Abortion Providers Research Articles

Exploring barriers to abortion access: Medical students’ intentions, attitudes and exposure to abortion

ObjectiveTo describe medical student attitudes and exposure to abortion and pregnancy options counseling and influences of that experience on the provision of these services in their future practice. Study DesignA survey was conducted of 3rd and 4th year medical students in 2019 at an US medical school in the Northeast. ResultsOne hundred and sixty-two students participated in the survey (response rate = 46 %, 162/353). Only 27 % reported receiving at least one educational lecture on abortion during medical school. Fifty-eight percent reported clinical exposure to surgical abortion. About 2/3 reported being somewhat likely to provide abortions in the future, despite most identifying as “pro-choice.” There was significant association between clinical exposure to surgical abortion and desire to include abortion in future practice (P = 0.03). The most common objections to performing future abortions were personal values, religious objection, and lack of training/experience. Most respondents did not feel comfortable providing counseling for abortion or adoption. Combined, only 14.4 % reported that they would be at least somewhat likely to apply to obstetrics-gynecology or family medicine residency programs, including programs with opportunities for such training. ConclusionsEarlier work has shown that medical student intentions to provide abortions prior to residency are better predictors of future abortion provision than during residency. Thus, medical school is a critical time for exposure to abortion and pregnancy options counseling. Such exposure and medical student attitudes are areas of research that should be further studied to contribute to the expansion and normalization of these services.

Co-design of a nurse-led model of care to increase access to medical abortion and contraception in rural and regional general practice: A protocol.

Women in rural and regional Australia experience a number of barriers to accessing sexual and reproductive health care including lack of local services, high costs and misinformation. Nurse-led task-sharing models of care for provision of long-acting reversible contraception (LARC) and early medical abortion (EMA) are one strategy to reduce barriers and improve access to services but have yet to be developed in general practice. Through a co-design process, we will develop a nurse-led model of care for LARC and EMA provision that can be delivered through face-to-face consultations or via telehealth in rural general practice in Australia. A co-design workshop, involving consumers, health professionals (particularly General Practitioners (GPs) and Practice Nurses (PNs)), GP managers and key stakeholders will be conducted to design nurse-led models of care for LARC and EMA including implant insertion by nurses. The workshop will be informed by the 'Experience-Based Co-Design' toolkit and involves participants mapping the patient journey for service provision to inform a new model of care. Recommendations from the workshop will inform a nurse-led model of care for LARC and EMA provision in rural general practice. The model will provide practical guidance for the set-up and delivery of services. Nurses will work to their full scope of practice to increase accessibility of EMA and LARC in rural Australia.

Seeking abortion care in Ohio and Texas during the COVID-19 pandemic

ObjectivesPolitical and public health responses to the COVID-19 pandemic changed provision of abortion care and exacerbated existing barriers. We aimed to explore experiences of individuals seeking abortion care in 2 abortion-restrictive states in the United States where state policies and practice changes disrupted abortion provision during the pandemic. Study designWe conducted 22 semistructured interviews in Texas (n = 10) and Ohio (n = 12) to assess how state executive orders limiting abortion, along with other public health guidance and pandemic-related service delivery changes, affected individuals seeking abortion care. We included individuals 18 years and older who contacted a facility for abortion care between March and November 2020. We coded and analyzed interview transcripts using both inductive and deductive approaches. ResultsParticipants reported obstacles to obtaining their preferred timing and method of abortion. These obstacles placed greater demands on those seeking abortion and resulted in delays in obtaining care for as long as 11 weeks, as well as some being unable to obtain an abortion at all. ConclusionsPolitical and public health responses to the COVID-19 pandemic - exacerbated pre-pandemic barriers and existing restrictions and constrained options for people seeking abortion in Ohio and Texas. Delays were consequential for all participants, regardless of their ultimate ability to obtain an abortion. ImplicationsDuring the COVID-19 pandemic, state executive orders and clinic practices exacerbated already constrained access to care. Findings highlight the importance of protecting timely care and the full range of abortion methods. Findings also preview barriers individuals seeking abortion may encounter in states that restrict or ban abortion.

Hyde and Seek: Searching for Solutions to The Hyde Amendment’s Financial Barriers to Abortion

The Hyde Amendment (Hyde) hinders abortion access to people who can become pregnant (we will refer to this cohort henceforth as “women” and recognize that not all people who can become pregnant identify as such) whose health insurance is funded by the federal government. In the forty-five years since its inception, the Hyde Amendment has disproportionately affected marginalized women. The conservative movement has augmented disparities in healthcare by passing incremental laws to restrict abortion access, including but not limited to, gestational age and specific procedure limitations, waiting periods, parental consent, and Targeted Regulation of Abortion Providers (TRAP) laws. With Roe V. Wade overturned with the Dobbs V. Jackson ruling (Dobbs), access to abortion is more restricted than it has been in the past 50 years. Eight states have completely banned abortion and many other states offer very limited exceptions to the ban. Now, more than ever, it is essential that funding is not a barrier to care in the states that continue to protect abortion rights. Our first recommendation calls for states to be held accountable to the minimal federal requirements set forth by Hyde and create a confidential forum for women to report informal barriers to care. Furthermore, we endorse the passing of the Equal Access to Abortion Coverage in Health Insurance Act (EACH Act), which would permanently end the renewal of Hyde. Our final recommendation calls on the government to create legislation that permanently institutes national mandatory guidelines for emergency obstetric care. These steps could counteract the increasingly restrictive encroachment on abortion rights.

Pharmacist direct dispensing of mifepristone for medication abortion in Canada: a survey of community pharmacists

IntroductionPharmacists were acknowledged as the most appropriate healthcare professional to dispense mifepristone for medication abortion shortly after the prescription therapy became available in January 2017 in Canada.ObjectiveWe aimed to identify...

Nevertheless, They Persisted: How Patterns of Opposition and Support Shaped the Survival of U.S. Abortion Clinics

AbstractStigmatized organizations are generally assumed to face a variety of unique operational challenges. This paper examines the survival of stigmatized organizations in light of such challenges. Specifically, we investigate how patterns of opposition and support from multiple external stakeholders and audiences affect organizational survival within the context of abortion provision in the United States. We use a fuzzy‐set qualitative comparative analysis (fsQCA) to examine the causal linkages between the above factors and the survival outcomes of the full identifiable industry of 983 abortion clinics that were in operation in the U.S. between 2011 and 2017. Our results reveal the existence of multiple paths to survival, based primarily on either the absence of overt opposition or the presence of factors like political support that enabled organizations to overcome other threats to survival. Our findings show how socio‐political factors affect the survival of organizations in stigmatized industries.

Bottom-up advocacy strategies to abortion access during the COVID-19 pandemic: Lessons learned towards reproductive justice in Brazil.

In Brazil, abortion is only allowed in cases of rape, serious risk to a woman's life or fetal anecephaly. Legal abortion services cover less than 4% of the Brazilian territory and only 1,800 procedures are performed, in average, per year. During the COVID-19 pandemic, almost half of the already few Brazilian abortion clinics shut down and women had to travel even longer distances, reaching abortion services at later gestational ages. In this paper, we describe three bottom-up advocacy strategies that emerged from difficulties deepened during the COVID-19 pandemic at a single abortion service in Brazil, amidst anti-gender policies from the federal government. Telemedicine abortion, outpatient surgical abortion and the provision of abortion after 20 weeks' gestation are important strategies that may reduce inequalities that impact the most vulnerable populations, such as black and indigenous women, children, adolescents and women experiencing domestic violence.

Utilization of abortion services from an unsafe provider and associated factors among women with history of induced abortion in Ghana

BackgroundIn sub-Saharan Africa (SSA), numerous studies have examined women’s choice of abortion methods and services using hospital-based data, community-based surveys and nationally representative data. Little research focuses on the factors influencing a woman’s choice of abortion provider. This study sought to identify factors that are associated with why a woman seeks abortion care services from an unsafe provider in Ghana.MethodsWe used nationally representative data of women from the 2017 Ghana Maternal Health Survey (GMHS). Data analysis was restricted to women aged 15–49 with a recent history of induced abortion. Analyses focused on a weighted sample of 1,880. Descriptive analysis and the chi-square test were used to examine the proportion of women utilizing abortion services from unsafe providers. Factors hypothesized to affect the utilization of abortion services from unsafe providers were examined using both bivariable and multivariable logistic regression analyses.ResultsThe proportion of survey respondents who reported that they utilize abortion service from unsafe providers were 57.5%. After adjusting for confounders, those who have knowledge of abortion legality [aOR: 0.381 (0.271–0.541)] and those who have attained secondary or higher education [aOR: 0.613 (0.411–0.914)] were less likely to use abortion services from unsafe providers. On the other hand, women belonging to the Ewe ethnic group [aOR: 0.696 (0.508–0.953)], those residing in the middle belt zone [aOR: 1.743 (1.113–2.728)], younger women aged 15–29 years [aOR: 2.037 (1.234–3.362)] were more likely to use abortion services from unsafe abortion providers.ConclusionsThis research suggests that increasing the knowledge of women on the legal status of abortion through public education and encouraging more women to pursue secondary or higher education can contribute to reducing the use of abortion services from unsafe providers. These interventions should be targeted among younger women and those who reside in the middle belt zones of Ghana.

What about access to birth control and emergency contraception now that abortion rights are overturned?

What about access to birth control and emergency contraception now that abortion rights are overturned?

How does the regulation of abortion provision for pregnancies resulting from rape affect its supply in the municipalities?

The provision of abortion in pregnancies resulting from rape in Brazil is limited, restricted to a few facilities and concentrated in large urban centers. We aimed to estimate the potential for expansion of this service considering the installed capacity in the country's municipalities. From the data of June 2021 in the Cadastro Nacional de Estabelecimentos de Saúde (Brazilian National Registry of Health Facilities, CNES), three different scenarios of abortion provision provided by law in pregnancies resulting from rape were elaborated, and the percentage of female population of childbearing age living in the municipalities of each scenario was calculated by region. The first scenario included the municipalities with installed provision; the second, those with potential for provision considering the current regulations; and the third, those with potential for provision considering only the recommendations of the World Health Organization and the Penal Code of Brazil. The scenarios were composed of 55, 662 and 3,741 municipalities, respectively, and were home to 26.7%, 62.1%, and 94.3% of the country's females between the ages of 10 and 49. In all regions, there was installed capacity to expand provision, both in light of current regulations and international recommendations.

Como a normatização sobre o serviço de aborto em gravidez decorrente de estupro afeta sua oferta nos municípios?

Abstract The provision of abortion in pregnancies resulting from rape in Brazil is limited, restricted to a few facilities and concentrated in large urban centers. We aimed to estimate the potential for expansion of this service considering the installed capacity in the country’s municipalities. From the data of June 2021 in the Cadastro Nacional de Estabelecimentos de Saúde (Brazilian National Registry of Health Facilities, CNES), three different scenarios of abortion provision provided by law in pregnancies resulting from rape were elaborated, and the percentage of female population of childbearing age living in the municipalities of each scenario was calculated by region. The first scenario included the municipalities with installed provision; the second, those with potential for provision considering the current regulations; and the third, those with potential for provision considering only the recommendations of the World Health Organization and the Penal Code of Brazil. The scenarios were composed of 55, 662 and 3,741 municipalities, respectively, and were home to 26.7%, 62.1%, and 94.3% of the country’s females between the ages of 10 and 49. In all regions, there was installed capacity to expand provision, both in light of current regulations and international recommendations.

Abortion services and providers in Canada in 2019: results of a national survey.

Background:Since 2016, abortion care has undergone several important changes, particularly related to the provision of medical abortion using mifepristone. We aimed to document characteristics of the abortion care workforce in Canada after the update of clinical practice guidelines of mifepristone use for medical abortion.Methods:We conducted a national, web-based, anonymized, bilingual (English/French) survey. We collected demographics and clinical care characteristics of physicians and nurse practitioners who provided abortion care in 2019. Between July and December 2020, we distributed the survey through professional organizations, including The College of Family Physicians of Canada and The Society of Obstetricians and Gynaecologists of Canada. We present descriptive statistics.Results:Overall, 465 respondents representing all 10 provinces and 3 territories in Canada completed the survey. Of these, 388 (83.4%), including 30 nurse practitioners, provided first-trimester medical abortion, of which 350 (99.4%) used mifepristone. Two hundred and nineteen (47.1%) respondents provided first-trimester surgical abortion, 109 (23.4%) provided second-trimester surgical abortion and 115 (24.7%) provided second- or third-trimester medical abortion. Half of respondents reported fewer than 5 years of experience with any abortion care. Respondents reported providing a total of 48 509 abortions in 2019, including 32 345 (66.7%) first-trimester surgical abortions and 13 429 (27.7%) first-trimester medical abortions. In Quebec, only 1918 (12.5%) of reported abortions were first-trimester medical abortions. Primary care providers provided 34 540 (71.2%) of the total abortions. First-trimester medical abortions represented 44.4% (n = 2334) of all abortions in rural areas, as opposed to 25.6% (n = 11 067) in urban areas.Interpretation:The increased availability of medical abortion facilitates abortion access, especially in primary care and rural settings, and where surgical abortion is not available. Rejuvenation of the workforce is a critical contributor to equitable access to abortion services.

Substantive and Political Learning among the US States: Abortion Policy Diffusion, 1993–2016

AbstractDo policymakers learn from the policy experiences of other governments, and if so, what do they learn? A long-established normative claim suggests that intergovernmental learning can and should occur among the US states, which serve as “laboratories of democracy” for the nation. We put this claim to a tough test, comparing the influences on the diffusion of instrumental Targeted Regulation of Abortion Providers (TRAP) laws with that of more symbolic abortion regulation, from 1993 to 2016. We find evidence of substantive intergovernmental learning in policy diffusion even for abortion regulation—but only for instrumental abortion regulation. On symbolic abortion policy, states appear to learn mainly political lessons. Furthermore, proponents and opponents appear to learn different lessons in these diffusions, with loss aversion motivating opponents especially highly. Our results suggest that policymakers have a sophisticated understanding of the differences among policies’ goals and act strategically in pursuit of those goals.

Quality of information offered to women by drug sellers providing medical abortion in Nigeria: Evidence from providers and their clients.

BackgroundEvidence confirmed that the demand for medical abortion (MA) increased significantly during the COVID-19 outbreak in many developing countries including Nigeria. In an abortion-restrictive setting like Nigeria, local pharmacies, and proprietary patent medicine vendors (PPMVs) continue to play a major role in the provision of MA including misoprostol. There is the need to understand these providers' knowledge about the use of misoprostol for abortion and the quality of information they provide to their clients. This analysis is focused on assessing the quality of care provided by both drug seller types, from drug sellers' and women's perspectives.MethodologyThis study utilized primary data collected from drug sellers (pharmacists and PPMVs) and women across 6 Local Government Areas in Lagos State, Nigeria. The core sample included 126 drug sellers who had sold abortion-inducing drugs and 386 women who procured abortion-inducing drugs from the drug sellers during the time of the study. We calculate quality-of-care indices for the care women received from drug sellers, drawing on WHO guidelines for medication abortion provision. The index based on information from the sellers had two domains—technical competency and information provided to clients, while the index from the women's perspectives includes an additional domain, client experience.ResultsResults show that the majority of drug sellers in the sample, 56% (n = 70), were pharmacists. However, far more than half of women 60% (n = 233) had visited PPMVs. Overall, the total quality score amongst all drug sellers (mean 0.48, SD0.15) was higher than the total score calculated based on women's responses (mean 0.39, SD 0.21). Using our quality-of-care index, pharmacies and PPMVs seem to have similar technical competency (mean score of 0.23, SD 0.13 in both groups (range 0–1), whilst PPMV's performed better on the information provided to client domain (mean score of 0.79, SD 0.17 compared with pharmacies 0.69, SD 0.25). Based on women's reports, PPMVs scored better on both quality of care domains (technical competency and information provided to clients) compared with pharmacies.Program/Policy ImplicationIn resource-constrained settings such as Nigeria, particularly in the context of health emergencies like COVID-19, there is the need to continue to strengthen and engage PPMVs' capacity and skills in dispensing and administration of MA drugs as a harm reduction strategy. Also, there is the need to target frontline providers in pharmacies for training and skill upscale in MA provision.

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

ObjectiveTo assess barriers to and facilitators of abortion provision among abortion-trained primary care providers. Study DesignWe conducted 21 qualitative in-depth interviews with 20 abortion-trained family physicians and one internal medicine physician in five New England states. We dual-coded interviews, using a consensus method to agree upon final coding schema. Through iterative dialogue, using an inductive content analysis approach, we synthesized the themes and identified patterns within each domain of inquiry. ResultsThe most commonly reported barriers were a lack of organizational support, the Hyde Amendment, which prevents the use of federal funds for most abortion care, and the mifepristone Risk Evaluation and Mitigation Strategy, a federal regulation which prohibits routine mifepristone pharmacy dispensing. The logistical barriers created by these policies require cooperation from additional stakeholders, creating more opportunities for abortion stigma and moral opposition to arise. Other salient barriers included inter-specialty tension (particularly with obstetrician-gynecologists), perceived need for pre-abortion ultrasound, absence of a clinician support network, and lack of knowledge of existing resources for establishing abortion care in primary care. ConclusionsIncreased abortion provision in primary care is one of many necessary responses to the human rights crisis produced by the Dobbs decision. Eliminating the Hyde Amendment and ending federal regulations restricting pharmacy dispensing of mifepristone are key interventions to address barriers to primary care abortion provision. Building interspecialty partnerships between family medicine and OB/GYN and spreading awareness of the evidence-based ultrasound-as-needed protocol and other educational resources are also likely to increase primary care abortion access. ImplicationsBy exploring barriers to and facilitators of primary care abortion provision, this study outlines a targeted approach to support increased access to abortions. In states with legal abortion post-Roe, it is important that motivated and trained primary care providers can offer abortions, rather than referring patients to overburdened specialty clinics.

Abortion Is Only the Beginning

Abortion Is Only the Beginning

Willing but not able: A survey of New Zealand health practitioners' interests in providing second trimester abortion care and the obstacles they face.

In 2020, abortion was removed from the Crimes Act. Abortions under 20 weeks gestation no longer require an indication and criteria for abortion above 20 weeks gestation has broadened. Prior to law reform, all abortions were provided on licensed premises and the responsible health practitioner was a doctor. Subsequently, any health practitioner with abortion in their scope of practice can provide abortion care. To describe the characteristics of health practitioners who expressed an interest in participating in second trimester abortion care, and to identify and describe the barriers to providing an optimal second trimester abortion service. This was an exponential non-discriminating snowball email survey using tick boxes and open comments. Quantitative data were analysed using descriptive statistics and free-text components were analysed using a general inductive approach. The 113 respondents included: 38 hospital-based obstetrics and gynaecology doctors, 22 primary care doctors, 13 midwives and 14 nurses/nurse practitioners. Thirty-three (29.2%) and 62 (54.9%) respondents reported interest in providing second trimester surgical and medical abortion care respectively. The most commonly identified barrier to both surgical and medical second trimester abortion provision was lack of trained staff, followed by an unsupportive work environment. Thematic analysis aligned with these findings and commonly featured difficulty in accessing feticide. We need to actively recruit and train all health practitioners interested in providing second trimester abortion care to strengthen the workforce. This requires an organisation to oversee an inclusive national framework for abortion training, including feticide, and provide professional supervision.

When doctors are “doxxed:” An analysis of information posted on an antiabortion website

ObjectivesTo systematically review information posted about abortion providers on an antiabortion website. Study designWithin a purposive sample of 64 abortion providers in 24 states, we reviewed 921 documents posted on the website. ResultsExtensive provider personal information obtained via public records laws and other public sources was posted on the website in an accessible and searchable format. ConclusionsPublic records laws and other public sources of information have opened potent avenues for collecting and disseminating providers’ personal information. ImplicationsThis website fits into a larger pattern of longstanding efforts to intimidate, threaten, and vilify providers.

Exploring Illinois contraceptive providers’ interest in medication abortion training

ObjectivesTo explore Illinois contraceptive providers’ interest in medication abortion training. Study designWe surveyed Illinois contraceptive providers to explore associations between interest in medication abortion training and provider, practice, and patient variables. ResultsOf 1040 reachable, eligible contacts, 251 responded to the survey (24% response rate) and more than half (56%) expressed interest in medication abortion training. Providers with the highest interest in medication abortion training were those with <2 days’ formal contraceptive training (n = 31; 76%) and those who received Title X funding (n = 32; 81%). ConclusionFindings suggest interest in medication abortion training among Illinois contraceptive providers. ImplicationsOur findings suggest some contraceptive providers may be interested in training opportunities around medication abortion. More research is needed to understand whether additional training could increase the number of providers able to counsel, refer, and provide medication abortion.

Provider Mistrust and Telemedicine Abortion Care Preferences Among Patients in Ohio, West Virginia, and Kentucky.

Objectives: The convenience and privacy provided by telemedicine medication abortion may make this service preferable to patients who mistrust their abortion provider. We assessed associations between mistrust in the abortion provider and preferences for telemedicine abortion. Study Design: From April 2020 to April 2021, we surveyed patients seeking abortion in Ohio, West Virginia, and Kentucky. Using unconditional logistic regression models, we examined unadjusted and adjusted associations between mistrust in the abortion provider and preferences for telemedicine abortion among all participants, and among only participants undergoing medication abortion. Results: Of 1,218 patients who met inclusion criteria, 546 used medication abortion services. Just more than half (56%) of all participants and many (64%) of medication abortion participants preferred telemedicine services. Only 6% of medication abortion participants received telemedicine medication dispensing services. Only 1.4% of all participants and 1% of medication abortion participants mistrusted the abortion provider. Participants who mistrusted the abortion provider were somewhat more likely to prefer telemedicine abortion (unadjusted odds ratio [OR]: 2.5, 95% CI: 0.8-7.9; adjusted OR: 2.9, 95% CI: 0.9-9), and medication abortion participants who mistrusted the abortion provider were also somewhat more likely to prefer telemedicine abortion (unadjusted OR: 3.5, 95% CI: 0.4-28.9; adjusted OR: 5.0, 95% CI: 0.6-43), although these associations were not statistically significant. Conclusions: In three abortion-restrictive states, most patients expressed preferences for telemedicine abortion, but few accessed them. Provider mistrust was rare, but those experiencing mistrust trended toward preferring telemedicine services. Telemedicine may improve access to abortion services for patients experiencing medical mistrust.