What prevents family medicine physicians from providing medical abortions for patients who need them?
This is a question that UC Davis and UC San Francisco researchers explored in a new study published today in the Journal of the American Board of Family Medicine. The study identified multiple barriers – including lack of training and restrictions from federal and state government as well as their institutions -that family physicians must navigate to provide abortion services to their patients.
“Family physicians are the first contact for many patients within the health care system,” said Na’amah Razon, assistant professor of family and community medicine at UC Davis Health and lead author of the study. “As such, they play a critical role in promoting better access to safe abortion options.”
Medication abortion using mifepristone
Medication abortion is a non-surgical procedure that uses medication to end a pregnancy. It involves taking two medicines in sequence: mifepristone and misoprostol. This combination is approved by the Food and Drug Administration (FDA) for medical abortion during the first 70 days of pregnancy.
Recent studies have shown that medical abortion is safe and effective for pregnancy termination, even without an in-person clinical evaluation.
Barriers to primary care providers
The new study highlighted the experiences of family medicine physicians interested in providing medical abortions.
The researchers interviewed 41 early career family physicians and seven leaders in family medicine from across the United States. They classified them into three groups based on their medical abortion training and whether or not they provide abortion services:
Those who have not received abortion training and do not provide abortions: Physicians in this group pointed to the lack of training in abortion as the most significant barrier to providing abortion services. This finding suggests a critical need to strengthen exposure and training opportunities throughout medical education.
Those who have received abortion training but do not provide abortions: This group of trained physicians, the largest in the sample, discussed the layers of state and institutional restrictions they encounter that prevent them from prescribing the abortion pill. The restrictions include regulations that require abortion to take place only in non-ambulatory or surgical settings, which makes abortion impossible in some primary care clinics. In addition, physicians in federally qualified health centers experience restrictions such as the Hyde Amendment which prohibits the use of federal funds for abortion care.
Some also pointed to logistical challenges imposed by an FDA drug safety program, called Risk Evaluation and Mitigation Strategy (REMS). The program’s criteria on mifepristone requires certified physicians to sign and obtain the signature of patients for the patient’s medical file. Despite research documenting the safety of mifepristone, a recent study by Razon and her colleagues found that the REMS criteria on mifepristone poses unique challenges to family physicians.
Those who have received abortion training and currently provide abortions: The majority of family physicians the study interviewed who provide abortions do so outside of primary care clinics. A total of 60% of participants in this group practiced in reproductive health clinics that allowed them to prescribe abortion pills. These physicians stated that institutional policies, lack of support from obstetrics and gynecology departments, and early career status of practitioners prevented some of them from providing abortions in primary care settings.
All participants in the study who provided medical abortion in primary care settings were based in the Northeast or West. None were practicing in states with significant abortion restrictions. Those who provided abortions in federally qualified health centers credited their persistence and were grateful for the support of their leadership.
Systemic barriers to medical abortions
“Our study highlights the ongoing individual, system and policy barriers family physicians face in integrating medication abortion into primary care,” said Razon, who is affiliated with the UC Davis Center for Healthcare Policy and Research. “This is a critical time where family physicians can and should play a role in strengthening abortion access.”
According to the researchers, improving access will require addressing the individual and system barriers that family physicians face. They proposed a framework to develop communications strategies to help motivate family physicians to provide medical abortion.
“Primary care doctors need the education, training and support to successfully integrate abortion care into their clinical practice,” said the senior author of the study Christine Dehlendorf. Dehlendorf is the director and professor at the Person-Centered Reproductive Health Program in the Department of Family and Community Medicine at the University of California, San Francisco (UCSF).
Co-authors of the study are: Sarah Wulf, Citlali Perez, Kelsey Holt, Edith Fox and Ilana Silverstein of UCSF’s Person-Centered Reproductive Health Program; Sarah McNeil of Contra Costa Regional Medical Center; Lisa Maldonado of the Reproductive Health Access Project; and Alison Byrne Fields of Aggregate. The study was funded through the Society of Family Planning Research Fund (SFPRF12-MA9).
