 2014 and 2017. The prevalence and nature of interprofessional opposition were examined using descriptive statistics, and regional differences were investigated using logistic regression. A modified grounded theoretical approach was used to analyze interview data.

RESULTS

Among the 91% of survey respondents who reported that they or their colleagues had wanted or needed to provide abortions in the prior year, 69% faced opposition from colleagues. Most commonly, opposition came from nurses (58%), nursing administration (30%) and anesthesiologists (30%), manifesting as resistance to participating in or cooperating with procedures (51% and 38%, respectively). Fifty-nine percent of respondents had denied care to patients in the prior year because of colleagues' opposition. Respondents in the Midwest and South were more likely than those in the Northeast to deny abortion care to patients because of such opposition (odds ratios, 3.2 and 4.4, respectively). Interviews revealed how participants had to circumvent opposing colleagues, making abortion provision difficult and leading to delays in and, infrequently, denial of abortion care.

CONCLUSIONS

Interprofessional opposition to abortion is widespread in U.S. teaching hospitals. Interventions are needed that prioritize patients' needs while recognizing the challenges hospital colleagues face in their abortion participation decisions.

Sources of support for and resistance to abortion training in obstetrics and gynecology residency programs

BACKGROUND

Only 64% of obstetrics and gynecology program directors report routine, scheduled training in abortion, despite the Accreditation Council for Graduate Medical Education's requirements for routine training. Most report that exposure to training is limited to specific clinical circumstances.

OBJECTIVE

We sought to describe residency program directors' perspectives of support for and resistance to abortion training in residency training programs in the United States.

MATERIALS AND METHODS

A national survey of directors explored the availability of abortion training as well as support for and resistance to abortion training within their departments and institutions. In addition, directors who indicated that training was not available at all, available only as an elective, or as routine but limited to specific clinical circumstances, were also asked which procedures were limited, in what ways, and by whom. Descriptive and bivariate analyses were performed.

RESULTS

A total of 190 residency program directors (79%) responded from throughout the United States (30% in the Northeast, 30% in the South, 23% in the Midwest, and 16% in the West), and 14% described their program as religiously affiliated. Most directors (73%) reported at least some institutional or government restrictions to training, and reported an average of 3 types of restrictions. Hospital policy was the most commonly reported restriction, followed by state law. Programs with routine abortion training reported an average of 2 restrictions, compared with 4 restrictions in programs with optional training, and 5 restrictions in programs with no abortion training.

CONCLUSION

Significant barriers to integrating abortion training into residents' schedules continue to exist decades after the Accreditation Council for Graduate Medical Education training mandate. We should use these data to develop better support and targeted strategies for increasing the number of trained abortion providers in the United States.

Exploring prenatal genetic counselors' perceptions of abortion laws in restrictive states

In many states, abortion laws are becoming increasingly restrictive. Prenatal genetic counselors often see patients after the diagnosis of a fetal abnormality or genetic disorder and discuss the option of termination of pregnancy. The purpose of this study was to understand prenatal genetic counselors' perspectives on how state abortion laws impact their practice. Qualitative semi-structured interviews were conducted with 16 prenatal genetic counselors in states with restrictive abortion laws who were recruited from the National Society of Genetic Counselors' online directory. Verbatim transcripts were analyzed thematically, yielding five themes: genetic counselors in this study described (a) how state laws restrict access to abortion; (b) how they navigate state laws and institutional policies regarding abortion; (c) how they tailor their professional practice in the context of state abortion laws; (d) how abortion laws burden patients; and (e) how they engage in forms of advocacy. Participants described the financial and emotional burden placed on their patients by state abortion laws and how the laws influence their patient interactions. As access to abortion becomes more restricted, it is important to be aware of how this will impact genetic counselors and their patients.

Recruitment and retention strategies for expert nurses in abortion care provision

OBJECTIVE(S)

The purpose of this thematic analysis is to describe recruitment, retention and career development strategies for expert nurses in abortion care provision.

STUDY DESIGN

Thematic analysis influenced by grounded theory methods were used to analyze interviews, which examined cognitive, emotional, and behavioral processes associated with how nurses make decisions about participation in abortion care provision. The purposive sample consisted of 16 nurses, who were interviewed between November 2012 and August 2013, who work (or have worked) with women seeking abortions in abortion clinics, emergency departments, labor and delivery units and post anesthesia care units.

RESULTS

Several themes emerged from the broad categories that contribute to successful nurse recruitment, retention, and career development in abortion care provision. All areas were significantly influenced by engagement in leadership activities and professional society membership. The most notable theme specific to recruitment was exposure to abortion through education as a student, or through an employer. Retention is most influenced by flexibility in practice, including: advocating for patients, translating one's skill set, believing that nursing is shared work, and juggling multiple roles. Lastly, providing on the job training opportunities for knowledge and skill advancement best enables career development.

CONCLUSION(S)

Clear mechanisms exist to develop expert nurses in abortion care provision.

IMPLICATIONS

The findings from our study should encourage employers to provide exposure opportunities, develop activities to recruit and retain nurses, and to support career development in abortion care provision. Additionally, future workforce development efforts should include and engage nursing education institutions and employers to design structured support for this trajectory.