Abortion clinic patients’ opinions about obtaining abortions from general women's health care providers

https://doi.org/10.1016/j.pec.2010.09.003Get rights and content

Abstract

Objective

Most U.S. women obtain abortions at specialty clinics. This qualitative study explores abortion clinic patients’ opinions about receiving abortions from general women's health care providers.

Methods

We conducted 20 h-long, semi-structured interviews with diverse women who had abortions in the U.S. Heartland. Each described her usual health care provider and how she accessed abortion care. We used qualitative analytic methods to organize and interpret the data.

Results

Despite having a general provider, most women sought clinic abortions. Some women offered reasons for preferring specialty care and others for preferring abortion from their general provider. Most women assumed their general provider did not “do abortion” and many believed those providers were opposed to abortion. Women who had delivered a baby were concerned with their image in their general provider's eyes. Two women were denied care by their general providers.

Conclusion

Women's preferences for abortion care centered on privacy, cost, empathy, ability to control their image, and desire for safe quality care. Two women who sought abortions through their general providers experienced negative repercussions.

Practice implications

General providers should proactively make patients aware of their positions on abortion and if supportive indicate that they can provide that care and/or a referral.

Introduction

Abortion is one of the most common health care needs for women of reproductive age. Approximately half of all pregnancies in the United States (U.S.) are unintended and 40 percent of those pregnancies end in abortion [1]. Consequently, by age 45, 1 in 3 women in the U.S. will have an abortion [2] resulting in approximately 1.2 million abortions annually. Despite the high demand for abortion services, that care is provided in a limited number of facilities across the country and the number of providers continues to decline. In 2005, only 1787 facilities in the country provided abortion care [3]. By comparison there are over 20,000 practicing obstetrician–gynecologists [4] to perform approximately the same number of Cesarean deliveries (1.3 million) [5] although that procedure is significantly more complicated to perform. Within the small number of facilities that offer abortion care, those that are identified as “abortion clinics” (381 facilities), in which over half of patient visits are for abortion services, provided 70 percent of all the abortions performed in the United States in 2005 [3]. This specialization of services is the result of three decades of contributing factors including the development of the women's health movement which pushed for women-controlled spaces for abortion care [6], [7], the failure of mainstream medicine to routinely incorporate abortion into medical training [8], [9], the rise of violence against abortion providers [10], and the high number of regulations that limit where and how abortion services can be provided [11].

As a result of the specialization of abortion services, most women now receive abortion care outside of the context of their general health care, yet the separation of abortion from other health care is not broadly recognized by many women. We do note that for some women the abortion clinic may be their only source of health care but is not usually a place where they can receive general women's health care, thus in the context of this paper we do not consider the abortion clinic a general woman's health care provider.

Although women may access abortions elsewhere, some women may need assistance to locate a qualified provider of abortion services and some women may desire a sympathetic relationship with their regular provider following their abortion experience. Women needing abortion care for medical indications in a desired pregnancy may need a direct referral to a provider given the complexity of their medical situation [12]. Women living in more conservative locations, however, may be the least likely to find a sympathetic provider for an abortion referral or for nonjudgmental care following an abortion.

The separation of abortion from general women's health care can create complicated disclosure situations for women. Women desiring an abortion referral do not know how their provider will react to this request. Likewise, since pregnancy history including abortion is often elicited on intake forms, women must navigate disclosing their abortions to a provider who may or may not be supportive of that decision. Surveys of physician attitudes about controversial health care reveal that such disclosure is risky. In a survey by Curlin and colleagues, 63 percent of physicians believed that it is ethically permissible to tell patients about their personal objections to a particular health care service and 29 percent did not think a physician had an obligation to make a referral for the objected service or were undecided [13]. And among physicians who identify as religious only 56 percent felt that physicians are obligated to disclose all possible health care options [13]. A recent systematic review documents the extent to which refusals are a violation of established standards of care [14] and anecdotal evidence suggests negative consequences for women [15], [16], [17], [18].

Little is known about how women experience physicians’ negative attitudes about abortion, referral refusals, or denials of care. What research there is suggests women prefer specialty abortion clinics in order to avoid those experiences [19]. This paper uses data from qualitative interviews with women obtaining abortions from specialized abortion facilities in the U.S. Heartland to begin to understand abortion care in relationship to providers of general women's health care. It offers insight into how women decide whether or not to seek abortion care, referral or support from their general women's health care provider, and what they might want from their general health care provider.

This paper is not proposing the hypothesis or drawing the conclusion that abortion care is better provided in either a specialty or a general health care practice. 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], [23], [24], [25], [26], [27], [28], [29], [30], [31], [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. While the quality of abortion care in the U.S. is high, access to care is inconsistent and favors women with higher incomes and who live in densely populated areas on the East and West Coasts [3]. Given longstanding recommendations in the reproductive health field to expand abortion services in more health care settings as a way of improving access [34], [35], we hope to shed light on what women think about disclosing their need for abortion to their general women's health provider and accessing abortion in those settings.

Section snippets

Methods

Between June 2006 and August 2007, we conducted 20 interviews with women who obtained abortions from three clinics in two states in the U.S. Heartland. Interviews focused on women's experiences with abortion care and abortion regulation. We defined the Heartland as states between Colorado on the West and Tennessee on the East and between South Dakota to the North and Texas to the South. As there are very few providers in the states where we conducted recruitment, we have decided not to reveal

Participant characteristics

Participant demographic characteristics are included in Table 1 of this paper. Nine women identified as white, seven as African American, three as Native American (one mixed Polynesian), and one as Hispanic. Women ranged in age from 18 to 43. Women in the sample had very diverse histories with pregnancy and the health care system. Fifteen of the women had at least one previous pregnancy prior to their most recent pregnancy. Of these women, six had experienced four or more pregnancies. Twelve of

Discussion

In the U.S., abortion is not routinely offered outside of specialty clinics. Despite the safety of care in the general health care setting, only two percent of abortions take place in private physicians, offices [3]. This study of women seeking abortion care in specialized facilities sought to understand their opinions about whether that care should be offered within general women's health care. Women in this study mentioned divergent sentiments. Some women found reasons to support specialty

Role of the funding source

This study was funded by a grant from the David and Lucile Packard Foundation.

Conflict of interest

None declared.

Acknowledgements

The authors are appreciative of Katrina Kimport, PhD, for her editing of the final draft of this article.

We confirm that all patient/personal identifiers have been disguised so the patients/persons described are not identifiable and cannot be identified through details of the story.

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