Abortion Providers Research Articles

US Supreme Court decision put medication abortions in the spotlight

Two drugs that the US Food and Drug Administration deemed safe and effective 20 years ago were in the news in 2022. Mifepristone and misoprostol—a drug combination for terminating pregnancies up to 10 weeks of gestation—made headlines, not because of any new scientific findings but because the US Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization overturned Roe v. Wade , the case codifying the right to abortion. The ruling in Dobbs gave states the ability to restrict and even outlaw abortion at a time when the majority of people who terminate a pregnancy in the US do so using mifepristone and misoprostol—roughly 54% in 2020, according to a survey of abortion providers by the Guttmacher Institute. That’s up from 39% in 2017. The percentage of medication abortions has most likely been higher in 2022, as the FDA decided late last year that doctors no longer had to

The impact of criminalisation on abortion-related outcomes: a synthesis of legal and health evidence

Abortion is criminalised to at least some degree in most countries. International human rights bodies have recognised that criminalisation results in the provision of poor-quality healthcare goods and services, is...

Experts Share Advice for Post-Roe World: ‘We Have to Be Proactive’

Experts Share Advice for Post-<i>Roe</i> World: ‘We Have to Be Proactive’

Increasing the availability of long-acting reversible contraception and medical abortion in primary care: the Australian Contraception and Abortion Primary Care Practitioner Support Network (AusCAPPS) cohort study protocol

IntroductionAlthough primary care practitioners are the main providers of long-acting reversible contraception (LARC) and early medical abortion (EMA) in Australia, few provide these services. A professional community of practice (CoP)...

“An Oasis in the Desert:” Dr. Garson Romalis and the Struggle to Maintain Access to Abortion in Canada

Dr. Garson Romalis (1937-2014) was an obstetrician, gynaecologist and abortion provider in Vancouver, British Columbia. Like other abortion providers in North America, Romalis, his family and his clinic were subjected to years of harassment by pro-life activists. In 1994, Romalis was shot in his home by an anti-abortion terrorist and in 2000, he was stabbed by another terrorist outside of his clinic. Yet Romalis continued to provide this legal and essential medical procedure to British Columbian women, and advocated for the education of more abortion providers. This study will discuss the life and contributions of Gary Romalis and outline the motivations of the man to continue this dangerous work. It will compare his experiences with that of the more famous Canadian abortion provider, Dr. Henry Morgentaler, and speculate upon the significance of the Jewish ideal of tikkun olam (to heal the world) in these men’s lifework. Abortion terrorism will be situated within the constellation of pro-life activities, the goal of which is the curtailment of access to abortion in Canada.

Intimacy, Anonymity, and "Care with Nothing in the Way" on an Abortion Hotline.

This essay is an ethnographic account of a volunteer, anonymous hotline of physicians and advanced practice providers who offer medical advice and guidance to those who are taking medications on their own to end their pregnancies. Attending to the phenomenology of caring on the Hotline reveals a new form of medical expertise at play, which we call "care with nothing in the way." By operating outside the State's scrutiny of abortion provision, the Hotline offers its volunteers a way to practice abortion care that aligns with their professional and political commitments andthat distances them from the directharm they see caused by thepolitical, financial, and bureaucratic constraints of their clinical work. Bydelineating the structure of this new regime of care, these providers call into question the notion of the "good doctor." Theyradically re-frame widely shared assumptions about the tenets of the ideal patient-doctor relationship and engender anew form of intimacy-one based, ironically, out of anonymity and not the familiarity that is often idealized in the caregiving relationship. We suggest the implications of "care with nothing in the way" are urgent, not only in the context of increasing hostility to abortion rights, but also for a culture of medicine plagued by physician burnout.

The role of paediatrics in the abortion debate.

The role of paediatrics in the abortion debate.

Abortion incidence and service availability in the United States, 2020.

This study provides a baseline assessment of abortion incidence and service delivery prior to Roe v. Wade being overturned. We collected information from all facilities known to have provided abortion services in the United States in 2019 and 2020. We examined abortion incidence by state, region and nationally and combined data on number of abortions with population data to estimate abortion rates. We also examined the number of abortion clinics, trends in medication abortion and service disruptions and changes in abortion protocols that occurred during the COVID-19 pandemic. We compare these findings to those of our prior Abortion Provider Census, which collected information for 2017. We documented 930,160 abortions in 2020, an 8% increase from 2017. Between 2017 and 2020, abortion incidence increased in all four regions of the country and in a majority of states. The total number of clinics providing abortion care remained stable nationally but increased in the Midwest and the West and declined in the Northeast and South. There were 492,210 medication abortions in 2020, a 45% increase from 2017. A substantial minority of clinics adjusted protocols in response to COVID, most commonly adopting remote pre- and post-abortion counseling. This study did not address factors behind the increase in abortion. However, this report demonstrates that the need for abortion care was growing just prior to the overturning Roe v. Wade, and the impact of this decision will be even more far-reaching than previously expected.

P046Impact of birthing volumes on abortion provision and surgical miscarriage management

<h3>Objectives</h3> Pregnancy is a condition with a finite number of outcomes, including birth, abortion, and pregnancy loss. Existing studies describe seasonality trends for birth and abortion, but no studies assess relationships between birthing volumes and surgical abortion or surgically managed early pregnancy loss (SEPL) volumes. To evaluate relationships between obstetric outcomes, we designed this retrospective review of birth, abortion, and SEPL volumes at our medical center. <h3>Methods</h3> This retrospective ecological study utilized CPT billing codes to detail birth, abortion, and SEPL volumes at Vanderbilt University Medical Center from 2011 to 2019. Abortion and miscarriage cases were validated by individual chart review by the study team. Data were plotted on line and bar graphs to evaluate changes over time and relationships between outcomes. <h3>Results</h3> A total of 50,472 obstetric outcomes occurred in the study period. Proportions of White and Black patients were similar in the birth and composite abortion SEPL outcomes (68.2% vs. 71.6%; 15.5% vs. 17.4%). Both birth and surgical abortion volumes per year essentially doubled (3,511 to 6,573, 13–29); SEPL volume increased by a factor of 2.6 (115–268). The proportions of abortions and SEPL outcomes remained constant throughout the study period (0.4% and 3.4%). <h3>Conclusions</h3> As birthing volumes increase, so do abortion and SEPL volumes. Outcome proportions remained stable over time; these proportions can be used to estimate future abortion and SEPL volumes based on anticipated delivery volumes. When increasing delivery volumes, medical centers must prepare for increases in patients experiencing the breadth of obstetric outcomes.

P009Nurse practitioner prescribing of mifepristone in canada

<h3>Objectives</h3> In 2017, mifepristone became available for medication abortion in Canada and nurse practitioners became eligible prescribers. Barriers to abortion — such as rural and remote location, patient knowledge and stigma — could potentially be addressed through nurse practitioner provision. This study aimed to examine barriers and enablers to implementation of mifepristone prescribing in nurse practitioners' practice. <h3>Methods</h3> We conducted a sequential exploratory mixed methods study from August 2020 to May 2021 including a cross-sectional survey of nurse practitioners in Canada followed by semi-structured interviews with these providers and with stakeholders in health administration, government, advocacy, and regulation. We used feminist and interpretive theoretical lenses for analysis and organized data thematically. Descriptive analyses were used to interpret quantitative survey data. <h3>Results</h3> 181 nurse practitioners completed the survey, of whom 36% (n=65) self-identified as medication abortion providers and 64% (n=116) as non-providers. Mentorship was a key enabler of nurse practitioners' provision of medication abortion. Barriers included limited pharmacy access, lack of surgical back-up, and employer restrictions. Twenty-two nurse practitioners and 20 stakeholders participated in interviews. Enablers included clinical leadership roles, engagement in community education and communication, and interprofessional outreach. Barriers included low priority of abortion in nurse practitioners' practices, lack of support from colleagues or employers, and infrastructural barriers to ultrasound and emergency services. <h3>Conclusions</h3> Regulatory change is insufficient to change practice. Findings support the critical role of mentorship to improve uptake of nurse practitioners' prescription of mifepristone and address employer restrictions and resource barriers, and point to the need to augment abortion education to foster understanding among colleagues. Findings can be integrated into policy, support practice changes, and direct future research to advance equitable access to abortion.

O12Barriers to abortion access for young southerners: a qualitative analysis of case notes from arc-southeast

<h3>Objectives</h3> Abortion funds have intervened to ensure young people can access safe, compassionate abortion care in the abortion-restrictive US Southeast. This study identifies barriers to abortion access and describes the obstacles young Southerners who seek abortion funding must navigate to inform strategies to reduce barriers to abortion care. <h3>Methods</h3> We conducted a secondary qualitative data analysis of case notes from people aged 21 or younger who resided in six Southeastern states and contacted the ARC-Southeast Healthline between May 2016 and May 2021 (n=2,278). Nine hundred and fifty information-rich case notes were selected for thematic analysis (n=950). <h3>Results</h3> The findings revealed that young Southerners encounter a multitude of barriers addressed by abortion funds within four primary categories: structural barriers, financial barriers, personal barriers, and the COVID-19 pandemic. Each type of barrier contributed to constrained bodily autonomy and delayed abortion care. Case notes also described the difficulties that youth seeking abortion care support navigate, which are scarcely documented in abortion access literature, such as pre-existing conditions, intimate partner violence, and immigration status. We conceptualized these findings into a framework synthesizing the challenges, impacts, and opportunities for abortion provision in the US Southeast. <h3>Conclusions</h3> The study findings suggest abortion funds serve a vital role in the disruption of structural violence imposed by Southern legislators to deter and delay youth from obtaining abortion care. To dismantle the systems of oppression that deny dignity and respect to young Southerners who seek abortion care, the best practices employed by abortion funds should be adopted to improve abortion care provision.

P044Maximizing available resources to increase medication abortion access in restricted legal environments: Lessons from rwanda

<h3>Objectives</h3> Rwanda expanded legal grounds for abortion in 2012, but limits provision to doctors in hospitals, resulting in unequal access. This study illustrates how technologies and infrastructure can bring first trimester medication abortion closer to more vulnerable populations within a restricted legal context. <h3>Methods</h3> A SAFE (safety, acceptability, feasibility, and effectiveness) study was implemented to assess a telemedicine model to enable primary care nurses to provide first-trimester medication abortion by teleconsulting with district hospital doctors. The doctors provided clinical guidance and authorized medication abortion remotely, while the nurses consulted with the client, provided medication, and conducted follow-up. The feasibility component of the study described the programmatic (service delivery protocol) and policy changes (level of provision) needed to comply with the restrictive laws while increasing access. <h3>Results</h3> Primary care nurses (two per health center) were successfully trained in medication abortion provision using mifepristone-misoprostol combination and ultrasound. Teleconsultation between doctors and nurses created a channel for doctors to provide remote authorization and allowed clients to receive services in their communities. Between October 15, 2021 and May 15, 2022, 165 clients received medication abortion at the health centers. Protocol ensured high adherence rates; all clients completed treatment. Referrals to the hospital decreased as only those in the second trimester or < 15 years were referred. <h3>Conclusions</h3> We successfully brought medication abortion services to communities by maximizing available technologies and infrastructure. This research has applicability beyond Rwanda: It provides a concrete example of how to design a task-shifting model to reach vulnerable populations in a restricted legal environment.

P043Southern health providers’ perspectives on policy considerations for implementation of telehealth medication abortion services

<h3>Objectives</h3> The Southeastern US has increased restrictions on abortion. Medication abortion provision via telehealth may connect those in the region to necessary abortion services, but evidence on implementation of this service, particularly considering state and organizational policies, is lacking. We explored providers' understanding and perceptions of existing state-level and organizational policies related to medication abortion provision via telehealth, potential impact on their practice, and their perceptions of recent changes to telemedicine policies nationally. <h3>Methods</h3> Semi-structured interviews with 21 administrators and clinicians in 13 Southeastern states (September–November 2021) were audio-recorded, transcribed verbatim, and analyzed using MaxQDA. A codebook was developed based on an initial set of transcripts and further refined by consensus and assessment of intercoder reliability. Transcripts were thematically analyzed utilizing constant comparative method. <h3>Results</h3> All participants identified of state policies that constrained their medication abortion service delivery beyond telemedicine bans. Most respondents felt high anxiety because of the changing policy landscape and discussed the lifting of Risk Evaluation and Mitigation Strategy on mifepristone as resulting in little change to their practice. Most participants discussed adjacent state-level policies, eg, ultrasound viewing laws, as posing salient barriers to medication abortion provision via telehealth. Some cited clinic/organizational policies, such as ultrasound waivers, as acting as buffers to the burdens posed by state-level restrictions and facilitators for provision of this service. <h3>Conclusions</h3> For participants, state-level telemedicine bans were not the primary barrier to medication abortion provision via telehealth, with most citing another law making the service infeasible. In light of the <i>Dobbs v. Jackson Women's Health Organization</i> decision, further attention should be paid to organizational policies, which may support unbundling of telehealth medication abortion and ensure abortion access for Southerners.

P014Evaluating abortion cash-pay availability during the early covid-19 pandemic: Data from a nationwide survey of abortion providers

<h3>Objectives</h3> Pregnant people seeking abortion may require access to cash-pay services, and little is known about cash-pay availability for abortion services among US abortion clinics. We examined differences in cash-pay options between hospital-affiliated clinics and non-hospital-affiliated clinics (independent or Planned Parenthood clinics). <h3>Methods</h3> We analyzed data from the second phase of a longitudinal nationwide survey of abortion providers conducted by the Society of Family Planning (collected May–July 2020). We compared cash-pay options for medication abortion, first-trimester surgical/procedural abortion, and dilation and evacuation offered by hospital-affiliated and non-hospital-affiliated clinics. <h3>Results</h3> Sixty-two clinics completed the survey (31 hospital-affiliated and 31 non-hospital-affiliated). We found that 85% of all clinics offered a cash-pay option for medication abortion, 86% for first-trimester abortion, and 78% for dilation and evacuation. We found that hospital-affiliated clinics were significantly less likely to report serving out-of-state patients (p<0.01), first-trimester surgical/procedural abortion (75% vs. 97%, p=0.02), and dilation and evacuation (62% vs. 100%, p<0.01). <h3>Conclusions</h3> Though a majority of all clinics surveyed offered cash-pay options for abortion, hospital-affiliated clinics were less likely to offer cash-pay options for abortion procedures. Given concerns regarding future abortion access, it will be important to expand availability of cash-pay options for abortion in all settings. From our data, hospital-affiliated clinics have the most room to improve on this front.

P024“Doulas do need to be there to support if they choose to have an abortion”: Family planning attitudes and stigma among doulas in georgia

<h3>Objectives</h3> This community-engaged study examines abortion and family planning doula services, attitudes toward these services, abortion stigma faced by abortion doulas, and doulas' recommendations to improve access to care. <h3>Methods</h3> From October 2020 to February 2022, academic researchers and a community-based maternal-child health organization conducted a cross-sectional, mixed-methods study with full-spectrum doulas in Georgia, where maternal mortality is high but abortion and contraceptive access are restricted. We interviewed and surveyed 20 doulas about their scope of abortion and contraceptive care, their personal attitudes toward family planning, and experiences with abortion stigma. <h3>Results</h3> Our sample was diverse by race/ethnicity (45% Black/African American, 40% White, 5% Latinx, 10% other) and services provided (85% birth, 60% postpartum, 40% full-spectrum, 35% abortion, 45% family planning). Participants reported positive attitudes toward abortion and contraception (Stigmatizing Attitudes and Beliefs=22.29 on an 18–40 scale; adapted Sexual and Reproductive Health Stigma Scale=8.6 on a 6–13 scale). Among abortion doulas, abortion provider stigma was moderate to high (average Abortion Provider Stigma Survey (APSS) score=24 on a 17–27 scale), and resilience was moderate (average resilience score=7 on a 4–11 scale). <h3>Conclusions</h3> This study contributes two main findings: first, family planning and abortion care training are needed and desired by doulas of all kinds. Second, abortion stigma is being experienced by abortion doulas. As contraceptive and abortion care is further restricted, doulas may serve as a vital link to family planning services. Increasing doulas' capacity to provide contraceptive counseling and abortion care is feasible and imperative.

P036Exploring us obstetrician-gynecologists’ characterization of periviable pregnancy-ending interventions: A mixed methods study

<h3>Objectives</h3> To explore how US obstetrician gynecologists (Ob-Gyns) characterize periviable pregnancy-ending interventions as obstetric or abortion care, and to understand how those determinations are made. <h3>Methods</h3> From April to June 2021, we performed an explanatory sequential mixed methods study of US Ob-Gyns, recruited through overlapping online communities. We administered a cross-sectional survey requesting characterization of eight potentially ambiguous clinical scenarios, using chi-square tests to compare determinations by physician and institutional factors. We then conducted semi-structured interviews in a diverse nested sample, merging quantitative and qualitative data about decision making in a joint mixed methods analysis. <h3>Results</h3> We received 209 survey responses, with 101 (48.3%) current abortion providers and 42 (20.1%) never-providers, and completed 21 qualitative interviews. Characterization of pregnancy-ending interventions as induced abortion ranged from 21.1% for a 22-week labor induction in setting of chorioamnionitis, to 83.1% for a 24-week feticidal injection and labor induction in setting of fetal anencephaly. Interventions were less often characterized as abortion when performed for maternal indications, for instance only 42.6% of respondents felt a 22-week dilation and evacuation for chorioamnionitis was an abortion, compared to 82.1% for 24-week dilation and evacuation for anencephaly (p<0.001). Other significant associations with abortion determination included method type (procedural more likely than medication-only), abortion experience (ever-providers more likely than never-providers), and state and institutional abortion regulations ("I have to call it a medical inducement.…I'm not allowed to use the word abortion."). <h3>Conclusions</h3> Unclear definitions and administrative overreach lead to inconsistency and subjectivity in care for periviable pregnancy complications. With widespread abortion restrictions, characterization of interventions can affect access to necessary medical care.

Current challenges faced by transgender and gender-diverse patients and providers in anesthesiology.

Current challenges faced by transgender and gender-diverse patients and providers in anesthesiology.

The double-edged sword of abortion regulations: Decreasing training opportunities while increasing knowledge requirements

ABSTRACT Purpose The authors explore how abortion regulations in Ohio, an abortion-restrictive state in the USA, impact obstetrician-gynecologists’ (OB/GYNs) training in reproductive healthcare and describe what OB/GYNs believe to be the broader impact of Ohio’s regulations on skill-building, skills maintenance, and professional retention of reproductive healthcare providers in the state. Authors discuss how their findings foreshadow abortion training limitations in Ohio and other abortion-restrictive states now that abortion regulations have returned to the states. Methods The authors conducted four semi-structured focus groups and five in-depth interviews between April 2019 and March 2020. Participants included OB/GYNs practicing obstetrics and gynecology in Ohio between 2010 and 2020. Thematic analysis was conducted using Atlas.ti. Results Twenty attending physicians and 15 fellows and residents participated in the study. Participants discussed the impact of Ohio’s written transfer agreement, gestational-limit, and abortion method and facility bans on training and skill-building opportunities. Participants felt that Ohio’s strict abortion regulations 1) limit opportunities to observe and perform abortion procedures during training; 2) require learning the ever-changing legality of abortion provision; 3) limit the number of abortions OB/GYNs can provide, leading to the atrophy of their skills over time; and 4) may prevent prospective medical students and residents from choosing to study in Ohio and may lead to physician attrition from the state. Conclusion Prior to the reversal of federal protections for abortion in 2022, OB/GYNs in Ohio and other abortion-hostile states experienced barriers to training in abortion care. In returning abortion regulation to the states, access to training is likely to be increasingly restricted. This research demonstrates how abortion-restrictions hamper physicians’ skills needed to care for patients, particularly in emergent situations. This puts patients at risk and places physicians in precarious ethical positions. Expanding protections and reducing restrictions on abortion will ensure OB/GYNs and trainees have the skills necessary to care for patients presenting for reproductive healthcare.

“I don’t regret it at all. It’s just I wish the process had a bit more humanity to it … a bit more holistic”: a qualitative, community-led medication abortion study with Black and Latinx Women in Georgia, USA

Traditional family planning research has excluded Black and Latinx leaders, and little is known about medication abortion (MA) among racial/ethnic minorities, although it is an increasingly vital reproductive health service, particularly after the fall of Roe v. Wade. Reproductive justice (RJ) community-based organisation (CBO) SisterLove led a study on Black and Latinx women’s MA perceptions and experiences in Georgia. From April 2019 to December 2020, we conducted key informant interviews with 20 abortion providers and CBO leaders and 32 in-depth interviews and 6 focus groups (n = 30) with Black and Latinx women. We analysed data thematically using a team-based, iterative approach of coding, memo-ing, and discussion. Participants described multilevel barriers to and strategies for MA access, wishing that “the process had a bit more humanity … [it] should be more holistic.” Barriers included (1) sociocultural factors (intersectional oppression, intersectional stigma, and medical experimentation); (2) national and state policies; (3) clinic- and provider-related factors (lack of diverse clinic staff, long waiting times); and (4) individual-level factors (lack of knowledge and social support). Suggested solutions included (1) social media campaigns and story-sharing; (2) RJ-based policy advocacy; (3) diversifying clinic staff, offering flexible scheduling and fees, community integration of abortion, and RJ abortion funds; and (4) social support (including abortion doulas) and comprehensive sex education. Findings suggest that equitable MA access for Black and Latinx communities in the post-Roe era will require multi-level intervention, informed by community-led evidence production; holistic, de-medicalised, and human rights-based care models; and intersectional RJ policy advocacy.

Nurse practitioners on 'the leading edge' of medication abortion care: A feminist qualitative approach.

To explore nurse practitioners' experiences of medication abortion implementation in Canada and to identify ways to further support the implementation of medication abortion by nurse practitioners in Canada. A qualitative approach informed by feminist theory and integrated knowledge translation. Qualitative interviews with stakeholders and nurse practitioners between January 2020 and May 2021. Data were analysed using critical feminist theory. Participants included 20 stakeholders, 16 nurse practitioner abortion providers, and seven nurse practitioners who did not provide abortions. We found that nurse practitioners conduct educational, communication and networking activities in the implementation of medication abortion in their communities. Nurse practitioners navigated resistance to abortion care in the health system from employers, colleagues and funders. Participants valued making abortion care more accessible to their patients and indicated that normalizing medication abortion in primary care was important to them. When trained in abortion care and supported by employers, nurse practitioners are leaders of abortion care in their communities and want to provide accessible, inclusive services to their patients. We recommend nursing curricula integrate abortion services in education, and that policymakers and health administrators partner with nurses, physicians, midwives, social workers and pharmacists, for comprehensive provincial/territorial sexual and reproductive health strategies for primary care. The findings from this study may inform future policy, health administration and curriculum decisions related to reproductive health, and raise awareness about the crucial role of nurse practitioners in abortion care and contributions to reproductive health equity. This study focused on provider experiences. In-kind support was provided by Action Canada for Sexual Health & Rights, an organization that provides direct support and resources to the public and is committed to advocating on behalf of patients and the public seeking sexual and reproductive health services.