Abstract
Objectives:
Most induced abortions are provided by abortion specialists, despite knowledge and skills overlap with other disciplines, particularly general obstetrics and gynecology (OB/GYN). We evaluated patient preferences for abortion and miscarriage care from a family planning specialist versus other providers, and perceptions of a general OB/GYN’s ability to provide safe miscarriage and abortion care.
Materials and Methods:
We conducted a cross-sectional survey among individuals aged 18–44 receiving induced abortion (n = 54) or nonabortion gynecological care (n = 111) in North Carolina hospital-based gynecology or family planning clinics between April and October 2023. The primary predictor was appointment type. The primary outcome was preference for induced abortion from a family planning specialist versus other providers; secondary outcomes were provider specialty preference for miscarriage care and patient perceptions of a general OB/GYN’s scope of practice. We evaluated associations between appointment type, outcomes, and participant characteristics.
Results:
This was a racially diverse population with half (50.3%) using public health insurance. Most (73.0%) felt abortion is “morally acceptable and should be legal.” Over half (53.1%) preferred induced abortion from a specialist provider, compared with one-third (32.7%) for miscarriage (p < 0.001), with no differences by appointment type. Educational attainment (p = 0.03) and Democratic party affiliation (p = 0.02) were independently associated with abortion specialist preference, but not significant in multivariable analysis. More participants believed a general OB/GYN can provide medications for miscarriage management compared with induced abortion (94.5% versus 86.6%, p = 0.01). Both medical and surgical first trimester induced abortions were more often identified as within-scope for a general OB/GYN than the ability to perform a hysterectomy (69.8%, p < 0.01). Most (78.8%) believed OB/GYNs should be required to train in abortion care.
Conclusions:
Participants were more likely to prefer a family planning specialist for induced abortion care versus miscarriage; however, nearly half preferred nonspecialist care. Incorporation of induced abortion into general practice settings may meet patient preferences while expanding access.
Keywords: abortion, miscarriage, patient preferences, complex family planning, general OB/GYN
Introduction
Induced abortion is safe,1 common,2 and a vital component of reproductive health care. Obstetrician gynecologists (OB/GYNs) comprise the majority of abortion providers in the United States.3 Since 1996, the Accreditation Council for Graduate Medical Education has required that induced abortion training be a standard, opt-out component of OB/GYN resident education.4 Given this requirement and the direct overlap of induced abortion care with miscarriage management, all general OB/GYNs should have the technical skills to provide safe abortion care in the first trimester. However, few OB/GYNs provide induced abortions in practice,5 and most abortions occur in dedicated family planning clinics staffed by OB/GYNs, family medicine physicians, and advanced practice clinicians who specialize in abortion care.3,6 This separation of induced abortion away from the remainder of sexual and reproductive health care is, in part, the result of decades of antiabortion advocacy, including targeted regulations of abortion providers (TRAP laws),7 stigma and harassment of both abortion patients and providers,8,9 gestational age limits, and outright bans.10 Limiting the venues in which induced abortion can be provided deliberately restricts the ability of nonspecialist practitioners to provide induced abortion despite having the necessary skills.
Prior research has demonstrated substantial patient interest and satisfaction in receiving induced abortion in primary care settings.11–14 Less is known about the abortion care preferences of established patients of OB/GYNs, who in theory could receive induced abortion from their known provider if not impeded by federal, state, or local policies. Prior research suggests that patients may not discuss induced abortion with their primary gynecological provider due to concerns that the provider would judge or treat them differently and assumptions that “normal” OB/GYNs do not perform induced abortions.15,16
We aimed to evaluate preferences for induced abortion and miscarriage care from a family planning specialist versus other provider types among individuals in North Carolina seeking induced abortion or other gynecological care from hospital-based clinics staffed by OB/GYNs, some of whom have specialized training in family planning. Given the legal and logistical barriers to obtaining induced abortion in North Carolina,17 we hypothesized that participants seeking induced abortion would prefer nonspecialist care. We also investigated beliefs about the ability of a general OB/GYN to provide safe induced abortion care compared with miscarriage management and other within-scope practices, and feelings toward a hypothetical abortion provider.
Material and Methods
Study design and population
We conducted a cross-sectional survey study among individuals aged 18–44 seeking either induced abortion or nonabortion gynecological care in two hospital-based clinics providing either general gynecology or family planning services within a North Carolina tertiary medical center. Both of these clinics are training sites for resident physicians, who serve as the primary patient-facing provider. The general gynecology clinic, which serves a large proportion of uninsured, underinsured, and Medicaid-insured patients, is staffed by board-certified general OB/GYNs. The family planning clinic is staffed by a combination of board-certified complex family-planning specialists and general OB/GYNs with training and interest in abortion care. All faculty staffing the family planning clinic also provide obstetric care.
Participants were recruited according to appointment type. Abortion-seeking participants were those presenting to the family planning clinic for induced abortion services, including medication abortion dispensing, in-office uterine aspiration, preoperative appointments prior to procedural abortions in the operating room, or follow-up appointments after induced abortion. Nonabortion participants included individuals presenting to either the family planning or general gynecology clinic for annual exams, contraceptive counseling or management, gynecology problem visits, or miscarriage care. We excluded individuals who were unable to become pregnant in the future due to prior hysterectomy, permanent contraception, or clearly diagnosed infertility such as premature ovarian failure. We additionally excluded individuals who did not speak and read English due to the exploratory nature of this small study, which limited our ability to conduct multilingual research. This study was approved by the Duke University Health Systems Institutional Review Board.
Instrument development
Survey items were developed from previously used measures when possible and revised with iterative feedback from content experts. The survey was administered using Duke University-licensed Qualtrics online software. The survey was pilot tested with five participants meeting eligibility criteria who were seeking nonabortion care. Pilot participants read through the questions and provided feedback regarding readability, comprehension, and content validity without providing personal information. Specific suggestions to improve question wording were solicited. This feedback was incorporated to finalize the survey instrument.
Screening and recruitment
Individuals presenting for eligible appointment types were approached by a study team member in a private space and offered participation in a short, confidential survey about preferences for miscarriage and abortion care. Participants could access the survey on a study iPad or personal device and provided anonymous informed consent by agreeing to continue. Participants who completed the survey were compensated with a $5 gift card.
Participants were recruited between April and October 2023. All nonabortion participants were recruited from April through June, while participants seeking induced abortion were recruited from April through October. Notably, the recruitment window for abortion-seeking participants overlapped with the enactment of new North Carolina abortion regulations on July 1, 2023, which decreased the legal gestational age limit for induced abortion from 20 weeks 6 days to 12 weeks 6 days and added additional requirements such as in-person counseling at least 72 hours prior to induced abortion.17 Prior to July 1, 2023, the general OB/GYN and family planning clinics were in the same physical location, although with separate templates and assigned providers; after July 1, the family planning clinic relocated from a hospital-adjacent outpatient setting to a clinical ward within the hospital in order to conform to new legal requirements.
Measures
Appointment type was identified via self-report. Participants were asked, “If in the future you needed an abortion, from which type of provider would you most prefer to receive abortion care?” Response options included general OB/GYN, specialist family planning provider (OB/GYN or other provider with specialized training in contraception and abortion), primary care or family medicine provider, emergency room provider, other women’s health provider, or no preference. Similarly, participants were asked, “If you needed medical care for a miscarriage, from which type of provider would you most prefer to receive miscarriage care?” with the same response options.
The following participant characteristics were collected from survey data: age, race/ethnicity, marital status, highest educational achievement, religious affiliation, political party affiliation,18 health insurance, receipt of food stamps, Supplemental Nutrition Assistance Program (SNAP) or Women, Infants and Children (WIC) benefits in the past 12 months, and whether anyone in their household was unable to receive medical care because of the cost in the past 12 months. Participant-reported race and ethnicity were collected and included in this analysis due to known disparities in access to induced abortion and other health care and experiences of racism in health care that could potentially contribute to preferences for abortion provider specialty. Participants could select all categories that applied among Black or African American, White, Asian, Pacific Islander or Native Hawaiian, American Indian or Alaskan Native, and other, with a text box entry. A separate question asked, “Are you Latina/Latinx, Hispanic, or of Spanish origin?” Responses were then coded according to the United States census categories for analysis.
We assessed personal attitude toward induced abortion using a single measure.19,20 Response options were “I believe having an abortion is morally acceptable and should be legal,” “I am personally against abortion for myself, but I don’t believe government should prevent a woman from making that decision for herself,” and “I believe having an abortion is morally wrong and should be illegal.” Participants were asked how many times they have ever been pregnant, including the current or recently ended pregnancy if applicable, and to provide the outcome of each pregnancy (full-term birth >37 weeks, preterm birth <37 weeks, miscarriage or stillbirth, abortion, ectopic pregnancy).
Participants were asked whether they thought a general practice OB/GYN could safely provide various types of medical and surgical care, including medical management of miscarriage, medication abortion, and first and second trimester surgical induced abortion or miscarriage management. We included “hysterectomy (perform surgery to remove the uterus)” as a within-scope procedure for comparison and “mastectomy (perform surgery to remove the breast)” as an out-of-scope comparison. Four-point Likert scale response options were dichotomized to “definitely/probably yes” and “definitely/probably no” for analysis. A variable was created to define those participants who responded “definitely/probably yes” to all six miscarriage and abortion care practices.
Participants were also asked whether they think OB/GYNs should be required to train in abortion care as part of their standard training (yes, no, I don’t know). Participants seeking nonabortion care were asked, “If you found out that the OB/GYN you are seeing today/recently saw provided abortions, how would this change your opinion of them?” (Improved opinion/think better of them, no change, worsened opinion/think less of them).
Sample size justification
Existing data suggested a conservative 25% difference in desire for primary care-based abortion among individuals seeking or open to abortion versus not seeking or open to abortion.21,22 To account for differential clinic volumes, we planned to recruit abortion-seeking participants in a 1:2 ratio with nonseeking participants. A sample size of 162 participants (54 abortion-seeking and 108 nonseeking) was determined via a priori power calculation to ensure 80% power to detect a 25% difference in the primary outcome with a two-sided alpha of 0.05.
Data analysis
All statistical analyses were conducted in Stata SE, version 18. The primary independent variable was appointment type, which was dichotomized as induced abortion care versus all others. The primary outcome was preference for induced abortion care from a family planning specialist versus all other providers (i.e., nonspecialist provider). The secondary outcome was specialty preference for miscarriage care. Descriptive statistics were generated. We evaluated unadjusted associations between appointment type, other characteristics, and the outcome variables, using chi-square or Fisher exact tests as appropriate for categorical variables, and the Wilcoxon rank sum test for continuous variables. Multivariable logistic regression models were built to assess associations between appointment type and specialty preference while adjusting for variables associated with the outcome at the p < 0.15 level. Records with missing data were dropped for multivariable analyses (see missingness in Table 1). No variables were included in the model a priori due to the exploratory nature of this study and the lack of known associations of participant characteristics with provider specialty preference.
Table 1.
Participant Characteristics
| n (%) | Abortion care appointment N = 54 (32.7%) |
Nonabortion care appointmenta N = 111 (67.3%) |
p Valueb | |
|---|---|---|---|---|
| Age | 29 [25,36] | 27 [23, 31] | 31.5 [25, 37] | <0.001 |
| Race/Ethnicity | 0.42 | |||
| Hispanic | 23 (14.1) | 11 (20.4) | 12 (11.0) | |
| Non-Hispanic Black | 74 (45.4) | 24 (44.4) | 50 (45.9) | |
| Non-Hispanic White | 49 (30.1) | 14 (25.9) | 35 (32.1) | |
| Non-Hispanic other racec | 17 (10.4) | 5 (9.3) | 12 (11.0) | |
| Marital status | 0.30 | |||
| Single, never married | 99 (60.4) | 34 (63.0) | 65 (59.1) | |
| Married | 32 (19.5) | 11 (20.4) | 21 (19.1) | |
| Not married, living with partner | 21 (12.8) | 8 (14.8) | 13 (11.8) | |
| Divorced/Separated/Widowed | 12 (7.3) | 1 (1.9) | 11 (10.0) | |
| Highest education | 0.69 | |||
| Less than high school diploma | 8 (4.9) | 1 (1.9) | 7 (6.4) | |
| High school diploma or GED | 46 (28.1) | 16 (29.6) | 30 (27.3) | |
| Some college, trade/tech school | 51 (31.1) | 15 (27.8) | 36 (32.7) | |
| College degree | 39 (23.8) | 15 (27.8) | 24 (21.8) | |
| Master’s degree or higher | 20 (12.2) | 7 (13.0) | 13 (11.8) | |
| Reproductive history | ||||
| Never pregnant | 34 (20.6) | — | 34 (30.6) | — |
| Number of pregnancies | 0.12 | |||
| 1 | 36 (21.8) | 19 (35.2) | 17 (22.1) | |
| 2 | 29 (17.6) | 10 (18.5) | 19 (24.7) | |
| 3 | 30 (18.2) | 15 (27.8) | 15 (19.5) | |
| 4 | 16 (9.7) | 6 (11.1) | 10 (13.0) | |
| 5+ | 20 (12.1) | 4 (7.4) | 16 (20.8) | |
| Ever abortion | 78 (47.3) | 54 (100) | 29 (26.1) | — |
| Parous (any delivery >20 weeks) | 93 (56.4) | 27 (50.0) | 66 (59.5) | 0.25 |
| Ever miscarriage | 53 (32.1) | 11 (20.4) | 42 (37.8) | 0.02 |
| Political party | 0.88 | |||
| Republican/Lean Republican | 15 (9.2) | 4 (7.6) | 11 (10.0) | |
| Neither/Independent | 61 (37.4) | 21 (39.6) | 40 (36.4) | |
| Democrat/Lean Democrat | 87 (53.4) | 28 (52.8) | 59 (53.6) | |
| Religion | 0.85 | |||
| No religious affiliation | 68 (41.7) | 20 (37.7) | 48 (43.6) | |
| Christian: Catholic or Orthodox | 30 (18.4) | 11 (20.8) | 19 (17.3) | |
| Christian: Protestant or other | 48 (29.5) | 17 (32.1) | 31 (28.2) | |
| Other | 17 (10.4) | 5 (9.4) | 12 (10.9) | |
| Health insuranced | 0.02 | |||
| None/Uninsured | 15 (9.2) | 6 (11.1) | 9 (8.3) | |
| Medicaid/Medicare/Military Health Insurance | 82 (50.3) | 19 (35.2) | 63 (57.8) | |
| Private insurance | 66 (40.2) | 29 (53.7) | 37 (33.9) | |
| In the past 12 months, were you or a member of your household… | ||||
| A recipient of food stamps, SNAP or WIC benefits | 71 (43.0) | 21 (37.0) | 51 (46.0) | 0.28 |
| Unable to seek health care due to cost | 18 (10.9) | 6 (11.1) | 12 (10.8) | 0.95 |
Values are n (%) or mean [IQR], column %.
Nonabortion care included appointments for annual exam (n = 22), gynecology problem visit (n = 51), birth control (n = 30), or miscarriage care (n = 8).
p Values are from chi-square or Fisher exact for categorical variables; Wilcoxon rank sum for continuous variables.
Non-Hispanic other race includes non-Hispanic Asian (n = 2), Native American or Pacific Islander (n = 1), non-Hispanic multiracial (n = 9), Other nonspecified (n = 5), and other religion includes Jewish (n = 2), Muslim (n = 2), Hindu (n = 3), and “other” unspecified (n = 10).
Nine participants indicated dual insurance coverage. N = 8 private and Medicaid/Medicare, n = 1 private and Military Health Insurance (Veterans Affairs (VA), TriCare or CHAMPUS); individuals with any private insurance were coded as private, n = 1 with VA only insurance was recoded as “Medicaid/Medicare/VA” due to similar lack of abortion coverage under North Carolina law.
Missing data: race/ethnicity (n = 2), marital status (n = 1), education (n = 1), political party (n = 2), religion (n = 2), and insurance/financial assistance (n = 1).
Two-sample tests of proportions were used to evaluate differences between specialist preference for abortion and miscarriage care and between scope of practice outcomes for miscarriage and abortion. Six abortion and miscarriage-related medical competencies were compared against the prespecified “in-scope” competency of hysterectomy, with p values adjusted for multiple comparisons using the Bonferroni correction method. Mastectomy was included as an out-of-scope comparison and compared with hysterectomy using a two-sample test of proportions. We also explored whether preference for abortion or miscarriage from a family planning specialist differed between participants who believed a general OB/GYN could safely provide all six types of miscarriage and abortion care versus all others, using chi-squared.
Results
Of 203 eligible participants, 165 completed the survey, for an overall response rate of 81.3% (Fig. 1). Response rate did not vary significantly by appointment type. One-third of participants (n = 54; 33%) were seeking induced abortion and two-thirds (n = 111; 67%) were seeking nonabortion gynecological care, including annual exam (n = 22), gynecology problem visit (n = 51), birth control appointment (n = 30), or miscarriage care (n = 8). Among abortion-seeking participants, 32 (59.3%) completed the survey prior to the July 1st legal changes, and 22 (30.7%) were recruited after July 1.
FIG. 1.
Recruitment diagram.
This was a racially diverse population (45.4% non-Hispanic Black, 30.1% non-Hispanic White, 14% Hispanic or Latinx). Half (50.3%) reported using public health insurance (Table 1). Abortion-seeking participants were younger (median age 27 versus 31.5, p < 0.001) and more likely to have private health insurance (53.7% versus 33.9%, p = 0.02) compared with nonabortion-seeking participants. Nonabortion participants were more likely to have ever experienced a miscarriage (37.8% versus 20.4% of abortion participants, p = 0.02), although this reproductive outcome was also highly associated with increasing age (p < 0.001).
Overall, 50.3% of participants (n = 83) had any history of induced abortion, including the 54 participants currently seeking induced abortion, plus 26.1% of nonabortion participants. Most felt that induced abortion is “morally acceptable and should be legal” (73%), while 22% were against abortion for themselves but against government interference, and 5% felt abortion is “morally wrong and should be illegal.” Participants currently seeking induced abortion or with any induced abortion history were more likely to report that abortion is morally acceptable (p < 0.001).
For induced abortion, 53.1% of participants preferred care from a family planning specialist, followed by a general OB/GYN (32.1%), emergency room provider (3.0%), other women’s health provider (2.4%), and primary care or family medicine provider (1.8%). No preference was reported by 7.9%. Preference for induced abortion care from a family planning specialist did not differ significantly by appointment type (61.1% of abortion-seeking participants versus 48.7% of nonseeking participants, p = 0.13) (Table 2). Higher educational attainment (p = 0.03) and Democratic political party affiliation (p = 0.02) were independently associated with preference for specialist abortion care. In a multivariable logistic regression model, no participant characteristics remained associated with abortion care specialty preference (Table 3).
Table 2.
Bivariate Associations of Participant Characteristics with Preferred Provider Specialty for Abortion and Miscarriage Care
| Prefer family planning specialist for abortiona n = 87 (52.7%) | p Valueb | Prefer family planning specialist for miscarriagea n = 54 (32.7%) | p Valueb | |
|---|---|---|---|---|
| Abortion appointment | 33 (61.1) | 0.13 | 18 (33.3) | 0.91 |
| Nonabortion appointment | 54 (48.7) | 36 (32.4) | ||
| Age | 30 [22, 44] | 0.36 | 29 [25, 37] | 0.46 |
| Race/Ethnicity | 0.50 | 0.85 | ||
| Hispanic | 9 (39.1) | 8 (34.8) | ||
| Non-Hispanic Black | 39 (52.7) | 23 (31.1) | ||
| Non-Hispanic White | 28 (57.1) | 15 (30.6) | ||
| Non-Hispanic other race | 10 (58.8) | 7 (41.2) | ||
| Marital status | 0.67 | 0.79 | ||
| Single, never married | 51 (51.5) | 32 (32.3) | ||
| Married | 20 (62.5) | 9 (28.1) | ||
| Not married, living with partner | 10 (47.6) | 8 (38.1) | ||
| Divorced/Separated/Widowed | 6 (50.0) | 5 (41.7) | ||
| Highest education | 0.03 | 0.15 | ||
| Less than high school diploma | 3 (37.5) | 3 (37.5) | ||
| High school diploma or GED | 16 (34.8) | 9 (19.6) | ||
| Some college, trade/tech school | 33 (64.7) | 22 (43.1) | ||
| College degree | 24 (61.5) | 14 (35.9) | ||
| Master’s degree or higher | 11 (55.0) | 6 (30.0) | ||
| Reproductive history | ||||
| Ever abortion | 48 (57.8) | 0.19 | 28 (33.7) | 0.78 |
| Parous (any delivery >20 weeks) | 46 (49.5) | 0.34 | 30 (32.3) | 0.88 |
| Ever miscarriage | 29 (54.7) | 0.73 | 17 (32.1) | 0.90 |
| Political party | 0.02 | 0.34 | ||
| Republican/Lean Republican | 4 (26.7) | 3 (20.0) | ||
| Neither/Independent | 28 (45.9) | 17 (27.9) | ||
| Democrat/Lean Democrat | 53 (60.9) | 32 (36.8) | ||
| Religion | 0.67 | 0.42 | ||
| No religious affiliation | 35 (51.5) | 20 (29.4) | ||
| Christian: Catholic or Orthodox | 16 (53.3) | 9 (30.0) | ||
| Christian: Protestant or other | 28 (58.3) | 20 (41.7) | ||
| Other | 7 (41.2) | 4 (23.5) | ||
| Health insurance | 0.10 | 0.35 | ||
| None/Uninsured | 7 (46.7) | 4 (26.7) | ||
| Medicaid/Medicare/VA | 38 (46.3) | 23 (28.1) | ||
| Private insurance | 42 (63.6) | 26 (39.4) | ||
| In the past 12 months, were you or a member of your household… | 42 (32.1) | |||
| A recipient of food stamps, SNAP or WIC benefits | 37 (52.1) | 0.89 | 19 (26.8) | 0.16 |
| Unable to seek health care due to cost | 8 (44.4) | 0.46 | 5 (27.8) | 0.64 |
Response options were dichotomized as “specialist family planning provider” versus all other options, including general OB/GYN, primary care or family medicine provider, emergency room provider, other women’s health provider, or no preference.
p Values are from chi-square or Fisher exact for categorical variables; Wilcoxon rank sum for continuous variables.
Missing data: race/ethnicity (n = 2), marital status (n = 1), education (n = 1), political party (n = 2), religion (n = 2), and insurance/financial assistance (n = 1).
OB/GYN, obstetrician gynecologist.
Table 3.
Adjusted Associations of Participant Characteristics with Preference for Family Planning Specialist for Abortion Care
| Prefer family planning specialist for abortion | ||||
|---|---|---|---|---|
| Unadjusted ORa | p Value | Adjusted ORb | p Value | |
| Abortion appointment | 1.5 (0.85, 3.21) | 0.13 | 1.60 (0.77, 3.30) | 0.21 |
| Highest education | 0.03 | 0.08 | ||
| Less than high school diploma | Ref | Ref. | ||
| High school diploma or GED | 0.89 (0.19, 4.21) | 0.54 (0.10, 2.89) | ||
| Some college, trade or tech school | 3.06 (0.65, 14.29) | 1.92 (0.37, 10.12) | ||
| College degree | 2.67 (0.55, 12.82) | 1.40 (0.25, 7.99) | ||
| Master’s degree or higher | 2.04 (0.38, 10.94) | 0.87 (0.13, 5.58) | ||
| Political party | 0.02 | 0.09 | ||
| Republican/Lean Republican | Ref | Ref. | ||
| Neither/Independent | 2.33 (0.67, 8.15) | 3.36 (0.86, 12.71) | ||
| Democrat/Lean Democrat | 4.29 (1.26, 14.56) | 4.29 (1.17, 15.69) | ||
| Health insurance | 0.10 | 0.74 | ||
| None/Uninsured | Ref | Ref. | ||
| Medicaid/Medicare/Military Health Insurance | 0.99 (0.33, 2.98) | 1.20 (0.37, 3.87) | ||
| Private insurance | 2.00 (0.65, 6.20) | 1.53 (0.45, 5.27) | ||
Univariate logistic regression models.
Multivariable logistic regression model including patient characteristics associated with the outcome at the p < 0.15 level. n = 161 due to missing data.
For miscarriage care, the most commonly preferred provider was a general OB/GYN (49.1%), followed by a family planning specialist (32.7%), an emergency room provider (7.3%), a primary care/family medicine provider (2.4%), and another women’s health provider (1.8%), with 4.9% selecting no preference. There was a significant difference in desire for miscarriage versus abortion care from a family planning specialist (32.7% versus 52.7%, respectively, p < 0.001). There were no differences in family planning specialist preference by appointment type (33.3% of abortion-seeking participants versus 32.4% nonseeking participants, p = 0.91) (Table 2). No participant characteristics were associated with desire for specialist miscarriage care, and multivariable analyses were not performed.
Vast majorities of participants believed a general practice OB/GYN can definitely or probably provide safe medication-induced abortion, medical management of miscarriage, and first trimester surgical abortion (Fig. 2). Participants were more likely to believe a general OB/GYN’s ability to provide medical miscarriage management compared with medication-induced abortion (94.5% versus 86.6%, p = 0.01). This trend was similar, although not statistically significant for first and second trimester surgical miscarriage and abortion care. Notably, participants were more likely to identify both first trimester miscarriage and abortion care skills as within-scope for a general OB/GYN than the ability to perform a hysterectomy (69.8%, p < 0.01) (Fig. 2). Participants were significantly less likely to believe that mastectomy was within-scope for a general OB/GYN compared with hysterectomy (56.2% versus 69.8%, p = 0.01). Over two-thirds of participants (69.7%) believed that a general practice OB/GYN can safely provide all six types of miscarriage and abortion care. There were no statistically significant differences in preference for abortion or miscarriage care from a family planning specialist based on scope of practice beliefs (data not shown).
FIG. 2.
Patient perceptions of general OB/GYN scope of practice.
Most participants (78.8%) believed that OB/GYNs should be required to train in abortion care, with no difference by appointment type (p = 0.16) or personal history of abortion (p = 0.82). Among 111 participants seeking nonabortion care, nearly all reported they would have an improved (43.2%) or unchanged (55.9%) opinion of their OB/GYN if they found out they provided abortion care. A single participant (0.9%) reported they would have a worsened opinion.
Discussion
Among a sample of North Carolina-based gynecology patients generally supportive of induced abortion, over half preferred abortion care from a family planning specialist provider, versus only one-third for miscarriage. There were no significant differences in specialty preference across appointment type or other participant characteristics. Participants were more likely to believe a general OB/GYN can provide miscarriage compared with induced abortion care; however, most believed first trimester induced abortion to be within a general OB/GYN’s scope of practice. Though exploratory, our results suggest differential conceptualizations of miscarriage and abortion care among individuals with access to gynecological care, as well as a potential unmet desire for nonspecialist abortion care.
While the medical and surgical management of spontaneous and induced abortion is identical, these common reproductive experiences carry vastly different social, political, and legal connotations. In North Carolina, individuals seeking induced abortion face barriers created by restrictive laws, including multiple in-person appointments, derogatory and misleading state-mandated counseling, a 72-hour required waiting period, and prohibition of insurance coverage.7,10 Although restrictive abortion laws also impede timely and patient-centered care for spontaneous abortion,23 North Carolina patients receiving miscarriage management face none of the above barriers. People seeking induced abortion also experience stigma, both externally from their communities as well as internalized stigma, which may stem from societal and personal values about motherhood and fertility, antiabortion advocacy, and legal restrictions implying personal deviancy and unsafe care.24 These many stigmas may promote a desire for anonymity in induced abortion care, even if abortion was available from a known provider. Misinformation and stigma may also promote overestimation of the risks of induced abortion compared with other reproductive outcomes such as miscarriage and term delivery,25,26 and therefore belief in the need for specialist care to facilitate safe abortion.
Induced abortion has been studied extensively over decades and carries minimal risks as practiced in the United States by a variety of provider types.1 Although OB/GYN physicians comprise the majority of U.S. abortion providers,3 high-quality and safe induced abortion is also provided by family medicine physicians, advanced practice providers, and others.27,28 A newly accredited OB/GYN subspecialty, complex family planning (CFP), offers contraceptive expertise and advanced training in procedural abortion, particularly at later gestational ages.29 CFP subspecialists bring expertise to complex cases and provide essential leadership and scholarship within a traditionally marginalized subspecialty; however, most specialized abortion providers are not CFP trained, nor do they need to be.1 Integration of induced abortion care into nonspecialized clinical settings could dramatically expand abortion access, and general practice OB/GYNs represent a large workforce with preexisting but underutilized skills to provide this care.3 This is particularly salient considering the increasing challenges of meeting demand for abortion in locations with preserved legal protections, and in light of the challenges facing OB/GYN residency programs in restrictive states in training the next generation of abortion providers.30 Unfortunately, integration of induced abortion into general OB/GYN settings would require overcoming the myriad social and political challenges that intentionally disincentivize abortion provision, including legal restrictions and onerous regulatory requirements,10 plus community-based and interprofessional stigma and harassment.8,9 Additional barriers include the logistical, scheduling, and billing challenges associated with office-based procedures. A recent qualitative study of OB/GYN and family medicine physicians who provide induced abortion within their primary practice identified institutional leadership as a crucial factor in successful abortion care provision and a barrier when clear professional support is not provided.31
Despite the demonstrated safety of nonspecialist abortion care and the strong overlap with miscarriage care, our data suggest a preference for specialist care for induced abortion, contrary to our hypothesis. Prior research has identified fears of provider judgment and desire for anonymity as reasons for desiring specialist abortion care, as well as belief in greater expertise and competency among specialized abortion providers.11,12,32 Our results do not directly support this later argument, given that belief in the full scope of practice among general OB/GYNs was not associated with preference for nonspecialist care, and most participants believed general OB/GYNs have the competence to provide at least first trimester abortion care. Other work has highlighted the perceived benefits of primary care-based induced abortion, including convenience, continuity of care, and trust of a familiar provider.12,13 In one study among individuals receiving induced abortion at urban family planning clinics, 58% would choose their primary care office for abortion if it were offered.11 Another study found that 67% of family medicine patients would prefer to see their family physician for a theoretical future abortion.12 In contrast, very few participants in our study desired abortion or miscarriage care from a primary care provider, and half desired abortion care from a specialist provider rather than a general OB/GYN. This disparate finding may reflect our study population’s differential access to primary care and preexisting access to gynecological care compared with prior studies, including access to a clinical setting where induced abortion was being provided by family planning specialists. Patients may have differential relationships with primary care providers versus OB/GYNs based on frequency of visits or care needs. Notably, participants in this study were receiving care in clinics run by resident physicians, which limits long-term continuity with a single provider. Prior experiences with abortion, including provider type and setting, may also have influenced care preferences. This hypothesis-generating research is unable to identify reasons driving participants’ preferences for specialist versus nonspecialist abortion and miscarriage care; future research is needed to elucidate factors driving abortion care preferences to ensure that patient needs are met while working to expand access.
Strengths of this study include attention to the preferences of individuals with preexisting access to care from an OB/GYN, a provider who should have the clinical skillset to provide induced abortion if not impeded by policy, as compared with prior work in primary care settings. We sampled a diverse population reflective of the community served by our institution’s hospital-based gynecology and family planning clinic. Limitations include a small sample size, which limits power and ability to perform robust multivariable analyses. Selection bias may have contributed to a population with positive views of induced abortion. Although our robust response rate implies representativeness of the approached population, exclusion of non-English speaking participants limits generalizability, and our results should not be used to draw conclusions about all gynecology patients in North Carolina or the broader United States.
Conclusions
North Carolina gynecology patients were more likely to prefer family planning specialist care for induced abortion compared with miscarriage; however, nearly half preferred nonspecialist abortion care. While reasons for these preferences remain unclear, stigma and knowledge deficits about the similarities of miscarriage and abortion care likely contribute. Incorporation of induced abortion care into general practice settings may meet patient preferences while expanding access to this crucial and increasingly restricted reproductive health service. Health system leaders in U.S. states with preserved abortion access should help facilitate the expansion of abortion provision among other trained providers, particularly general OB/GYNs. Future research should continue to assess patient needs and preferences and evaluate logistical capabilities to integrate abortion care into more varied practice settings.
Acknowledgments
The authors would like to acknowledge the assistance of Alaattin Erkanli, PhD, and Tracey Truong, MS, in reviewing statistical methods.
Authors’ Contributions
C.J.-G.: Conceptualization, methodology, funding acquisition, data curation, formal analysis, project administration, and writing—original draft. S.S.: Methodology, resources, and writing—review and editing. L.H.: Methodology, resources, and writing—review and editing. N.D.: Project administration, resources, and writing—review and editing. R.F.: Resources and writing—review and editing. J.J.S.: Supervision, conceptualization, methodology, and writing—review and editing.
Author Disclosure Statement
The authors report no conflict of interest.
Funding Information
This work was supported by the Charles B. Hammond Resident Research Fund, Duke University, Department of Obstetrics & Gynecology. J.J.S. was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) of the National Institutes of Health (NIH) under award number K12HD103083. This article is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Duke University Department of Obstetrics & Gynecology.
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