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.
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Cited by (22)
Physician beliefs about abortion safety and their participation in abortion care
2023, Sexual and Reproductive HealthcarePerspectives of internal medicine physicians regarding medication abortion provision in the primary care setting
2021, ContraceptionCitation Excerpt :As IM-trained physicians represent a larger proportion of PCPs compared to FM-trained physicians, the provision of medication abortions by IM PCPs has the potential to improve women's access to abortion by reducing geographic-related barriers, defragmenting health care, and bypassing the harassment and violence that many women experience when visiting a specialized abortion clinic [15]. However, few studies have evaluated the potential role of IM PCPs in providing medication abortion care or examined IM PCP's perspectives on abortion care [16]. To better understand the attitudes towards medication abortion provision among IM PCPs affiliated with a large academic medical center in western Pennsylvania, we surveyed trainee and attending IM PCPs about their willingness to provide medication abortions, interest in future provision of medication abortion, and potential barriers to provision.
Knowledge of medication abortion among adolescent medicine providers
2012, Journal of Adolescent HealthCitation Excerpt :The 2000 Kaiser study found that 47% of clinicians believed that medication abortion was very safe and 69% believed it was very effective [14]. A later study of California resident physicians showed somewhat improved medication abortion knowledge; 64% of residents believed medication abortion was very safe and 75% believed it was very effective [25]. Our data are most comparable with findings from general practitioners who receive similar training in abortion methods as most primary care-trained (pediatrics or medicine) SAHM members.
Abortion clinic patients' opinions about obtaining abortions from general women's health care providers
2010, Patient Education and CounselingCitation Excerpt :The high safety record of abortions in the U.S. [20,21] is evidence of the clinical proficiency of the current specialty care delivery system. At the same time, evidence also suggests that early abortion is safely performed by primary care providers including family physicians, internists, nurse practitioners, nurse midwives and physician assistants [22–32]. Additionally, many obstetrician–gynecologists perform abortion procedures only periodically for women with medical or fetal indications [3,33] suggesting that high volume is not necessary to maintain surgical skills for some providers.
Mifepristone: ten years later
2010, ContraceptionCitation Excerpt :Medical abortion can be easily incorporated into primary practices that do not provide uterine aspiration when referral services for surgical completion are available [65]. There is on-going interest and training of family medicine physicians and some interest among internists in providing medical abortion [66]. Mifepristone has also been dispensed by telemedicine when local services are not available [67].
Urban female patients' perceptions of the family medicine clinic as a site for abortion care
2009, ContraceptionCitation Excerpt :Although first-trimester induced abortion in the US is common, safe and can be performed in the outpatient primary care setting, early abortion services are generally offered apart from a woman's “usual” place of medical care. While there is a trend to increase the training in, and provision of, early abortion services within primary care [11–20], no prior published study has described why female patients in an urban, inner-city FMC would accept and/or utilize early abortion services in the FMC setting. Our results indicate that the majority of female patients sampled in our study support the provision of abortion in the FMC and many would access these services.
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.