Barriers to abortion provision in primary care in New England, 2019-2020: A qualitative study

Barriers to providing procedural abortion care among trained clinicians: An evaluation of an abortion training program

OBJECTIVES

Understand the barriers and facilitators that clinicians face in delivering procedural abortion care following participation in an abortion training program and how these barriers may differ based on professional characteristics (e.g. specialty, career stage) and institutional factors (e.g., clinic policies).

STUDY DESIGN

This analysis is part of a larger evaluation of a clinical training program focused on equipping clinicians with procedural abortion skills. Data collection occurred 07/2020-01/2024 and included semi-structured interviews and post-program surveys collected annually following program completion. Program participants who completed at least two surveys are included.

RESULTS

Forty-four ob-gyn and family medicine physicians met the inclusion criteria for this study. About one-third of program participants provided procedural abortion care 6 months following training and at their last survey (18-, 30- or 42 months post-training), and one-third did not provide at either time point. Barriers and facilitators for those providing abortion care often changed as program participants became more established in their practices (particularly post-residency). While local and state policies influenced the ability to provide care, other institutional and professional factors, including career stage, were often reported with some differences by specialty and career stage.

CONCLUSIONS

Structural and institutional barriers proved significant to those seeking to provide care post-training. Institutions looking to support abortion care should also ensure that this support is given to family medicine physicians. As program participants often had challenges finding work, training programs should focus on helping program participants build networks of providers to provide comprehensive training and job placement support.

IMPLICATIONS

Institutional, career and personal factors have compounding effects on individuals' ability to utilize their abortion training. While abortion training programs are helpful in training providers, program participants from these programs need additional networking and institutional supports to be able to provide procedural abortion care.

(Mis)Informed decision-making: How U.S. healthcare providers use science to influence pregnancy options counseling

The language and authority of science have become central to the U.S. abortion debate. Although the pro-choice movement has traditionally positioned itself as defenders of scientific consensus, pro-life activists have increasingly leveraged scientific claims to advance their policy goals. As a result, scientific expertise now plays a pivotal role in the moral and political struggle over abortion, reshaping the foundations of abortion and pregnancy care. Although previous studies have focused on abortion discourse and scientific claim-making through the macro lens of state politics, legislation, and social movements, this study investigates how these dynamics manifest in the intimate setting of patient-provider interactions. Through in-depth interviews with 54 U.S. healthcare providers, this study explores how providers share scientific expertise during pregnancy options counseling, and how their approaches differ based on their personal attitudes toward abortion. Despite stark differences in the content of the information shared, pro-choice- and pro-life-leaning providers reported using similar strategies to communicate scientific evidence, including deliberating choosing language (e.g., "baby" versus "fetus") and selectively citing studies to explain abortion's physical and mental health effects. Although both groups claimed to prioritize neutrality and transparency, they also reported using tailored approaches to make their scientific expertise more compelling, credible, and accessible to their patients. Existing clinical guidelines advocate for providers to prioritize scientifically accurate, evidence-based counseling. This study demonstrates how, in practice, providers make value-laden judgments that shape how "informed" decision-making is defined.

Spatial Disparities in Mifepristone Use for Early Miscarriage and Induced Abortion Among Obstetrician-Gynecologists Practicing in Massachusetts

Background

About 25% of pregnancies end in early miscarriage or abortion annually in the United States. While mifepristone is part of the most effective medication regimen for miscarriage and abortion, regulatory burdens and legal restrictions limit its provision in obstetric-gynecological practice. The extent of geographic disparities in mifepristone use is unknown.

Objectives

We sought to ascertain whether regional "deserts" for mifepristone-based miscarriage and abortion care exist in Massachusetts using geographic regions specified by the Commonwealth's Executive Office of Health and Human Services.

Methods

We fielded a cross-sectional survey of obstetrician-gynecologists practicing in Massachusetts. We weighted survey data to account for differential nonresponse by provider sex, region, and years in independent practice.

Results

Among obstetrician-gynecologists in independent practice with region data (n = 148), 51.0% reported using mifepristone for miscarriage and 43.5% for abortion. Significant differences in reported use were observed across regions (p < 0.001 for both indications). Barriers to using mifepristone for miscarriage management also varied across regions. Respondents outside of Boston and Western Massachusetts were more likely to report gaps in knowledge about regulations and prescribing and had less prior experience using mifepristone. In a multivariable model adjusting for provider sex and practice type, obstetrician-gynecologists outside of Boston had significantly lower odds of using mifepristone for miscarriage (adjusted odds ratio [aOR] = 0.14, 95% confidence interval [95% CI] = 0.08-0.25) and abortion (aOR = 0.46, 95% CI = 0.26-0.82), compared to Boston-based obstetrician-gynecologists.

Conclusion

Mifepristone provision varies significantly by Massachusetts region. This may lead to spatial disparities in reproductive health outcomes.

Patient experiences of undergoing abortion with and without an ultrasound scan in Britain

BACKGROUND

Routine ultrasound scanning to determine gestational age and pregnancy location has long been part of pre-abortion assessment in Britain, despite not being legally required or recommended in national clinical guidelines. To support implementation of fully telemedical abortion care (implemented in Britain in April 2020), the Royal College of Obstetricians and Gynaecologists (RCOG) issued clinical guidance for an 'as-indicated' approach to pre-abortion ultrasound, removing the need for a clinic visit. We aimed to understand patient experiences of ultrasound in abortion care by conducting a qualitative study with individuals who had abortions with and without an ultrasound scan.

METHODS

Between November 2021 and July 2022, we recruited patients who had a medical abortion at home without a pre-procedure ultrasound at 69 days' gestation or less at British Pregnancy Advisory Service (BPAS), and also had at least one other abortion with an ultrasound from any provider in Britain. We conducted interviews using a semi-structured interview guide to explore our participants' experiences and conducted reflexive thematic analysis.

RESULTS

We recruited 24 participants and included 19 interviews in our analysis. We developed three themes from our data. These were 'Ultrasound scans and their relationship with autonomy and decision-making', 'Intrusive and out of place: the ultrasound as an inappropriate technology' and 'Towards preference-centred, quality care'.

CONCLUSIONS

Further research and user-testing of strategies to improve the scan experience should be undertaken. Patient testimonies on the negative impact of ultrasound scans in abortion care should reassure providers that omitting them according to patient preference is a positive step towards providing patient-centred care.

Mifepristone Use Among Obstetrician-Gynecologists in Massachusetts: Prevalence and Predictors of Use

OBJECTIVES

We estimated the prevalence of mifepristone use for evidence-based indications among obstetrician-gynecologists in independent practice in Massachusetts and explored the demographic and practice-related factors associated with use.

METHODS

We used data from a cross-sectional survey administered to Massachusetts obstetrician-gynecologists identified from the American Medical Association Physician Masterfile. We measured the prevalence of mifepristone use for four clinical scenarios: early pregnancy loss, medication abortion, cervical preparation before dilation and evacuation procedures, and cervical preparation before induction of labor. Multivariate regression was used to calculate the odds of mifepristone use for these scenarios based on practice type, years in practice, physician sex, and history of medication abortion training.

RESULTS

A total of 198 obstetrician-gynecologists responded to the survey (response rate = 29.0%); this analysis was limited to 158 respondents who were not in residency or fellowship. Overall, 46.0% used mifepristone for early pregnancy loss and 38.6% for medication abortion. Fewer used mifepristone for cervical preparation before dilation and evacuation (26.0%) or before induction of labor (26.4%). Respondents in academic practice settings, with more years in practice, of female sex, and with sufficient medication abortion training were significantly more likely to use mifepristone for one or more evidence-based clinical indications.

CONCLUSIONS

Sufficient medication abortion training during residency significantly predicts whether obstetrician-gynecologists use mifepristone in practice. The U.S. Supreme Court's overturning of Roe v. Wade will allow state-level abortion bans and restrictions to be in effect, which will reduce exposure to abortion training during residency. Increasing training in and utilization of mifepristone are critical for equitable access to reproductive health services. Further interventions may need to be developed to increase mifepristone use in nonacademic practice settings.

Mifepristone implementation in primary care: Clinician and staff insights from a pilot learning collaborative

OBJECTIVES

The ExPAND Mifepristone (ExPAND) learning collaborative aims to support primary care providers in overcoming logistical barriers to mifepristone provision. This qualitative study describes clinician and staff perspectives on the impact of ExPAND in two federally qualified health center networks (FQHCs).

STUDY DESIGN

Researchers conducted semi-structured qualitative interview with a purposive sample of clinicians, staff, and leadership from two Illinois FQHCs. We analyzed transcripts in batches using modified grounded theory to identify themes regarding the reception of ExPAND and barriers to and facilitators of mifepristone implementation.

RESULTS

Participants (n = 13) expressed strong support for providing mifepristone for miscarriage management at their clinics. Most also personally supported mifepristone for abortion care. Many participants felt that ExPAND reflected their clinics' values, as it strengthens the primary care relationship, emphasizes patient-centered care, and addresses disparities in access. Barriers to implementation included fear that providing abortion care would jeopardize FQHC funding and logistical hurdles due to the coronavirus disease pandemic.

CONCLUSIONS

Participants felt that mifepristone provision in primary care was an important service, and that ExPAND helped achieve that goal. Future clinics participating in ExPAND would benefit from education about how FQHCs can provide mifepristone for abortion care while complying with federal funding restrictions.

IMPLICATIONS

Learning collaboratives like ExPAND can prepare primary care clinics to provide mifepristone. Participants describe a clear benefit of mifepristone integration to their patients, and they report mifepristone integration aligns with clinic values.