Abstract
Objective:
To better understand medication abortion attitudes and interest in future provision among Internal Medicine primary care providers (IM PCPs), and to characterize barriers to provision.
Study Design:
We conducted a survey with IM attendings and trainees at a large academic medical center in Western Pennsylvania. We used descriptive statistics to characterize attitudes towards medication abortion provision, including the belief that it is within their scope of practice and interest in future provision, and to explore perceived barriers to provision. We used logistic regression models to assess factors associated with each of these attitudes.
Results:
Of 397 eligible attendings and trainees, 121 (30%) completed the survey. Among those surveyed, 44% believed medication abortion is within the scope of practice of IM PCPs with trainees and female-identifying providers being significantly more likely to believe medication abortion is within their scope of practice compared to attending physicians and male physicians (60% vs 30%, p < 0.01 and 53% vs 31%, p = 0.01, respectively). Similarly, 43% endorsed interest in future provision, with trainees (67% vs 23%, p < 0.001) and female providers (54% vs 27%, p = 0.002) being more likely to express interest. The most cited barriers to provision included limited training in residency (70%) and low familiarity with abortion medications (57%).
Conclusions:
Many IM providers– particularly trainees– believe medication abortion is within their scope of practice and would like to provide this care. Interventions are needed to provide education and assistance complying with state and federal regulations to enable safe and efficient medication abortion provision by IM providers.
Implications:
IM departments and residency programs should seek to ensure training is offered to clinicians interested in providing medication abortion as a part of their primary care practice.
Keywords: COVID-19, Medication abortion, Reproductive justice, Women’s health
1. Introduction
Medication abortion up to 70 days gestation via a regimen of mifepristone and misoprostol has been FDA-approved as a safe and effective method of pregnancy termination [1]. Despite provision of these medications being, in theory, within the scope of practice of primary care providers (PCPs), over 70% of all US abortions are performed in specialized abortion clinics and only one percent are performed in primary care settings [2,3]. Given increasingly restrictive legislation and reduced number of facilities offering medication abortion, geo-spatial analyses suggest that 20% of US women would need to travel further than 40 miles to obtain an abortion [4,5]. In addition, many women experience significant harassment and/or violence when visiting specialized abortion clinics. In a recent survey, nearly 90% of abortion clinics reported patients experiencing some form of harassment, most commonly picketing (87%) and patient blocking (42%) [3].
Several recent studies have indicated that patients seeking abortions would prefer to receive this care at their PCP’s office compared to a specialized abortion clinic [2,6–10]. Reasons for desiring this care be provided by PCPs include convenience, privacy, established relationship with PCP, and the opportunity for continuity of care [6–9]. While some Family Medicine (FM) physicians around the country are trained to prescribe these medications as part of holistic primary care for patients with reproductive capacity, evidence suggests that few IM physicians are doing the same [11–14]. As IM-trained physicians represent a larger proportion of PCPs compared to FM-trained physicians, the provision of medication abortions by IM PCPs has the potential to improve women’s access to abortion by reducing geographic-related barriers, defragmenting health care, and bypassing the harassment and violence that many women experience when visiting a specialized abortion clinic [15]. However, few studies have evaluated the potential role of IM PCPs in providing medication abortion care or examined IM PCP’s perspectives on abortion care [16].
To better understand the attitudes towards medication abortion provision among IM PCPs affiliated with a large academic medical center in western Pennsylvania, we surveyed trainee and attending IM PCPs about their willingness to provide medication abortions, interest in future provision of medication abortion, and potential barriers to provision.
2. Material and methods
2.1. Data collection
We conducted a cross-sectional, online survey in June 2020. IM physicians at a large academic medical center in western Pennsylvania were sent a personalized email invitation to participate which included an embedded link to the survey. Eligible participants included IM attending physicians who serve as PCPs for a panel of patients (i.e., are not hospitalists) and IM trainees (residents, Women’s Health fellows, and General Internal Medicine fellows). Eligibility criteria were assessed on the first page of the survey, after which physicians provided informed consent for their participation. Participants who did not respond within 2 weeks were sent a personalized reminder email with an additional link to the survey.
The 26 survey questions were developed by the study team with several questions adapted with permission from the “Staff Attitude Survey” from the Reproductive Health Access Project (https://www.reproductiveaccess.org/resource/staff-attitude-survey/). The survey was then piloted by two residents and four attending physicians for comprehensibility. Following survey completion, eligible participants could opt in to receive a $10 gift card as a token of appreciation by entering their e-mail address in a second, unlinked survey. The study was approved by the University of Pittsburgh Institutional Review Board.
2.2. Survey measures
The two key outcomes were belief that the provision of medication abortion is within the scope of primary care practice and willingness to provide medication abortion in the future. To assess views on scope of practice, participants were asked “Do you believe providing medication in abortions is within the scope of practice of Internal Medicine primary care physicians?” To assess future willingness, participants were asked “If training were provided, and the practice were to accommodate the medical and legal logistics, would you be willing to provide medication abortions?” Response options for both survey items were “Yes,” “No,” and “I’m not sure.”
Other outcomes included providers’ perceived barriers to providing medication abortion, level of comfort working in a setting that provides medication abortions, perception of patients’ ease of access to abortion, and perceptions of patients’ “need” and “desire” to access medication abortions in the primary care setting.
Participant characteristics were assessed including position (attending/trainee), gender identity (male/female/other), race/ethnicity (categorized for analysis as non-Hispanic white, Hispanic, Asian or Other), religion (categorized for analysis as No Religion, Catholic, Protestant/other Christian, Jewish, Hindu, or Other), and political identity. Political identity was assessed using a standard 3-point scale: Democrat/Democrat-leaning, Independent, and Republican/Republican-leaning [17].
2.3. Data analysis
We generated descriptive statistics for all variables and used Pearson’s χ2 tests or Fisher exact tests as appropriate to assess associations between participant characteristics and the two primary outcomes: belief medication abortion is within their scope of practice and willingness to provide medication abortion in the future. We then dichotomized outcomes to yes versus no/unsure and used logistic regression to calculate unadjusted and adjusted odds of responding “yes” to each medication abortion outcome. Adjusted models included variables that were associated with the respective dichotomized outcome in bivariate analysis at the p < 0.05 level. Age was excluded from adjusted analyses given collinearity with trainee status (e.g., no trainees were >40 years old); we felt that trainee status was the more salient variable to include in adjusted models. We then generated descriptive statistics for outcomes of perceived patient ease of access, patient need to access medication abortion, and patient desire to access medication abortion and used Pearson’s χ2 or Fisher exact tests as appropriate to assess associations between trainee status and each outcome. All analyses were performed with Stata statistical software (StataCorp LLC, Release 16 College Station, TX).
3. Results
The overall response rate was 30% (121/397), with a similar response rate between trainees (55/180, 29%) and attending physicians (66/217, 30%). Respondents were mostly female (60%), Non-Hispanic White (64%), and attending physicians (55%). Trainees were significantly younger than attending physicians (p < 0.001) (Table 1). At the time of survey, only two providers (1.6%) reported currently providing medication abortion in their primary care practice.
Table 1.
Participant characteristics among general internists surveyed at an Academic Medical Center in Pennsylvania in 2020, by attending or trainee status.
| Totala n = 121 (%) | Attendings n = 66 (55%) | Traineesb n = 55 (45%) | p-valuec | |
|---|---|---|---|---|
| Age | ||||
| <31 years old | 41 (34) | 3 (5) | 38 (69) | <0.001 |
| 31-40 years old | 39 (33) | 22 (34) | 17 (31) | |
| 41-50 years old | 15 (13) | 15 (23) | 0 (0) | |
| > 50 years | 25 (21) | 25 (39) | 0 (0) | |
| Gender Identity | ||||
| Female | 72 (60) | 37 (57) | 35 (64) | 0.45 |
| Race/Ethnicity | 0.93 | |||
| Non-Hispanic White | 75 (64) | 38 (60) | 37 (69) | |
| Hispanic | 11 (9) | 7 (11) | 4 (7) | |
| Asian | 22 (19) | 13 (21) | 9 (17) | |
| Non-Hispanic other | 9 (8) | 5 (7) | 4 (8) | |
| Religion | 0.50 | |||
| No religion | 36 (31) | 16 (25) | 20 (37) | |
| Catholic | 29 (25) | 16 (25) | 13 (24) | |
| Protestant Christian | 18 (15) | 10 (16) | 8 (15) | |
| Jewish | 15 (13) | 11 (17) | 4 (7) | |
| Hindu | 11 (9) | 7 (11) | 4 (7) | |
| Other religiond | 9 (8) | 4 (7) | 5 (9) | |
| Political identity | ||||
| Democrat/Democrat-leaning | 85 (72) | 43 (67) | 42 (78) | 0.44 |
| Independent | 19 (16) | 12 (19) | 7 (13) | |
| Republican/Republican-leaning | 14 (12) | 9 (14) | 5 (9) |
Missing data: age (n = 1), gender (n = 1), race (n = 4), religion (n = 3), political affiliation (n = 29).
Trainees includes residents (n = 50) and General Internal Medicine (n = 3) and Women’s Health fellows (n = 2).
p-values are from χ2 tests or Fisher exact as appropriate, with significance determined at p < 0.05 level. Percentages are column percentages.
Other religion includes Muslim, Buddhist, Unitarian.
Nearly half of providers surveyed (44%) believed medication abortion is within the scope of practice of IM PCPs and another 20% were unsure (Table 2). Trainees were significantly more likely to believe medication abortion is within their scope of practice compared to attending physicians (60% vs 30%, p = 0.001), as were female providers when compared to their male colleagues (53% vs 31%, p = 0.009). Likewise, there were significant differences in beliefs about scope of PCP practice based on participant age (p = 0.008), race/ethnicity (p = 0.006), and political identity (p = 0.01). Overall, 43% reported interest in future provision of medication abortion, with trainees (67% vs 23%, p < 0.001) and female providers (54% vs 27%, p = 0.002) being more likely to express interest. Interest in future provision was also significantly different based on age (p < 0.001) and religious (p = 0.023) and political (p = 0.002) identity.
Table 2.
Bivariate relationships between participant characteristics and belief that medication abortion is within the scope of PCP and participant interest in future provision, among general internists surveyed at an Academic Medical Center in Pennsylvania in 2020 (n = 121).
| Medication abortion in scope of PCP (%) | Interest in future provision (%) | |||||||
|---|---|---|---|---|---|---|---|---|
| Yes | No | Unsure | p-valuea | Yes | No | Unsure | p-valuea | |
| Total | 44 | 36 | 20 | 43 | 35 | 22 | ||
| Position | < 0.01 | < 0.01 | ||||||
| Attending | 30 | 50 | 20 | 23 | 50 | 27 | ||
| Trainee (Resident/Fellow)b | 60 | 20 | 20 | 67 | 16 | 16 | ||
| Age | 0.01 | < 0.01 | ||||||
| < 31 years old | 46 | 27 | 27 | 54 | 27 | 20 | ||
| 31–40 years old | 62 | 28 | 10 | 56 | 18 | 26 | ||
| 41–50 years old | 40 | 40 | 20 | 7 | 40 | 53 | ||
| > 50 years old | 8 | 54 | 38 | 23 | 69 | 8 | ||
| Gender identity | 0.01 | < 0.01 | ||||||
| Female | 53 | 25 | 22 | 54 | 22 | 24 | ||
| Male | 31 | 52 | 17 | 27 | 52 | 21 | ||
| Race | 0.01 | 0.29 | ||||||
| Non-Hispanic White | 51 | 33 | 16 | 47 | 32 | 21 | ||
| Hispanic | 64 | 36 | 0 | 27 | 36 | 36 | ||
| Asian | 27 | 50 | 23 | 50 | 41 | 9 | ||
| Non-Hispanic other | 11 | 22 | 67 | 22 | 33 | 44 | ||
| Religion | 0.17 | 0.02 | ||||||
| No religion | 50 | 31 | 19 | 44 | 19 | 36 | ||
| Catholic | 31 | 41 | 28 | 38 | 59 | 3 | ||
| Protestant/Christian | 72 | 22 | 6 | 56 | 28 | 36 | ||
| Jewish | 47 | 33 | 20 | 40 | 27 | 33 | ||
| Hindu | 36 | 45 | 18 | 45 | 27 | 27 | ||
| Other religionc | 11 | 67 | 22 | 33 | 56 | 11 | ||
| Political identity | 0.01 | < 0.01 | ||||||
| Democrat/Democrat-leaning | 51 | 27 | 22 | 51 | 24 | 26 | ||
| Independent | 37 | 53 | 11 | 22 | 68 | 11 | ||
| Republican/Republican-leaning | 14 | 71 | 14 | 29 | 57 | 14 | ||
p-values are from χ2 tests, or Fisher exact if expected values less than 5 (age, race, religion, and political identity).
Among the fellows surveyed (n = 5), 100% believe medication abortion is within the scope of practice of PCPs and all 100% report interest in future provision.
Other Religion includes Muslim, Buddhist, Unitarian.
In adjusted logistic regression analysis (Table 3), trainee status (adjusted odds ratio [aOR] 3.66, 95% confidence interval [CI] 1.64–8.20) and female gender identity (aOR 2.40, 95% CI 1.03–5.59) were each associated with belief that medication abortion was within the scope of PCPs, while Republican-leaning political identity (aOR 0.18, 95% CI 0.04–0.95) was associated with decreased likelihood of this belief compared to Democratic-leaning identity. Similarly, both trainee status (aOR 7.38, 95% CI 3.00–18.18) and female gender identity (aOR 4.41, 95% CI 1.70–11.45) were associated with increased interest in future provision, while Independent political identity (aOR 0.18, 95% CI 0.04-0.07) was associated with decreased interest.
Table 3.
Unadjusted and adjusted relationships between participant characteristics and belief that medication abortion is within the scope of PCP and participant interest in future provision, among general internists surveyed at an Academic Medical Center in Pennsylvania in 2020 (n = 121).
| Logistic regression models (yes vs no/unsure) Medication abortion in scope of PCP | Interest in future provision | |||
|---|---|---|---|---|
| Unadjusted OR (95% CI) | Adjusted ORa (95% CI) | Unadjusted OR (95% CI) | Adjusted ORa (95% CI) | |
| Position | ||||
| Attending | Ref | Ref | Ref | Ref |
| Trainee (Resident or Fellow) | 3.45 (1.63, 7.32) | 3.66 (1.64, 8.20) | 6.99 (3.12, 15.64) | 7.38 (3.00, 18.18) |
| Gender Identity | ||||
| Male | Ref | Ref | Ref | Ref |
| Female | 2.46 (1.14, 5.29) | 2.40 (1.03, 5.59) | 3.18 (1.45, 6.99) | 4.41 (1.70, 11.45) |
| Race | ||||
| Non-Hispanic White | Ref | - | Ref | - |
| Hispanic | 1.70 (0.46, 6.31) | - | 0.43 (0.11, 1.74) | - |
| Asian | 0.37 (0.13, 1.03) | - | 1.14 (0.44, 2.96) | - |
| Non-Hispanic other | 0.12 (0.01, 1.02) | - | 0.33 (0.06, 1.68) | - |
| Religion | ||||
| No religion | Ref | - | Ref | - |
| Catholic | 0.45 (0.16, 1.25) | - | 0.76 (0.28, 2.07) | - |
| Protestant/ Christian | 2.6 (0.77, 8.81) | - | 1.56 (0.50, 4.88) | - |
| Jewish | 0.88 (0.26, 2.92) | - | 0.83 (0.24, 2.83) | - |
| Hindu | 0.57 (0.14, 2.30) | - | 1.04 (0.27, 4.05) | - |
| Other religionb | 0.13 (0.01, 1.10) | - | 0.63 (0.13, 2.90) | - |
| Political identity | ||||
| Democrat/Democrat-leaning | Ref | Ref | Ref | Ref |
| Independent | 0.57 (0.20, 1.59) | 0.55 (0.18, 1.67) | 0.26 (0.08, 0.85) | 0.18 (0.04, 0.70) |
| Republican/Republican-leaning | 0.16 (0.03, 0.77) | 0.18 (0.04, 0.95) | 0.39 (0.11, 1.34) | 0.52 (0.12, 2.32) |
Adjusted for position, gender, and political identity (n = 118).
Other Religion includes Muslim, Buddhist, Unitarian.
Factors most frequently identified as “significant barriers” to medication abortion provision included limited training in residency (67%) and after residency (70%), low familiarity with abortion medications (59%), inability to provide medical care potentially related to medication abortion (e.g., evaluation for and provision of RhoGam, timely labs, access to ultrasound) (54%), and limited experience determining gestational age (45%) (Fig. 1). Less than 10% of providers identified concerns about their personal safety or stigma towards abortion providers as significant barriers to medication abortion provision. Over half (56%) of participants reported they would be “comfortable” or “very comfortable” working in a setting that provided medication abortions. Of the 53 providers that stated they would be uncomfortable working in a setting that provided abortions, the most cited reasons were a desire to not to be involved with provision of abortion services (17%), concerns about safety of medication abortions (17%), and personal opposition to abortion (13%) (data not shown).
Fig. 1.
Provider-perceived barriers to future medication abortion provision among general internists at an Academic Medical Center in Pennsylvania, 2020 (n = 121). *Inability to provide medical care potentially related to medication abortion (e.g., RhoGam provision, timely labs, access to ultrasound). †Difficulty complying with state regulations. ‡Limited OBGYN support in the event of complications.
Overall, 40% of responding providers believe it is “very” or “somewhat easy” for patients to access abortion in their region, while approximately a quarter of participants (26%) reported being unsure about ease of access (Table 4). A third of participants believe there is a patient need for IM-PCP abortion access (33%) while 42% believed patients would like to access abortion care in this setting. Significant differences in these beliefs were noted across trainee status, with trainees being overall more likely than attendings to believe that patients have difficulty accessing abortion, and have both a need and desire to seek abortion services in primary care settings.
Table 4.
Provider perception of patient experience accessing abortion, among general internists at an Academic Medical Center in Pennsylvania, 2020 (n = 121).
| Total n (%) | Attending n (%) | Trainee n (%) | P-valuea | |
|---|---|---|---|---|
| Perceived ease of access to abortion | 0.02 | |||
| Very easy | 7 (6) | 6 (9) | 1 (2) | |
| Somewhat easy | 41 (34) | 29 (44) | 12 (22) | |
| Somewhat difficult | 35 (29) | 15 (23) | 20 (36) | |
| Very difficult | 6 (5) | 2 (3) | 4 (7) | |
| I’m not sure | 32 (26) | 14 (21) | 18 (33) | |
| Perceived patient need to access abortion in primary care setting | 0.02 | |||
| Yes | 39 (32) | 15 (23) | 24 (44) | |
| No | 30 (25) | 22 (33) | 8 (15) | |
| I’m not sure | 52 (43) | 29 (44) | 23 (42) | |
| Perceived patient desire to access abortion in primary care setting | < 0.01 | |||
| Yes | 49 (41) | 19 (29) | 30 (55) | |
| No | 22 (18) | 18 (27) | 4 (7) | |
| I’m not sure | 50 (41) | 29 (44) | 21 (38) |
p-values are from χ2 tests or Fisher exact as appropriate, with significance determined at p < 0.05 level. Percentages are column percentages.
4. Discussion
Among respondents of this study of IM PCPs and trainees, nearly half of providers, including the majority of trainees, believe that providing medication abortions is within the PCP scope of practice. Likewise, a similar proportion would be interested in providing medication abortions in the future. There were significant differences in perspectives by participant demographic characteristics, with trainees, women, and Democrat-leaning providers significantly more likely to report belief in medication abortion being within IM PCP scope of practice and to express interest in future provision.
The disparate attitudes between trainees and attendings may reflect shifting cultural and/or generational responses to an increasingly restrictive environment regarding abortion access. In the 45 years since Roe v. Wade, states have enacted more than 1200 laws to limit access to abortion, some of which include the FDA’s Risk Evaluation and Mitigation Strategy (REMS) requirements for in-person prescribing of mifepristone and “certification” of all providers by the drug distributer; bans on abortion at later gestational ages; and targeted restrictions on abortion providers (i.e., TRAP laws) including mandating hallway width and HVAC requirements for facilities that provide abortion care [18–20]. These restrictions have been accelerating in the past decade, with more than 40% of all restrictions since Roe v. Wade being implemented between January 2011 and July 2019 [21]. In our study, trainees perceived a greater patient need to access abortion in the primary care setting which may drive their increased willingness to provide this service compared to attendings. However, attitudinal differences may also be shaped by trainees’ decreased familiarity with system-level and administrative barriers to provision. Whether these diverging attitudes toward abortion provision will translate into shifting practice norms remains to be seen.
Regarding perceived barriers to providing medication abortions, participants most frequently identified knowledge-based barriers, including lack of training and low familiarity with medications. FM residency programs traditionally incorporate obstetric care into their training, while IM programs do not. As such, the knowledge-based barriers identified in our study may partially account for the discrepancy between the percentage of FM and IM PCPs that have adopted medication abortion into their practice. A variety of strategies could address knowledge gaps, including enhanced evidence-based training on abortion provision both during and following residency, developing practice-specific evidence-based guidelines for medication abortion provision, and working with OBGYN colleagues to establish protocols for efficiently addressing complications [22].
Other important findings include a discrepancy between patient-reported desire to access abortion care in the primary care setting, and physician perception of that desire. Among respondents in our study, only 29% of attending physicians and 41% of overall participants indicated belief that patients would like to receive medication abortions in the primary care setting. In contrast, a recent survey among reproductive-aged women in a primary care clinic found that 68% of patients supported offering medication abortion in the clinic setting, while a separate survey among women undergoing pregnancy terminations in an abortion clinic found that 58% of patients would prefer to have undergone their abortion with their PCP [2,7].
When the fragmented abortion care network was further disrupted during COVID-19, enhanced provision of medication abortion became increasingly important [23,24]. As a result, there are ongoing efforts to employ “no-test” protocols which forego lab testing, ultrasound, and RhoGam provision for select patients [25]. Recent research suggests these protocols are both safe and effective, which may help address some implementation challenges for PCPs who may not have streamlined access to ultrasound or RhoGam evaluation [26]. IM PCPs are in a unique position to respond to the need for improved abortion access given patient preference for PCPs serving as their abortion care providers, IM provider interest in providing this care, as well as the physical location of many IM PCPs in hospital-based clinics, which may have less difficulty complying with TRAP requirements such as admitting privileges and hallway width.
There are several limitations of this survey, including data collection at a single academic medical center with robust IM Women’s Health academic and clinical programs. Likewise, surveyed providers are part of an academic system both associated with a women’s hospital with a clinically-busy Family Planning division, and set in an urban location with independent abortion clinics. As a result, findings may not be generalizable to institutions with fewer advocates in Women’s Health or differing political or ideological orientation toward abortion, or in regions with more limited access. Although our response rate (30%) is typical for studies involving physicians, it is low nonetheless and may reflect response bias in our findings [27].
In conclusion, this survey among IM physicians at a large academic medical center indicates that nearly half of providers surveyed feel that medication abortion is within their scope of practice and are willing to provide this care in the future; these rates are higher among trainees compared to attending physicians. Future work in both research and advocacy should seek to reduce barriers to provision of medication abortion in the primary care center to enable improved access to this care—such as permanent removal of the mifepristone REMS requirement— both during and following the COVID-19 crisis.
Funding Sources
The Center for Women’s Health Research and Innovation at the University of Pittsburgh provided funding for participant compensation. Dr. Judge-Golden is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health [TL1TR001858, PI: Kapoor]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This funding source was not involved in study design, data collection, analysis or interpretation, in the writing of this report, or in the decision to submit the article for publication.
Footnotes
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
References
- [1].Schaff EA, Fielding SL, Westhoff C, et al. Vaginal misoprostol administered 1, 2, or 3 days after mifepristone for early medical abortion: a randomized trial. JAMA 2020;284:1948–53. [DOI] [PubMed] [Google Scholar]
- [2].Page C, Stumbar S, Gold M . Attitudes and preferences toward the provision of medication abortion in an urban academic internal medicine practice. J Gen Intern Med 2012;27:647. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Jones RK, Kooistra K . Abortion incidence and access to services in the United States, 2008. Perspect Sex Reprod Health. 2011;43:41–50. [DOI] [PubMed] [Google Scholar]
- [4].Bearak JM, Burke KL, Jones RK . Disparities and change over time in distance women would need to travel to have an abortion in the USA: a spatial analysis. Lancet Public Health 2017;2:e493–500. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [5].Grossman D, White K, Hopkins K, Potter J . Change in distance to nearest facility and abortion in Texas, 2012-2014. JAMA 2017;317(4):437–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [6].Rubin SE, Godfrey EM, Shapiro M, Gold M . Urban female patients’ perceptions of the family medicine clinic as a site for abortion care. Contracept 2009;80:174–9. [DOI] [PubMed] [Google Scholar]
- [7].Godfrey EM, Rubin SE, Smith EJ, Khare MM, Gold M . Women’s preference for receiving abortion in primary care settings. J Womens Health 2010;19:547–53. [DOI] [PubMed] [Google Scholar]
- [8].Summit A, Casey L, Bennett A, Karasz A, Gold M. I Don’t Want to Go Any where Else’: patient experiences of abortion in family medicine. Fam Med 2016;48:30–4. [PubMed] [Google Scholar]
- [9].Logsdon MB, Handler A, Godfrey EM . Women’s preferences for the location of abortion services: a pilot study in two Chicago Clinics. Matern Child Health J 2012;16:212–16. [DOI] [PubMed] [Google Scholar]
- [10].Rubin SE, Godfrey E, Gold M . Patient attitudes toward early abortion services in the family medicine clinic. J Am Board Fam Med 2008;21:162–4. [DOI] [PubMed] [Google Scholar]
- [11].Dehlendorf C, Brahmi D, Engel D, Grumbach K, Joffe C, Gold M. Integrating abortion training into family medicine residency programs. Fam Med 2007;39:337–42. [PubMed] [Google Scholar]
- [12].Herbitter C, Greenberg M, Fletcher J, Dalby J, Gold M. Family planning training in US family medicine residencies. Fam Med 2011;43:174–81. [PubMed] [Google Scholar]
- [13].Prine L, Lesnewski R, Berley N, Gold M . Medical abortion in family practice: a case series. J Am Board Fam Pract 2003;16:290–5. [DOI] [PubMed] [Google Scholar]
- [14].Schubert FD, Akse S, Bennett AH, Glassman NR, Gold M. A review of contraception and abortion content in family medicine textbooks. Fam Med 2015;47:524–8. [PubMed] [Google Scholar]
- [15].Kaiser Family Foundation. Professionally active primary care physicians by field, September 2020. https://www.kff.org/other/state-indicator/primary-care-physicians-by-field/?currentTimeframe=0 [Accessed March 15, 2021].
- [16].Schwarz EB, Luetkemeyer A, Foster DG, Weitz TA, Lindes D, Stewart FH . Willing and able? Provision of medication for abortion by future internists. Womens Health Issues 2005;15:39–44. [DOI] [PubMed] [Google Scholar]
- [17].The American National Election Studies. The ANES guide to public opinion and electoral behavior. Ann Arbor (MI): University of Michigan, Center for Political Studies, http://www.electionstudies.org; 2020. [accessed January 8, 2021]. [Google Scholar]
- [18].Nash E, Gold R, Mohammed L, Ansari-Thomas Z, Capello O. Policy Trends in the US. Guttmacher Institute; 2017. https://www.guttmacher.org/article/2018/01/policy-trends-states-2017 [accessed January 15, 2021]. [Google Scholar]
- [19].Group Mifeprex REMS Study . Sixteen Years of Overregulation: Time to Unburden Mifeprex. NEJM 2017;376:790–4. [DOI] [PubMed] [Google Scholar]
- [20].The Guttmacher Institute. Abortion Incidence and Service Availability in the United States, 2017. https://www.guttmacher.org/report/abortion-incidence-service-availability-us-2017; 2017 [accessed January 15, 2021].
- [21].Food and Drug Administration et al. v. American College of Obstetricians and Gynecologists, et al. , 592 U.S (2021). [Google Scholar]
- [22].Espey E, Ogburn T, Chavez A, Qualls C, Leyba M . Abortion education in medical schools: a national survey. Am J Obstet Gynecol 2005;192:640–3. [DOI] [PubMed] [Google Scholar]
- [23].Bayefsky MJ, Bartz D, Watson KL . Abortion during the Covid-19 pandemic — ensuring access to an essential health service. N Engl J Med 2020;382:e47. [DOI] [PubMed] [Google Scholar]
- [24].Kumar M, Daly M, De Plecker E . Now is the time: a call for increased access to contraception and safe abortion care during the COVID-19 pandemic. BMJ Glob Health 2020;5:e003175. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [25].Raymond E, Grossman D, Mark A, et al. Commentary: No-test medication abortion: a sample protocol for increasing access during a pandemic and beyond. Contracept 2020;101:361–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [26].Aiken A, Lohr P, Lord J, Ghosh N, Starling J. Effectiveness, safety and acceptability of no-test medical abortion provided via telemedicine: a national cohort study. BJOG 2021;128(9):1464–74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [27].McLeod C, Klabunde C, Willis G, Start D . Health care provider surveys in the United States, 2000-2010: a review. Eval Health Prof 2013;36:106–26. [DOI] [PubMed] [Google Scholar]