Elsevier

Contraception

Volume 77, Issue 6, June 2008, Pages 397-404
Contraception

Original research article
Determinants of demand: method selection and provider preference among US women seeking abortion services

https://doi.org/10.1016/j.contraception.2008.02.003Get rights and content

Abstract

Background

Medication abortion has the potential to increase abortion availability, primarily through new provider networks; however, without a better understanding of how and why women make decisions regarding both their abortion method and their provider, expansion efforts may be misguided and valuable resources may be wasted.

Study Design

We undertook an exploratory study to investigate method and provider preferences. Semistructured one-on-one interviews were conducted with 205 abortion clients at three family planning clinics.

Results

Study participants greatly preferred the clinic setting for their abortion; the majority of women in the study would not have gone to their regular physician if they had been given the option. In addition, method choice trumps provider choice for the majority of women who would have preferred their regular provider. Participants who chose the aspiration procedure were more likely to have previous knowledge about the medication method. Travel time was not a predictor of preferring one's regular physician over the clinic.

Conclusions

Expanding provider networks via the private sector is unlikely to be a panacea. In addition to these efforts, more attention may need to be paid to addressing logistic barriers to access. Physicians offering abortion services need to let their patients know they offer such services prior to their patients' need for them. Questions remain regarding the information being circulated about medication abortion.

Introduction

Approximately half of all pregnancies in the United States are unintended, and >40% of these pregnancies end in termination [1]. While the abortion rate has declined slightly in recent years, this service is still sought annually by approximately 2% of women of reproductive age [2]. Although the demand remains high, there are growing concerns about the supply of providers and access to services. For example, only 13% of US counties have an abortion provider; consequently, 34% of women in the United States (49% in the Midwest and 45% in the South) live in counties with no access to abortion, creating a substantial burden for women who must travel a great distance to reach a provider [2]. This burden increases for women living in the 24 states with enforceable mandatory delay laws, many of which require multiple visits [3].

A related concern is the decline, over several decades, in the number of abortion provision sites, as well as in the number of individual clinicians performing the service [2], [4]. In addition, since most abortions are performed at abortion clinics [2], women with established health care providers often must seek out a new provider at a new location in order to obtain abortion services. While these various barriers to access may cause financial, logistic and/or emotional hardships, they also contribute to delays in the abortion procedure itself, for which the associated risks have been shown to increase with gestation [5].

Medication abortion has the potential to greatly improve the availability of abortion services by expanding provider networks to include physicians who do not offer aspiration procedures. Diversifying the types of providers might be especially useful in rural areas where family physicians provide the majority of health care [6]. In the handful of states without physician-only abortion laws [3], nurse practitioners and physician assistants could also provide this service. A related benefit to expanding provider networks could be a reduction in the harassment of abortion patients, which is still a fairly common occurrence [7].

Unfortunately, such an expansion has yet to occur, as medication abortion is infrequently available from any provider not already offering aspiration abortion [8], [9]. Both logistic and legislative issues quite likely play a large role in this lack of uptake [9], [10], [11]. A third possible reason, briefly addressed in prior publications [8] and requiring further exploration, is a perceived lack of demand for medication abortion from women utilizing private health care. If the latter is indeed a barrier to adding medication abortion services, it should be validated and addressed. However, little is known about women's interest in medication abortion, let alone their willingness to forgo a choice of surgical or medical method. While a few studies of American women have explored reasons for choosing medication abortion (the majority of which were conducted prior to the approval of mifepristone in this country or were performed among women using methotrexate regimens) [12], [13], [14], [15], very little is known about why some American women select the aspiration option when choosing to have an abortion [16]. Moreover, to our knowledge, there exist no published data exploring clients' desires regarding the type of abortion provider (specifically the interest in one's private or “regular” physician), nor how method and provider choices might intersect. Until there is a better understanding of the clinical decision making of abortion clients, the promise of the use of medication abortion to improve access to services through expanded provider networks is likely to remain unrealized.

Section snippets

Materials and methods

An exploratory study was undertaken to investigate how abortion clients select their method of abortion, how they select their abortion provider, and how these two choices interact. The study took place from May through July 2006 at three Planned Parenthood of Greater Iowa (PPGI) clinics that offered both aspiration and medication abortion services. The study was approved by the University of Michigan Health Sciences Institutional Review Board and by the Planned Parenthood Federation of

Descriptives

During the interview period, 638 patients aged ≥18 years had abortions at the participating clinics. Of these, 205 were interviewed. The response rate is therefore estimated at 32%; however, this percentage is somewhat conservative due to a small number of non-English speakers, estimated at three to four per week (personal communication with clinic managers), who were not eligible for the study. All but one woman who expressed interest in the study signed consent forms and were interviewed.

The

Discussion

This research study is exploratory and, therefore, primarily descriptive. Given the paucity of studies that have investigated abortion method preferences and the absence of published work on abortion provider preferences, these data may offer some important insights into these arenas. Additionally, while the study was conducted in only one state, there are implications for many parts of the country.

Expanding provider networks into the private sector (primarily via provision of medication

Acknowledgments

This study was funded by Danco Laboratories, LLC. Thanks are expressed to Rachel Snow for comments on an earlier draft of this study.

References (19)

There are more references available in the full text version of this article.

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    Another hypothesis is that respondents from rural sites prefer to access abortion outside of the primary care setting. One study of people seeking abortion care in Iowa found that the majority of those surveyed would not prefer to obtain abortion care from their regular family medicine or OB/GYN physician, citing uncertainty of confidentiality, or because their doctor knew their family [8]. Confidentiality concerns are similarly found in studies of other stigmatized services, including substance use disorder treatment [18].

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