Article

“She's on her own”: A thematic analysis of clinicians' comments on abortion referral

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Abstract

Objective: To understand the motivations around and practices of abortion referral among women's health providers. Methods: We analyzed the written comments from a survey of Nebraska physicians and advanced-practice clinicians in family medicine and obstetrics-gynecology about their referral practices and opinions for a woman seeking an abortion. We analyzed clinician's responses to open-ended questions on abortion referral thematically. Results: Of the 496 completed surveys, 431 had comments available for analysis. We found four approaches to abortion referral: 1) facilitating a transfer of care, 2) providing the abortion clinic name or phone number, 3) no referral, 4) and misleading referrals to clinicians or facilities that do not provide abortion care. Clinicians described many motivations for their manner of referral, including a fiduciary obligation to refer, empathy for the patient, respect for patient autonomy, the lack of need for referral. We found that abortion stigma impacts referral as clinicians explained that patients often desire additional privacy and clinicians themselves seek to avoid tension among their staff. Other clinicians would not provide an abortion referral, citing moral or religious objections, or stating they didn't know where to refer women seeking abortion. Some respondents would refer women to other providers for additional evaluation or counseling before an abortion, while others sought to dissuade the woman from obtaining an abortion. Conclusions: While practices and motivations varied, few clinicians facilitated referral for abortion beyond verbally naming a clinic if an abortion referral was made at all. Implications: Interprofessional leadership, enhanced clinician training and public policy that addresses conscientious refusal of abortion referral are needed to reduce abortion stigma and ensure women can access safe care.

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... Twenty-six studies ( Weitz and Cockrill, 2010) described instances of providers acting as gatekeepers to abortion care, including actions taken to actively discourage abortion seekers from accessing services. About one-third of these studies (de Vries et al., 2020;Fathallah, 2019;Freeman and Coast, 2019;Freedman et al., 2010;Heller et al., 2016;Homaifar et al., 2017;Hulme-Chambers et al., 2018;Kimport et al., 2016;Margo et al., 2016;Pheterson and Azize, 2008) focused on matters directly related to the delivery of timely services or issues related to geography (i.e. accessibility). ...
... In a few studies, participants specifically described their providers' obstructionist behavior. Providers intentionally misled abortion seekers by providing false referrals to adoption agencies, crisis pregnancy centers or therapists (Homaifar et al., 2017;Margo et al., 2016). In some of these cases, providers felt that abortion seekers needed additional counseling, aware that crisis pregnancy centers, specifically, would dissuade individuals from having an abortion (Homaifar et al., 2017). ...
... Providers intentionally misled abortion seekers by providing false referrals to adoption agencies, crisis pregnancy centers or therapists (Homaifar et al., 2017;Margo et al., 2016). In some of these cases, providers felt that abortion seekers needed additional counseling, aware that crisis pregnancy centers, specifically, would dissuade individuals from having an abortion (Homaifar et al., 2017). Abortion seekers in one study viewed requirements for unnecessary testing and multiple visits as an attempt to deter care . ...
Article
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Abortion stigma shapes the environment in which abortion is delivered and received and can have important implications for quality in abortion care. However, this has not previously been clearly articulated and evidenced. We conducted a scoping review of existing qualitative evidence to characterise the relationship between abortion stigma and quality in abortion care. Using a systematic process, we located 50 qualitative studies to include in our analysis. We applied the interface of the WHO quality of care and abortion stigma frameworks to the qualitative evidence to capture manifestations of the interaction between abortion stigma and quality in abortion care in the existing literature. Four overarching themes linked to abortion stigma emerged: A) abortion as a sin and other religious views; B) regulation of abortion; C) judgement, labelling and marking; and D) shame, denial, and secrecy. We further characterized the emerging ways in which abortion stigma operates to inhibit quality in abortion care into seven manifestations of the relationship between abortion stigma and quality in abortion care: 1) poor treatment and the repercussions, 2) gatekeeping and obstruction of access, 3) avoiding disclosure, 4) arduous and unnecessary requirements, 5) poor infrastructure and lack of resources, 6) punishment and threats and 7) lack of a designated place for abortion services. This evidence complements the abortion stigma-adapted WHO quality of care framework suggested by the International Network for the Reduction of Abortion Discrimination and Stigma (inroads) by illustrating specifically how the postulated stigma-related barriers to quality abortion care occur in practice. Further research should assess these manifestations in the quantitative literature and contribute to the development of quality in abortion care indicators of that include measures of abortion stigma, and the development of abortion stigma reduction interventions to improve quality in abortion care.
... 1 While some physicians may experience true ambivalence, or the simultaneous "presence of opposing considerations," 7 other "respondents who are well-educated and well-informed about policy questions might be able to provide the arguments of both partisans, while adhering more strongly to one, or to neither." 6 False dichotomies between pro-and anti-abortion attitudes ignore clinicians with complex abortion attitudes, including those who generally oppose abortion but find it acceptable in specific cases, those who generally support abortion but find it unacceptable in certain contexts, and those who are willing to help patients access abortion care even in contexts that they personally find morally objectionable. 1,8,9 Physicians' attitudes have consequences for abortion access, especially when they translate to willingness to participate in abortion-related care. Clinicians must balance their (potentially conflicting) personal and professional attitudes 10 against empathy for patients, patient safety and autonomy, fiduciary or professional responsibilities, religious or moral orientation, and desire to respect the beliefs of colleagues. ...
... Clinicians must balance their (potentially conflicting) personal and professional attitudes 10 against empathy for patients, patient safety and autonomy, fiduciary or professional responsibilities, religious or moral orientation, and desire to respect the beliefs of colleagues. 8,11 Medical specialty may be related to abortion attitudes, though the relationship is likely a two-way street. In one study, pediatric and obstetric specialists asserted that their primary responsibilities were to fetuses and to pregnant patients, respectively-a relationship that might be explained by a priori alignment of their values and professional pursuits. ...
Article
Introduction: Abortion is a polarizing social and medical issue, even among physicians. Though the public may expect physicians to hold purely scientific attitudes about abortion, their attitudes and behaviors are just as strongly informed by social and political factors as the public's. In a recent survey study of physicians at an academic medical center about their abortion attitudes, most reported strong support for abortion access. However, more were unwilling to consult in abortion-related cases, and many perceived little or no professional connection to abortion and were reticent to publicly advocate for their position. Methods: In order to investigate the nuances in physicians' abortion attitudes, we analyzed the open-ended, qualitative responses provided by physicians at the end of a quantitative survey using modified concept mapping procedures and theme generation. Results: Two hundred twenty-two open-ended responses resulted in 487 data units. We categorized respondents' comments into 2 main groups: attempts to depersonalize, or distance oneself, from abortion and expressions of nuance or ambivalence about abortion. Ambivalence and nuance in abortion attitudes centered around multiple factors that varied from individual to structural. Conclusions: Our findings support previous literature suggesting that physicians' abortion attitudes are not binary and add that nuanced attitudes may be perceived as unwelcome. Acknowledging ambivalence and addressing physicians' tendency to depersonalize abortion could result in more honest, open, and nuanced discourse and contribute to addressing structural issues that result in poor health outcomes, achieving broader reproductive justice goals, and greater access to abortion services.
... French and colleagues [19] surveyed clinicians' referral practices for a range of conditions and found that only 52% of 496 participants indicated they had a professional obligation to refer in the case of abortion. Analysis of qualitative comments revealed only 18% would facilitate a referral, while 39% would provide 'just-the-name' of a clinic or doctor, 29% would offer nothing and 15% would provide misleading information [20]. Similar figures are reported by Holt and colleagues [21] who also report that 14% of US primary care physicians routinely attempt to dissuade women from abortion. ...
... Despite quantitative evidence that rates of CO are low in Australia compared to other countries [17], these qualitative results are consistent with findings reported from several surveys of US doctors; that a significant minority (15%) of practitioners who claim a CO do not adhere to obligations to refer, but instead attempt to delay or deny access [18][19][20][21]. If even a small proportion of doctors with a CO refuse to refer, this could have a significant impact on women's access, particularly if conscientious objectors are over-represented in certain geographic areas, or see more vulnerable patients presenting later in pregnancy [40,41]. ...
Article
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Background In Victoria, Australia, the law regulating abortion was reformed in 2008, and a clause (‘Section 8’) was introduced requiring doctors with a conscientious objection to abortion to refer women to another provider. This study reports the views of abortion experts on the operation of Section 8 of the Abortion Law Reform Act in Victoria. Methods Nineteen semi-structured qualitative interviews were conducted with purposively selected Victorian abortion experts in 2015. Interviews explored the impact of abortion law reform on service provision, including the understanding and implementation of Section 8. Interviews were transcribed verbatim and analysed thematically. Results The majority of participants described Section 8 as a mechanism to protect women’s right to abortion, rather than a mechanism to protect doctors’ rights. All agreed that most doctors would not let moral or religious beliefs impact on their patients, and yet all could detail negative experiences related to Section 8. The negative experiences arose because doctors had: directly contravened the law by not referring; attempted to make women feel guilty; attempted to delay women’s access; or claimed an objection for reasons other than conscience. Use or misuse of conscientious objection by Government telephone staff, pharmacists, institutions, and political groups was also reported. Conclusion Some doctors are not complying with Section 8, with adverse effects on access to care for some women. Further research is needed to inform strategies for improving compliance with the law in order to facilitate timely access to abortion services.
... The American College of Obstetrics and Gynecology (ACOG) asserts that all patients should receive referrals, even if the provider is personally opposed (ACOG 2021). In practice, previous studies of ob-gyn and primary care providers indicate that the provision of referrals is not universal (Daniel et al., 2020;Desai et al., 2018;Dodge et al., 2018;Holt et al., 2017;Homaifar et al., 2017;Stulberg et al., 2016). One study of primary care physicians found that, while about two-thirds of physicians regularly referred patients for abortions, only about a fifth of physicians referred patients to a specific abortion provider (Holt et al., 2017). ...
... Lack of knowledge about where and whom to refer patients for abortion care has been consistently identified as a barrier to physician referrals (Holt et al., 2017;Homaifar et al., 2017;Zurek et al., 2015). However, researchers have not fully examined knowledge gaps about where and to whom to refer patients to for abortions, especially in the context of physicians who are willing to participate in abortion care. ...
Article
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Abortion care is a crucial part of reproductive healthcare. Nevertheless, its availability is constrained by numerous forces, including care referrals within the larger healthcare system. Using a unique study of physician faculty across multiple specialties, we examine the factors associated with doctors' ability to refer patients for abortion care among those who were willing to consult in the care of a patient seeking an abortion (N = 674). Even though they were willing to refer a patient for an abortion, half (53%) of the physicians did not know how and whom to make those referrals, though they care for patients who may need them. Those with the least referral knowledge had not been taught abortion care during their medical training and were in earlier stages of their career than those who had more knowledge. This research exposes another obstacle for those seeking an abortion, a barrier that would be overcome with a clear and robust referral system within and across medical specialties.
... The American College of Obstetrics and Gynecology (ACOG) asserts that all patients should receive referrals, even if the provider is personally opposed (ACOG 2021). In practice, previous studies of ob-gyn and primary care providers indicate that the provision of referrals is not universal (Daniel et al., 2020;Desai et al., 2018;Dodge et al., 2018;Holt et al., 2017;Homaifar et al., 2017;Stulberg et al., 2016). One study of primary care physicians found that, while about two-thirds of physicians regularly referred patients for abortions, only about a fifth of physicians referred patients to a All rights reserved. ...
... Lack of knowledge about where and whom to refer patients for abortion care has been consistently identified as a barrier to physician referrals (Holt et al., 2017;Homaifar et al., 2017;Zurek et al., 2015). However, researchers have not fully examined knowledge gaps about where and to whom to refer patients to for abortions, especially in the context of physicians who are willing to participate in abortion care. ...
Preprint
Abortion care is a crucial part of reproductive healthcare. Nevertheless, its availability is constrained by numerous forces, including care referrals within the larger healthcare system. Using a unique study of physician faculty across multiple specialties, we examine the factors associated with doctors' ability to refer patients for abortion care among those who were willing to consult in the care of a patient seeking an abortion (N=674). Even though they were willing to refer a patient for an abortion, half (53%) of the physicians did not know how and whom to make those referrals, though they care for patients who may need them. Those with the least referral knowledge had not been taught abortion care during their medical training and were in earlier stages of their career than those who had more knowledge. This research exposes another obstacle for those seeking an abortion, a barrier that would be overcome with a clear and robust referral system within and across medical specialties.
... A study investigating abortion referral-making by primary care and OB-GYN clinicians in Nebraska found similar results; 29% of providers reported they would not refer for abortion and 15% reported providing misleading referrals. [13]. Among health and social service providers of a variety of professional backgrounds 18% would ''Refer to a 'crisis pregnancy center' or similar organization that will encourage continuing the pregnancy" and 7% would directly encourage the client to continue the pregnancy [14]. ...
... Existing research also has yet to explore meaningfully how a patient's social location may shape the value of an abortion referral. While a handful existing studies control for individual attributes such as age, race, income, and rurality [13,20], these studies consider only delays to accessing abortion and do not consistently compare subgroups. ...
Article
In recent years, reproductive health researchers and practitioners have increased their focus on abortion referrals as an overlooked component of access. March 2019 proposed changes to the regulation of publicly funded family planning services that severely restrict abortion referrals have heightened public attention. In October 2017, Provide, Inc. convened researchers and practitioners to assess our knowledge of abortion referral and make recommendations for future research. We found that existing literature on abortion referral is limited and may overlook important outcomes as well as variations in patient experiences by age, race, income, and other attributes. Recommendations include more robust attention to patient experiences and research that assesses a broad range of referral-making practices and outcomes, with specific attention to vulnerable populations and to referral quality and the distinction between appropriate and inappropriate referral.
... These recommendations are incorporated into the 2014 Quality Family Planning Recommendations developed by the Centers for Disease Control and Prevention and the US Office of Population Affairs [6]. However, providers often refer clients exclusively to prenatal care [7], and approximately one third of providers indicate that they do not discuss or refer for abortion [8][9][10][11]. Federal regulations implemented in 2019 eliminated the requirement for sites funded by Title X (the only federal program in the US specifically dedicated to supporting the delivery of family planning care) to provide pregnancy counseling on all options [12]. These regulations also prohibited staff at Title X sites from providing abortion referrals, instead requiring them to provide referrals for prenatal services for all pregnant patients. ...
... Nondirective pregnancy options counseling and referral has been described as essential for informed consent in reproductive healthcare [38] and as a service that should be available to all pregnant individuals seeking pregnancy-related resources in health care settings [6]. However, the stigma associated with deciding not to parent impacts both providers' [10] and patients' [21] willingness to discuss alternatives. Unpublished qualitative data from interviews with attendees of Provide's training programs indicates that the most common reason providers do not offer all options is because they prefer for the client to broach the topic of abortion or adoption first, or to "express despair" about the pregnancy before offering alternatives. ...
Article
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Objective: To estimate the association between discussion of all options (adoption, abortion, and parenting) in pregnancy options counseling and patient-reported experience with counseling. Study Design: Patients (n=316) who received a positive pregnancy test Oct 2018-June 2019 at one of 14 randomly selected clinics in a southern US publicly funded family planning system participated in an anonymous digital survey about their experience with counseling. The survey assessed which options (parenting, adoption, abortion) they discussed with their provider and how they rated their counseling experience using a 20-item scale based on validated measures of patient reproductive health counseling experience. We used Poisson regression to estimate the prevalence ratio for discussing all pregnancy options and rating their provider with a perfect score. Results: Approximately 10% of patients reported their provider discussed all options. After adjustment for patient, provider, and clinic characteristics, patients were approximately 80% more likely to rate their counseling as “excellent” on all analyzed scale items when their provider discussed all options compared to when they did not (adjusted prevalence ratio [aPR]=1.80, 95% CI: 1.43, 2.28). Discussion of all pregnancy options was associated with a more positive patient-reported experience among patients who planned to continue their pregnancy (aPR=1.82, 95% CI: 1.37, 2.42) and among those who did not (aPR=1.62, 95% CI: 1.08, 2.44). Patients whose provider had received options counseling training were more likely to report all options were discussed. Conclusion: Discussion of all options during pregnancy counseling is associated with a more positive patient experience. These findings indicate patient preference for supportive, non-directive counseling on all pregnancy options. Implications: Our study's findings support non-directive discussion of all pregnancy options (including parenting, abortion and adoption) as a best practice, and stand in contrast to regulations that restrict discussion of all options.
... Furthermore, studies have shown that a complex dynamic underlies midwives' willingness to offer a range of comprehensive abortion care services. Conflicts may exist between professional norms and religious beliefs 32,4 . Conscientious objection 1,5 , grounded on individual religious and moral belief systems 32,5 , will constrain some midwives, despite scientific evidence of the health related values of these services to women. ...
Article
Full-text available
In Ghana, abortion-related mortality is considered a major public health issue that needs to be addressed. Midwives have been trained to safely and effectively provide post-abortion care in the country, yet the expected decline in maternal deaths from abortion complications especially in the rural settings is yet to be realized. Primary Healthcare (PHC) facility is the first point of contact for the rural populace, yet there is minimal evidence on the capacity of midwives serving there to provide post-abortion care. This study assessed the knowledge and practice of post abortion care among midwives in selected primary healthcare (PHC) facilities in Ashanti region of Ghana. A cross sectional descriptive survey design was utilized for the study, and a multi-staged sampling technique was used to select 16 PHCs comprising both government (11) and private (5) owned, from which 112 participants were recruited. A pre-tested structured, self-developed questionnaire was employed to obtain information from the study participants. Obtained data were analyzed using SPSS version 21. A total of 109 questionnaires were accurately completed out of 112 administered, giving a response rate of 97.3%. The midwives’ knowledge of post abortion care (PAC) was mainly in the areas of PAC as treatment for abortion complications 49(36%), while knowledge on the other PAC components was low. Only 63(58%) of the respondents had training on PAC, which was basically on the use of Manual Vacuum Aspiration (MVA) to complete incomplete abortion 52(41%). Among the 70(64%) respondents who indicated that their PHC facilities provide PAC services, only 72(66%) of them actually carried out post abortion care. Reasons advanced by the other 39(36%) who never carried out PAC were lack of; confidence 30(815), skills 27(73%), and knowledge 20(54%). The study recommended the training of midwives serving in PHCs in all components of post-abortion care as a feasible strategy for decentralizing PAC services and reaching out to the neglected rural populace. This aspect of reproductive health need to be re-emphasized in midwifery training curricula, buttress with regular mandatory continuing professional development in the area to improve skills.
... 40,41 Abortion through TM may at the least be a highly autonomous option and at most a life-saving alternative for women seeking abortion. [49][50][51][52] Several areas, however, remain to be investigated in order to substantiate policy recommendations on abortion care through TM. In addition to the physiciansupervised TM models described in this review, there are less comprehensive services which make use of TM to some degree, from which outcome data have not been published. ...
Article
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Background: Telemedicine is increasingly used to access abortion services. Objective: To assess the success rate, safety and acceptability for women and providers of medical abortion using telemedicine. Search strategy: We searched Pubmed, EMBASE, clinicalTrials.gov, and Web of Science up until November 10th 2017. Study criteria: We selected studies where telemedicine was used for comprehensive medical abortion services i.e. assessment/counselling, treatment, and follow-up, reporting on success rate (continuing pregnancy, complete abortion and surgical evacuation), safety (rate of blood transfusion and hospitalization) or acceptability (satisfaction, dissatisfaction, and recommendation of the service). Data collection and analysis: Quantitative outcomes were summarized as a range of median rates. Qualitative data was summarized in a narrative summary. Main results: Rates relevant to success rate, safety and acceptability outcomes for women ≤ 10+0 weeks gestation (GW) ranged from: 0%-1.9% for continuing pregnancy, 93.8%-96.4% for complete abortion, 0.9%-19.3% for surgical evacuation, 0%-0.7% for blood transfusion, 0.07%-2.8% for hospitalization, 64%-100% for satisfaction, 0.2%-2.3% for dissatisfaction, 90%-98% for recommendation of the service. Rates in studies also including women >10+0 GW ranged from: 1.3%-2.3% for continuing pregnancy, 8.5%-20.9% for surgical evacuation, and 90%-100% for satisfaction. Qualitative studies on acceptability showed no negative impacts for women or providers. Conclusion: Based on a synthesis of mainly self-reported data, medical abortion through telemedicine seems to be highly acceptable to women and providers, success rate and safety outcomes are similar to those reported in literature for in-person abortion care and surgical evacuation rates are higher. This article is protected by copyright. All rights reserved.
... The inability to obtain accurate information about abortion has been documented as a barrier to abortion access [14,15]. However, this barrier has not been explored in depth. ...
Article
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Objective For individuals traveling significant distances for time-sensitive abortion care, accurate information about service options and locations is critical, but little is known regarding information barriers that individuals may encounter and strategies for circumventing these barriers. Study design In early 2015, we conducted in-depth interviews with 29 patients who had traveled for abortion care at six facilities in Michigan and New Mexico. We identified information-related barriers that respondents encountered in understanding their pregnancy options and/or where to obtain an abortion between the time of pregnancy discovery, including any contact with a crisis pregnancy center, to the day of the abortion procedure through inductive and deductive analysis. Results We identified two logistical information-related barriers — a general lack of reproductive-related knowledge and unhelpfulness on the part of perceived members of the healthcare community — and one broader barrier of perceived stigma within respondents' narratives. Of the seven respondents who did not encounter a logistical information-related barrier, having previous personal or close experience with abortion and internet savviness were both identified as strategies enabling them to circumvent the barriers. Conclusion Lack of clear, easy-to-find and accurate information about abortion services and availability represents a key barrier to obtaining an abortion; health care providers play a crucial role in ensuring pregnant patients' right to informed consent within reproductive health care delivery. Implications Women's health care providers should provide their patients with the full spectrum of resources and referrals for pregnancy and abortion care; recent federal guidelines proposing to restrict abortion counseling and referral at Title X-funded facilities would only exacerbate the current challenges that pregnant patients encounter when seeking abortion-related information and further decrease linkages to timely, desired abortion care.
... Existing literature suggests that knowledge and training [6,7], as well as personal beliefs and professional obligation can impact health care providers' abortion referral practices [8,9]. Research suggests that family practice and obstetrics and gynecology providers may provide indirect abortion referrals [10], with some findings suggesting that such referrals from obstetrics and gynecology providers may include directing patients to a Planned Parenthood website [11]. However, generalist providers' views of Planned Parenthood in the context of abortion referrals are largely unknown, especially within integrated academic health care systems. ...
... A growing evidence base on abortion referral-making suggests deficiencies in clinicians' practice (Dodge et al. 2012;French et al. 2015;Hebert et al. 2016;Holt et al. 2017;Homaifar et al. 2017). A recent national populationbased survey of almost 800 primary care physicians (PCPs) revealed that 43% of family medicine and general internal medicine physicians reported seeing women seeking abortion (Holt et al. 2017). ...
Article
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Purpose Engaging trusted care providers and empowering them with information and skills about abortion is a critical opportunity to improve coordination of care for women seeking abortion, if and when these services are needed. Description Provide, a nonprofit that works in partnership with health and social service providers to build a health system that is equipped to respond to women's health care needs around abortion, launched a referrals training program in 2013. To assess the effectiveness of this training program, we conducted an evaluation of satisfaction with training and the impact of the intervention on provider knowledge of safety of abortion, self-efficacy to provide abortion referrals, and intention to provide pregnancy options counseling and referrals in the future. Assessment Approximately 90% of participants were "very satisfied" with their training experience. Results show significant increase in intention to provide non-judgmental pregnancy options counseling and referrals for abortion care after participants went through training. Post-training, significantly more reported that they would present all pregnancy options without judgment or bias (94 vs. 82%, p < .0001), provide a referral for abortion care if needed (80 vs. 50%, p < .0001), and follow-up with the client (71 vs. 39%, p < .0001). Further, more also reported they would refer a client for prenatal care if the client requested it (78 vs. 67%, p < .0001). Conclusion Our results suggest that abortion referrals training hold potential to build the capacity of health and social service providers' ability to meet client needs related to pregnancy and could be implemented at a larger scale.
... Although we found no evidence that abortion stigma deters women from consulting a doctor or seeking medical help for infertility, Norris et al. (2011) pointed out that feelings of stigma are not necessarily a constant; instead they may be triggered under certain situations such as interactions with medical professionals. Medical exchanges in which women are required to reveal their reproductive histories could potentially be stressful for some women, particularly if they fear negative reactions to their reproductive decisions from health care providers (Homaifar et al., 2017). ...
Article
To determine whether a history of abortion is associated with the experience of infertility among women, 2,199 women who ever met medical criteria for infertility were studied. Data for the study come from the National Survey of Fertility Barriers (NSFB), a nationally representative telephone survey of US women aged 25–45. Linear and logistic regression analysis revealed that a history of induced abortion was not statistically associated with fertility-specific distress, talking to a doctor about fertility, or seeking medical treatment for infertility. Having had an induced abortion may increase women’s confidence in their ability to get pregnant in the future.
Article
Introduction: Access to abortion is a public health priority. Yet little is known about pregnancy options counseling and abortion referral practices, both essential to timely abortion care, among advanced practice clinicians (APCs; nurse practitioners, nurse-midwives, physician assistants). Methods: Data were drawn from a stratified random sample of Colorado APCs, oversampling certified nurse-midwives (CNMs), women's health nurse practitioners (WHNPs), and rural clinicians. Pregnancy options counseling and abortion referral practices were described. Weighted multivariate logistic regression models were used to examine associations between participant characteristics and providing options counseling, referring for abortion, and referring to crisis pregnancy centers. Results: Of 513 participants (response rate 21%), 419 provided pregnancy testing. Only 201(48%) reported they were willing and able to counsel on all 3 options. Religious or personal objection was the primary rationale for unwillingness to present abortion as an option (63%). However, lack of knowledge was the main rationale for unwillingness (64%) and inability to counsel (79%), whereas institutional barriers fueled inability to refer (59%). Although 53% referred for abortion care, 31% referred to crisis pregnancy centers. Characteristics positively associated with providing options counseling included being a CNM or WHNP (odds ratio [OR], 2.73; 95% CI, 1.32-5.66), having received options counseling training (OR, 2.84; 95% CI, 1.48-5.43), and feeling adequately trained on abortion counseling (OR, 6.61; 95% CI, 3.62-12.08). Characteristics positively associated with referring for abortion included being a CNM or WHNP (OR, 2.27; 95% CI, 1.18-4.36), having received options counseling training (OR, 2.39; 95% CI, 1.36-4.22), and feeling adequately trained on abortion counseling (OR, 3.5; 95% CI, 2.00-6.11). Only provider type was associated with referring to crisis pregnancy centers; CNMs and WHNPs had the lowest odds (OR, 0.29; 95% CI, 0.15-0.54). Discussion: Pregnant patients in Colorado may not receive evidence-based pregnancy options counseling or abortion referrals. Clinician training on options counseling and abortion referrals is needed.
Article
Purpose of review: This article reviews key aspects of pregnancy options counseling, and highlights how inappropriate counseling can create barriers to timely and safe abortion care. Recent findings: Access to safe abortion services in the United States is increasingly constrained. One way to combat this hostile environment is to ensure that individuals presenting for care early in pregnancy have access to comprehensive and unbiased pregnancy options counseling. There are unfortunately many barriers to individuals receiving adequate pregnancy options counseling, and marginalized groups experience disproportionate effects of inappropriate counseling. Research shows that individuals desire appropriate pregnancy options counseling when seeking early pregnancy care, and that providers often serve as a barrier to this care. Provider miseducation and opposition to pregnancy options counseling, particularly as it concerns abortion care, creates challenges and delays for people seeking abortion services. Crisis Pregnancy Centers use misinformation to further these barriers to appropriate care. Summary: Nondirective and patient-centered pregnancy options counseling is standard of care. People seeking pregnancy options counseling desire and deserve comprehensive and accurate information. Providers must not serve as barriers to safe and appropriate care. Increasing nondirective pregnancy options counseling research, education, and training is crucial to ensuring access to safe and appropriate abortion care.
Article
Background: Obstetrician-gynecologists (ob-gyns) play a critical role in improving access to timely abortion care. This cross-sectional study estimates the proportion of ob-gyns providing abortion referral in the prior year and identifies predictors of direct (facilitated) referral compared with indirect referral (providing contact information). Methods: In 2016-2017, we invited a national sample of 2,500 ob-gyns to complete a survey. We restricted the final sample of 1,280 respondents (52% response rate) to participants who had abortion-seeking patients in the last 12 months (n = 868, 68% of the sample). We calculated descriptive statistics by referral type and conducted logistic regression analyses to examine associations between physician and practice setting characteristics and abortion referral type (direct vs. indirect). Results: Eighty-eight percent of ob-gyns provided abortion referral (479 [55%] indirect referrals; 287 [33%] direct referrals). Abortion provision in the prior year (adjusted odds ratio, 2.82; 95% confidence interval, 1.80-4.42) was a significant predictor of direct referrals. Compared with ob-gyns practicing in the Northeast, ob-gyns in the South had lower odds of direct referrals (adjusted odds ratio, 0.39; 95% confidence interval, 0.24-0.62), whereas those in the West had higher odds (adjusted odds ratio, 1.91; 95% confidence interval, 1.14-3.23). Ob-gyns providing direct referrals were more likely to practice within 25 miles of an abortion facility compared with those who provided indirect referrals (25% vs. 5%, respectively; p < .001). Conclusions: Although the majority of ob-gyns refer patients for abortion care, most offer indirect referrals, only providing contact information for an abortion provider. Ob-gyns should facilitate referrals as access becomes more constrained, especially in regions where abortion facilities are limited.
Article
The United States is facing a national crisis related to increasing rates of maternal morbidity and mortality. Over the past few years, significant focus has been turned to initiatives that aim to address maternal morbidity and mortality rates. In parallel, the United States has seen a significant increase in restrictive abortion access state laws. The link between abortion restrictions and worsening maternal outcomes has been proposed. This review article outlines the national crisis of maternal morbidity and mortality, the potential role of limiting abortion access in this crisis, and the significant racial, socioeconomic, and geographical disparities that exist.
Article
Objective To determine college health centers’ referral patterns for students seeking induced abortion. Study Design We conducted a cross-sectional simulated patient study at 4-year colleges in Pennsylvania between June 2017 and May 2018. A researcher posing as a student seeking abortion referral contacted student health centers twice during the course of the study using a structured script, once as a minor (under 18 years), and once as an adult. The primary outcome was “direct referral”, defined as a referral to an abortion provider. We measured proportions of student health centers who provided no referral, “indirect referral” (referral to a non-specific provider), and “inappropriate referral” (referral to a non-abortion provider). We analyzed the relationship between the proportion of direct referrals and minor status of the caller as well as college characteristics (religious affiliation, location, student body mean income, and size). We included variables found to be significant as covariates in a generalized linear model that accounted for the cluster of multiple calls to each institution. Results We attempted contact with 115 institutions, once as a minor and once as an adult, resulting in 202 successful contacts. Direct referral was the most common outcome (49.5%), followed by inappropriate referral (33.7%) and no referral (21.8%). The proportion of direct referrals given to minors was similar when compared to adults (48.0% vs 52.0%, OR 0.82, 95% CI 0.47-1.42). Religiously affiliated institutions were less likely to provide a direct referral than non-religiously affiliated schools (aOR 0.47, 95% CI 0.30-0.75). With each increase in students’ household income tertile, health centers were more likely to provide a direct referral (aOR 1.22, 95% CI 1.05-1.42). Conclusions Half of college student health centers in Pennsylvania do not provide direct abortion referrals, and many provide inappropriate referrals. Student health centers at religiously affiliated institutions and those with poorer students are less likely to provide direct abortion referrals. Implications Student health providers should inform themselves about fake health clinics and local abortion providers. Colleges should train staff, create accurate resources and define clear policies around referral. Professional and policymaking organizations should affirm the duty of all college health centers, regardless of religious affiliation, to provide abortion referrals.
Article
Objective: An informed, timely referral from a generalist practitioner has the potential to facilitate care for a patient seeking an abortion. However it is unclear what barriers, if any, generalist practitioners perceive in this process. The objective of this study was to qualitatively characterize abortion referral patterns among generalist practitioners. Study design: We conducted individual interviews with generalist practitioners practicing at Northwestern Medicine, encompassing four hospitals across the greater Chicago metropolitan area. The interview guide focused on abortion-related topics including: referral patterns, attitudes about providing referrals, and specifics of the abortion referral process. We analyzed the data for content and themes using an inductive approach. Results: We completed 37 interviews. Practitioners in all fields and practice sites were willing to provide abortion referrals. Practitioners perceived barriers in the referral process, with a lack of knowledge chief among them. Further, practitioners saw abortion referrals as more burdensome than other specialty referrals. Conclusion: Generalist practitioners are willing to provide abortion referrals, but perceive multiple barriers in the abortion referral process. Generalist practitioners can help to ensure their patients receive timely and quality abortion care if they feel prepared and empowered to assist with these referrals.
Article
OBJECTIVE: To assess abortion-related attitudes, practices, and perceptions among physicians of all specialties at a Wisconsin academic medical center. STUDY DESIGN: We developed and disseminated a cross-sectional web and mail survey to physicians at our academic center using a list generated by Human Resources. We performed descriptive analyses and assessed bivariate relationships between measures of support for abortion, perceived climate of opinion, willingness to consult in abortion-related cases, and sociodemographic and professional characteristics. We used binary logistic regression to model willingness to consult. RESULTS: We sent the survey to 1,357 physicians and received 913 (67%) responses. Participants reported strong support for unrestricted access to abortion and the efforts of abortion providers but estimated relatively lower support among peers. Compared to 556 (62%) who reported “a lot” of support for abortion access, only 183 (21%) estimated the same level of support among peers. Similarly, 615 (69%) participants reported “a lot” of support for abortion providers, compared to only 227 (25%) who estimated the same level of support among peers. Participants most commonly estimated that peers “somewhat” support abortion access (381; 43%) and abortion providers (344; 39%). Across specialties, 799 (90%) physicians said they were at least “somewhat” willing to consult in abortion-related cases. Compared to obstetrician-gynecologists and family physicians, other specialists were less likely to be willing to consult (aOR=0.43, 95% CI 0.29-0.65), though majorities of both groups were willing. Physicians who perceived equal or higher support for abortion among peers were more likely to be willing to consult (aOR=2.17, 95% CI 1.60-2.95). CONCLUSION: Most physicians at out center reported support for abortion; however, those who perceived less support among peers reported less willingness to consult in abortion-related care, regardless of specialty.
Article
In July 2019, the Trump administration began implementing its domestic gag rule to ban discussion of abortion in pregnancy options counseling and ensure physical separation of contraceptive and abortion services at clinical sites funded by the federal government's Title X Family Planning program. In this paper, we examine how organizational policy utilization correlated with organization-level protocols for discussing abortion in options counseling interactions while the domestic gag rule policy was under legal contest. From April 2018 to July 2019, we conducted in-depth interviews with 50 administrators in charge of setting clinical protocols regarding options counseling after a positive pregnancy test at 20 Title X-covered and 14 non-Title X-covered safety-net healthcare organizations in Ohio. We found that organizational characteristics and Title X policy utilization did not explain the heterogeneity in approaches to abortion referral that administrators reported. Administrators from 2 of 20 organizations covered by Title X policy requirements pre-emptively restricted discussion of abortion in their facilities in advance of policy enactment. Meanwhile, administrators from 10 of 14 non-Title X-covered organizations did not restrict discussion of abortion. Our analysis demonstrates how safety-net healthcare organizations' response to federal policy is shaped by administrators' institutional entrepreneurship within the abortion aversion complex: a pattern of policy miscomprehension and endorsed abortion stigma that facilitates the structural stigmatization of abortion within safety-net healthcare organizations. We conclude that current efforts to reverse the domestic gag rule will fail unless local abortion aversion complexes are targeted with intervention.
Article
Objectives: Crisis pregnancy centers (CPCs) are nonprofit antiabortion organizations that claim provision of pregnancy resources. With the Reproduction Freedom, Accountability, Comprehensive Care, and Transparency Act repealed, CPCs are no longer mandated to share information on state-funded family planning and abortion services. As patients increasingly seek healthcare guidance online, we evaluated crowd-sourced reviews of CPCs using the social networking site Yelp. Methods: CPCs were identified with the CPC Map, a geo-based location resource. Of California's 145 CPCs, 84% had Yelp pages, and 619 reviews (2010-2019) were extracted. Thematic codes were individually applied to 220 excerpts and then analyzed in detail using thematic analysis to capture emergent themes related to motivations for and experiences of CPCs. To ensure thematic saturation, we applied a natural language-processing technique called the meaning extraction method to computationally derive themes of discussion from all of the extracted posts. Results: Motivations to seek care from CPCs included pregnancy confirmation, gaps in healthcare coverage, parenting and emotional support, and abortion care. A review of experiences reveal that CPC faith-based practice garnered both positive- and negative-based experiences. Reviewers also articulated inaccurate medical information, lack of transparency, and reduced options at CPCs. Conclusions: This is the first study to analyze California CPCs using a social media platform. Pregnant patients turn to social media to share experiences about pregnancy resources, to find healthcare providers, and to increase transparency of services. This content provides valuable insight into the concerns of pregnant patients and offers an intimate view of California CPCs at a time when no federal regulations are in place.
Article
Objectives Research on abortion referral practices has focused on referral to first-trimester abortion care. Research has not examined whether and how these recommendations apply to referrals for abortion later in pregnancy. Methods We conducted a secondary analysis of semi-structured interviews with thirty third-trimester abortion patients of their experiences of referral from prenatal and/or pre-third-trimester abortion care. We used thematic coding to identify referral-related actions participants desired or wished providers would avoid. Results Participants reported needs in referral for information that third-trimester abortion was a possibility and about third-trimester providers and funding resources. Several also reported a need for emotional support from the prenatal or abortion care provider who denied them abortion care. Conclusions Many factors important for first-trimester abortion referral are important in third-trimester abortion referral, but the specifics of third-trimester care (namely the paucity of clinics, need for travel, and possibility of strong emotional attachment to the pregnancy) require additional practice actions. Practice implications Providers can support their patients in need of third-trimester abortion care by proactively providing: information that third-trimester abortion is available; information on third-trimester providers and funding support (e.g., an abortion referral hotline); and clear, non-judgmental emotional support.
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Introduction The International Confederation of Midwives (ICM) represents 132 midwifery associations in 113 countries. The ICM disseminates the Essential Competencies for Basic Midwifery Practice (EC) that describes the global scope of midwifery practice. The basic (core) and expanded (additional or optional) role of midwives in providing abortion-related care services was first described in 2010. A literature review about three items that are particularly critical to access to abortion services was conducted. Findings that emerged in the recent 2016–2017 update study about these three items are presented. Methods A modified Delphi study was administered via the Internet in a series of three rounds. Thirty-seven statements of abortion-related knowledge and skill were presented. Results A total of 895 individuals participated. The total of respondents across all three rounds represented 90 of the 105 member countries at the time of the study. The role of midwives in providing comprehensive abortion care, including referral for abortion and provision of postabortion family planning, achieved the necessary 85% agreement to be designated as essential (basic) knowledge or skill for the global scope of midwifery practice. The provision of medication abortion and performance of manual vacuum aspiration abortion were designated as optional for midwives who wished to provide these services. Endorsement of these latter practices was highest in both Francophone and Anglophone regions of Africa, Asian Pacific countries, and countries at a lower state of economic development. Conclusion The role of midwives in provision of abortion-related care services was reaffirmed in the recent Delphi study to inform the update to the EC. The role of midwives as direct providers of medical and vacuum aspiration abortions was reaffirmed for those individual midwives who wish to obtain the requisite competency to provide those services, in jurisdictions where these services are legally authorized.
Article
Objective: To assess the quality of information available online for abortion self-referral and to determine whether quality varies by region or distance to an abortion provider. Methods: This was a cross-sectional study. We used a standard protocol to perform internet searches from August 2016 to June 2017 for abortion services in the 25 most populous U.S. cities and the 43 state capitals that were not one of the 25 most populous cities. We classified the first 10 webpage results and the first five map results and advertisements as facilitating abortion referral (local independent abortion provider, local Planned Parenthood facility, national abortion provider or organization, prochoice website, or abortion directory), not facilitating abortion referral (nonproviding physician office, nonmedical website, abortion provider greater than 50 miles from the location, news article, general directory, other), or hindering abortion referral (crisis pregnancy center or antichoice website). We used U.S. Census Bureau subregions to examine geographic differences. We made comparisons using a χ test. Results: Overall, from 612 searches from 68 cities, 52.9% of webpage results, 67.3% of map results, and 34.4% of advertisements facilitated abortion referral, whereas 12.9%, 21.7%, and 29.9%, respectively, hindered abortion referral. The content of the searches differed significantly based on U.S. Census Bureau subregion (all P≤.001) and distance to an abortion provider (all P≤.02). Conclusion: Two thirds of map results facilitated abortion self-referral, whereas only half of webpage results did so. Advertisements were the least likely to facilitate and the most likely to hinder self-referral. Quality was lowest in areas that were farthest from abortion providers.
Article
Objectives: To compare pregnancy options counseling and referral practices at state- and Title X-funded family planning organizations in Texas after enforcement of a policy restricting abortion referrals for providers participating in state-funded programs, which differed from Title X guidelines to provide referrals for services upon request. Study design: Between November 2014 and February 2015, we conducted in-depth interviews with administrators at publicly funded family planning organizations in Texas about how they integrated primary care and family planning services, including pregnancy options counseling and referrals for unplanned pregnancies. We conducted a thematic analysis of transcripts related to organizations' pregnancy options counseling and referral practices, and compared themes across organizations that did and did not receive Title X funding. Results: Of the 37 organizations with transcript segments on options counseling and referrals, 15 received Title X and 22 relied on state funding only. All Title X-funded organizations but only nine state-funded organizations reported offering pregnancy options counseling. Respondents at state-only-funded organizations often described directing pregnant women exclusively to prenatal care. Regardless of funding source, most organizations provided women a list of agencies offering abortion, adoption and prenatal care. However, some respondents expressed concern that providing other information about abortion would threaten their state funding. In contrast, respondents indicated staff would make appointments for prenatal care, assist with Medicaid applications and, in some instances, directly connect women with adoption-related services. Conclusions: Pregnancy options counseling varied by organizations' funding guidelines. Additionally, abortion referrals were less common than referrals for other pregnancy-related care. Implications: Programmatic guidelines restricting information on abortion counseling and referrals may adversely affect care for pregnant women at publicly funded family planning organizations.
Article
In the last century, conscientious objection has moved from objection to conscripted military service to include health care providers who have moral concerns about participation in specific aspects of health care. Although guidance for the use of conscientious objection has developed in both nursing and midwifery, changes in the political landscape may be creating a source of conflict between providers and the use of conscientious objection. Particularly in aspects of sexual and reproductive care like abortion, contraception, and lesbian, gay, bisexual, transgender, or queer health care, the ethical requirement for prompt referral is becoming increasingly difficult to meet in many contexts. Changes to federal regulations protecting conscience clauses have tilted strongly in favor of the rights of providers in recent years; this challenges the delicate balance of patient and provider rights that has developed over the years. These may now represent an unavoidable conflict between different aspects of the ethical obligations of providers, in particular the obligation to seek justice, and bring into question whether the current status of conscientious objection is sustainable. In this article, we examine these conflicts in the context of the current political climate.
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Context: Although stigma has been identified as a potential risk factor for the well-being of women who have had abortions, little attention has been paid to the study of abortion-related stigma. Methods: A systematic search of the databases Medline, PsycArticles, PsycInfo, PubMed and Web of Science was conducted; the search terms were "(abortion OR pregnancy termination) AND stigma(*) ." Articles were eligible for inclusion if the main research question addressed experiences of individuals subjected to abortion stigma, public attitudes that stigmatize women who have had abortions or interventions aimed at managing abortion stigma. To provide a comprehensive overview of this issue, any study published by February 2015 was considered. The search was restricted to English- and German-language studies. Results: Seven quantitative and seven qualitative studies were eligible for inclusion. All but two dated from 2009 or later; the earliest was from 1984. Studies were based mainly on U.S. samples; some included participants from Ghana, Great Britain, Mexico, Nigeria, Pakistan, Peru and Zambia. The majority of studies showed that women who have had abortions experience fear of social judgment, self-judgment and a need for secrecy. Secrecy was associated with increased psychological distress and social isolation. Some studies found stigmatizing attitudes in the public. Stigma appeared to be salient in abortion providers' lives. Evidence of interventions to reduce abortion stigma was scarce. Most studies had limitations regarding generalizability and validity. Conclusion: More research, using validated measures, is needed to enhance understanding of abortion stigma and thereby reduce its impact on affected individuals.
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Objectives: To evaluate the additional burdens experienced by Texas abortion patients whose nearest in-state clinic was one of more than half of facilities providing abortion that had closed after the introduction of House Bill 2 in 2013. Methods: In mid-2014, we surveyed Texas-resident women seeking abortions in 10 Texas facilities (n = 398), including both Planned Parenthood-affiliated clinics and independent providers that performed more than 1500 abortions in 2013 and provided procedures up to a gestational age of at least 14 weeks from last menstrual period. We compared indicators of burden for women whose nearest clinic in 2013 closed and those whose nearest clinic remained open. Results: For women whose nearest clinic closed (38%), the mean one-way distance traveled was 85 miles, compared with 22 miles for women whose nearest clinic remained open (P ≤ .001). After adjustment, more women whose nearest clinic closed traveled more than 50 miles (44% vs 10%), had out-of-pocket expenses greater than $100 (32% vs 20%), had a frustrated demand for medication abortion (37% vs 22%), and reported that it was somewhat or very hard to get to the clinic (36% vs 18%; P < .05). Conclusions: Clinic closures after House Bill 2 resulted in significant burdens for women able to obtain care. (Am J Public Health. Published online ahead of print March 17, 2016: e1-e8. doi:10.2105/AJPH.2016.303134).
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This study examines who hears what secrets, comparing two similar secrets-one that is highly stigmatized and one that is less so. Using a unique survey representative of American adults and intake forms from a medical clinic, I document marked differences in who hears these secrets. People who are sympathetic to the stigmatizing secret are more likely to hear of it than those who may react negatively. This is a consequence of people not just selectively disclosing their own secrets but selectively sharing others’ as well. As a result, people in the same social network will be exposed to and influenced by different information about those they know and hence experience that network differently. When people effectively exist in networks tailored by others not to offend, then the information they hear tends to be that of which they already approve. Were they to hear secrets they disapproved of, then their attitudes might change, but they are less likely to hear those secrets. As such, the patterns of secret hearing contribute to a stasis in public opinion.
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Abortion stigma is widely acknowledged in many countries, but poorly theorised. Although media accounts often evoke abortion stigma as a universal social fact, we suggest that the social production of abortion stigma is profoundly local. Abortion stigma is neither natural nor 'essential' and relies upon power disparities and inequalities for its formation. In this paper, we identify social and political processes that favour the emergence, perpetuation and normalisation of abortion stigma. We hypothesise that abortion transgresses three cherished 'feminine' ideals: perpetual fecundity; the inevitability of motherhood; and instinctive nurturing. We offer examples of how abortion stigma is generated through popular and medical discourses, government and political structures, institutions, communities and via personal interactions. Finally, we propose a research agenda to reveal, measure and map the diverse manifestations of abortion stigma and its impact on women's health.
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Roe v. Wade was heralded as an end to unequal access to abortion care in the United States. However, today, despite being common and safe, abortion is performed only selectively in hospitals and private practices. Drawing on 61 interviews with obstetrician-gynecologists in these settings, we examine how they determine which abortions to perform. We find that they distinguish between more and less legitimate abortions, producing a narrative of stratified legitimacy that privileges abortions for intended pregnancies, when the fetus is unhealthy, and when women perform normative gendered sexuality, including distress about the abortion, guilt about failure to contracept, and desire for motherhood. This stratified legitimacy can perpetuate socially-inflected inequality of access and normative gendered sexuality. Additionally, we argue that the practice by physicians of distinguishing among abortions can legitimate legislative practices that regulate and restrict some kinds of abortion, further constraining abortion access.
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Restrictions on access to abortion in the United States have reached proportions unprecedented since the nationwide legalization of abortion in 1973. Although some restrictions aim to discourage women from having abortions, many others impede access by affecting the timeliness, affordability, or availability of services. Evidence indicates that these restrictions do not increase abortion safety; rather, they create logistic barriers for women seeking abortion, and they have the greatest effect on women with the fewest resources. In this commentary, we recall the important role that obstetrician-gynecologists (ob-gyns) have played, both before and after Roe v. Wade, in facilitating access to safe abortion care. Using the literature on abortion safety and access as a foundation, we propose several practical ideas about what we as ob-gyns can do to address the current threat to abortion access, whether or not we provide abortion services in practice. We hope that this commentary will encourage discourse within our profession and prompt other suggestions. As ob-gyns who are dedicated to addressing health disparities and promoting the health and well-being of our patients, we can make a difference.
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Willing and Unable explores the social world where abortion politics and mainstream medicine collide. The author interviewed physicians of obstetrics and gynecology around the United States to find out why physicians rarely integrate abortion into their medical practice. While abortion stigma, violence, and political contention provide some explanation, her findings demonstrate that willing physicians are further encumbered by a variety of barriers within their practice environments. Structural barriers to the mainstream practice of abortion effectively institutionalize the buck-passing of abortion patients to abortion clinics. As the author notes, "Public-health-minded HMOs and physician practices could significantly change the world of abortion care if they stopped outsourcing it." Drawing from forty in-depth interviews, the book presents a challenge to a commonly held assumption that physicians decide whether or not to provide abortion based on personal ideology. Physician narratives demonstrate how their choices around learning, doing, and even having abortions themselves disrupt the pro-choice/pro-life moral and political binary.
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When consulted by a pregnant adolescent, pediatricians should be able to make a timely diagnosis and to help the adolescent understand her options and act on her decision to continue or terminate her pregnancy. Pediatricians may not impose their values on the decision-making process and should be prepared to support the adolescent in her decision or refer her to a physician who can.
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Following a long-term decline, abortion incidence stabilized between 2005 and 2008. Given the proliferation of state-level abortion restrictions, it is critical to assess abortion incidence and access to services since that time. In 2012-2013, all facilities known or expected to have provided abortion services in 2010 and 2011 were surveyed. Data on the number of abortions were combined with population data to estimate national and state-level abortion rates. Incidence of abortions was assessed by provider type and caseload. Information on state abortion regulations implemented between 2008 and 2011 was collected, and possible relationships with abortion rates and provider numbers were considered. In 2011, an estimated 1.1 million abortions were performed in the United States; the abortion rate was 16.9 per 1,000 women aged 15-44, representing a drop of 13% since 2008. The number of abortion providers declined 4%; the number of clinics dropped 1%. In 2011, 89% of counties had no clinics, and 38% of women of reproductive age lived in those counties. Early medication abortions accounted for a greater proportion of nonhospital abortions in 2011 (23%) than in 2008 (17%). Of the 106 new abortion restrictions implemented during the study period, few or none appeared to be related to state-level patterns in abortion rates or number of providers. The national abortion rate has resumed its decline, and no evidence was found that the overall drop in abortion incidence was related to the decrease in providers or to restrictions implemented between 2008 and 2011.
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Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circum-stances is a necessary exercise. The sixth edition of the American College of Physicians (ACP) Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still very pertinent. It reflects on many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging con-cerns. In addition, by reiterating ethical principles that have pro-vided guidance in resolving past ethical problems, the Manual may help physicians avert future problems. The Manual is not a substi-tute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession. Ann Intern Med. 2012;156:73-104. www.annals.org For author affiliation, see end of text. The secret of the care of the patient is in caring for the patient. —Francis Weld Peabody (1) S ome aspects of medicine, like the patient–physician re-lationship, are fundamental and timeless. Medicine, however, does not stand still—it evolves. Physicians must be prepared to deal with changes and reaffirm what is fun-damental. This sixth edition of the Ethics Manual exam-ines emerging issues in medical ethics and professionalism and revisits older issues that are still very pertinent. Changes to the Manual since the 2005 (fifth) edition in-clude new or expanded sections on treatment without in-terpersonal contact; confidentiality and electronic health records; therapeutic nondisclosure; genetic testing; health system catastrophes; caring for oneself, persons with whom the physician has a prior nonprofessional relationship, and very important persons (VIPs); boundaries and privacy; so-cial media and online professionalism; surrogate decision making and end-of-life care; pay-for-performance and pro-fessionalism; physician–industry relations; interrogation; cross-cultural efficacy, cultural humility, and physician vol-unteerism; attending physicians and physicians-in-training; consultation, shared care, and the patient-centered medical home; protection of human subjects; use of human biolog-ical materials and research; placebo controls; scientific pub-lication; and sponsored research. A case method for ethics decision making is included (Appendix). Changes to the Manual from the fifth edition are noted in Box 1. The Manual is intended to facilitate the process of making ethical decisions in clinical practice, teaching, and medical research and to describe and explain underlying ethics principles, as well as the physician's role in society and with colleagues. Because ethics and professionalism must be understood within a historical and cultural con-text, the second edition of the Manual included a brief overview of the cultural, philosophical, and religious un-derpinnings of medical ethics in Western cultures. In this edition, we refer the reader to that overview (2, 3) and to other sources (4, 5) that more fully explore this rich heritage. The Manual raises issues and presents general guide-lines. In applying these guidelines, physicians should con-sider the circumstances of the individual patient and use their best judgment. Physicians have moral and legal obli-gations, and the two may not be concordant. Physician participation in torture is legal in some countries but is never morally defensible. Physicians must keep in mind the distinctions and potential conflicts between legal and eth-ical obligations and seek counsel when concerned about the potential legal consequences of decisions. We refer to the law in this Manual for illustrative purposes only; this should not be taken as a statement of the law or the legal consequences of actions, which can vary by state and coun-try. Physicians must develop and maintain an adequate knowledge of key components of the laws and regulations that affect their patients and practices. Medical and professional ethics often establish pos-itive duties (that is, what one should do) to a greater extent than the law. Current understanding of medical ethics is based on the principles from which positive duties
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Abortion is highly stigmatized in the United States and elsewhere. As a result, many women who seek or undergo abortion keep their decision a secret. In many regions of the world, stigma is a recognized contributor to maternal morbidity and mortality from unsafe abortion, even when abortion is legal. Women may self-induce abortion in ways that are dangerous, or seek unsafe clandestine abortion from inadequately trained health care providers out of fear that their sexual activity, pregnancy, or abortion will be exposed if they present to a safe, licensed facility. However, unsafe abortion rarely occurs in the United States, and accordingly, stigma as a cause of unsafe abortion in the United States context has not been described. I consider the relationship of stigma to two serious abortion complications experienced by U.S. patients. Both patients wished to keep their abortion decision a secret from family and friends, and in both cases, their inability to disclose their abortion contributed to life-threatening complications. The experiences of these patients suggest that availability of legal abortion services in the United States may not be enough to keep all women safe. The cases also challenge the rhetoric that "abortion hurts women," suggesting instead that abortion stigma hurts women.
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To describe obstetrician-gynecologists' (ob-gyns') views and willingness to help women seeking abortion in a variety of clinical scenarios. We conducted a mailed survey of 1,800 U.S. ob-gyns. We presented seven scenarios in which patients sought abortions. For each, respondents indicated if they morally objected to abortion and if they would help patients obtain an abortion. We analyzed predictors of objection and assistance. The response rate was 66%. Objection to abortion ranged from 16% (cardiopulmonary disease) to 82% (sex selection); willingness to assist ranged from 64% (sex selection) to 93% (cardiopulmonary disease). Excluding sex selection, objection was less likely among ob-gyns who were female (odds ratio [OR] 0.5, 95% confidence interval [CI] 0.4-0.8), urban (OR 0.3, 95% CI 0.1-0.7), or Jewish (OR 0.3, 95% CI 0.1-0.7) compared with male, rural, or religiously unaffiliated ob-gyns. Objection was more likely among ob-gyns from the South (OR 1.9, 95% CI 1.2-3.0) or Midwest (OR 1.9, 95% CI 1.2-3.1), and among Catholic, Evangelical Protestant, or Muslim ob-gyns, or those for whom religion was most important, compared with reference. Among ob-gyns who objected to abortion in a given case, approximately two-thirds would help patients obtain an abortion. Excluding sex selection, assistance despite objection was more likely among female (OR 1.8, 95% CI 1.1-2.9) and United States-born ob-gyns (OR 2.2, 95% CI 1.1-4.7) and less likely among southern ob-gyns (OR 0.3, 95% CI 0.2-0.6) or those for whom religion was most important (OR 0.3, 95% CI 0.1-0.7). Most ob-gyns help patients obtain an abortion even when they morally object to abortion in that case. Willingness to assist varies by clinical context and physician characteristics. II.
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There is a heated debate about whether health professionals may refuse to provide treatments to which they object on moral grounds. It is important to understand how physicians think about their ethical rights and obligations when such conflicts emerge in clinical practice. We conducted a cross-sectional survey of a stratified, random sample of 2000 practicing U.S. physicians from all specialties by mail. The primary criterion variables were physicians' judgments about their ethical rights and obligations when patients request a legal medical procedure to which the physician objects for religious or moral reasons. These procedures included administering terminal sedation in dying patients, providing abortion for failed contraception, and prescribing birth control to adolescents without parental approval. A total of 1144 of 1820 physicians (63%) responded to our survey. On the basis of our results, we estimate that most physicians believe that it is ethically permissible for doctors to explain their moral objections to patients (63%). Most also believe that physicians are obligated to present all options (86%) and to refer the patient to another clinician who does not object to the requested procedure (71%). Physicians who were male, those who were religious, and those who had personal objections to morally controversial clinical practices were less likely to report that doctors must disclose information about or refer patients for medical procedures to which the physician objected on moral grounds (multivariate odds ratios, 0.3 to 0.5). Many physicians do not consider themselves obligated to disclose information about or refer patients for legal but morally controversial medical procedures. Patients who want information about and access to such procedures may need to inquire proactively to determine whether their physicians would accommodate such requests.
ACOG Committee opinion no. 385: the limits of conscientious refusal in reproductive medicine
American College of Physicians ethics manual: sixth edition.
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Counseling the adolescent about pregnancy options
FIGO professional and ethical responsibilities concerning sexual and reproductive rights
  • International joint policy statement