Willing and able? Provision of medication for abortion by future internists
Introduction
Unwanted pregnancy remains a significant burden for the United States, where the abortion rate is among the highest known in a developed nation (Henshaw, Singh, & Hass, 1999). Abortion is one of the most common surgical procedures performed in the United States; in 2000, approximately 1.3 million abortions were performed (Finer & Henshaw, 2003). Despite the need for services, over 87% of U.S. counties lack an aspiration abortion provider (Henshaw & Finer, 2003). Research has documented that one-quarter of women who seek abortions travel 50 miles or further for services (Henshaw & Finer, 2003). International experience (Ahman & Shah, 2002) and our own pre-Roe v. Wade history (Polgar & Fried, 1976) demonstrate that limited access to abortion services does not decrease the number of abortions performed, but rather increases the number of women who are injured by unsafe abortions or attempts to self-abort. In the United States, when induced abortion was legalized, abortion-related mortality dropped sharply (Cates, Grimes, & Schulz, 2003).
The development of medications such as mifepristone, which has been shown to safely and effectively terminate pregnancies prior to 9 weeks of gestation, has created the opportunity to introduce early abortion services in the setting of traditional primary care office practice (Breitbart, Rogers, & Vanderhei 2000; Creinin, 2000).
Provision of mifepristone by primary care providers has the potential to markedly increase the number of locations where women may access abortion services, decrease the visibility of abortion providers, and possibly reduce the risk of violence directed toward providers and their patients. Given the continuing decline in numbers of abortion providers (Finer & Henshaw, 2003), it is also important to note that the time and resources required to train a health-care provider to dispense mifepristone are significantly less than to train an aspiration abortion provider (Breitbart, 2000).
Prior studies of provision of medication abortion have focused on the intentions of those generally trained to provide aspiration abortions, namely gynecologists and family practitioners. However, medication abortion has the potential to be provided by a much larger group of physicians. Every year in the United States, we train over twice as many internists as gynecologists and family practitioners combined (National Residency Matching Program, 2003). To our knowledge, there has been no organized effort to train general internists to provide mifepristone, and internists have not been studied with regard to their interest in and intention to provide medication abortion services.
This study was designed to assess what internal medicine residents know about mifepristone and whether they intend to incorporate medication abortion into their clinical practices. For the sake of comparison with prior studies, we also surveyed a number of residents training in family practice and gynecology. Our hypothesis was that some internists are interested in providing medication abortion services, but that current curricula leave internists less knowledgeable about how to provide medication for abortion than residents training in family practice or gynecology.
Section snippets
Setting and participants
We identified 12 postgraduate training programs (seven internal medicine, two family practice, and three gynecology) in the San Francisco Bay Area. These programs included three academic training programs, four Kaiser Permanente programs, three county facilities, a Catholic health center, and a private medical center. However, one academic program does not allow contact with residents for research purposes. In addition, we excluded from our sample 12 “transitional” interns training at these
Results
The demographic characteristics of responding internists are described in Table 1. Internists were similar to other trainees with regards to year of training, age, gender, ethnicity, and religiosity. Responding internists were only slightly more likely than family practitioners to report a personal opposition to abortion (19% versus 16%, p = .366) but were more likely than gynecologists to report a personal opposition to abortion (p < .001).
About half (53%) of residents training in primary care
Discussion
Our findings suggest that many (42%) internal medicine residents are interested in providing mifepristone for early abortion despite the fact that historically internists have rarely performed aspiration abortion procedures. Although the internists we surveyed were less willing to prescribe mifepristone than family practice and gynecology residents, their willingness to provide mifepristone was similar to that reported by a much larger group of gynecologists and family practitioners previously
Acknowledgments
The David and Lucille Packard Foundation, the Open Society Institute, and the Health Resources Service Administration training grant #1D22HP00349-01 funded this work. We would like to thank Eric Vittinghoff, PhD, and Deborah Grady, MD, MPH, for their help with this work.
Dr. Eleanor Bimla Schwarz is a general internist and clinical research fellow at the University of California, San Francisco (USCF). Her interests include comprehensive primary care, reproductive health services, and birth defect prevention.
References (14)
- et al.
Unsafe abortionworldwide estimates for 2000
Reproductive Health Matters
(2002) - et al.
Factors affecting the outcome of early medical abortiona review of 4132 consecutive cases
British Journal of Obstetrics Gynecology
(2002) Counseling for medical abortion
American Journal of Obstetrics and Gynecology
(2000)- et al.
Medical abortion service delivery
American Journal of Obstetrics and Gynecology
(2000) Medical abortion regimenshistorical context and overview
American Journal of Obstetrics and Gynecology
(2000)- et al.
The roles of clinical assessment, human chorionic gonadotropin assays, and ultrasonography in medical abortion practice
American Journal of Obstetrics and Gynecology
(2000) - et al.
Randomized trial of oral versus vaginal misoprostol at one day after mifepristone for early medical abortion
Contraception
(2001)
Cited by (0)
Dr. Eleanor Bimla Schwarz is a general internist and clinical research fellow at the University of California, San Francisco (USCF). Her interests include comprehensive primary care, reproductive health services, and birth defect prevention.
Dr. Annie Luetkemeyer is an infectious disease fellow at UCSF focusing on HIV and tuberculosis coinfection. She has an active interest in women’s health, including issues of maternal-child transmission of HIV, contraception, and medical abortion.
Dr. Diana Greene Foster is a demographer who works on the evaluation of quality and access to care and the effectiveness of reproductive health programs.
Ms. Tracy Weitz is a doctoral student in medical sociology with an interest in abortion provision and comprehensive women’s health.
Dr. Deborah Lindes is an assistant clinical professor of Medicine at the University of California, San Francisco, and a clinican-educator at California Pacific Medical Center and. Her major areas of interest are in primary care, women’s health, and resident education.
Dr. Felicia H. Stewart, a gynecologist, is director of the Advancing New Standards in Reproductive Health (ANSIRH) program of the Center for Reproductive Health Research and Policy at the University of California, San Francisco, who is interested in abortion and contraceptive technology.