Abstract
This cross-sectional study uses national medical claims data set to examine the workforce providing abortion care and management of pregnancy loss.
Nearly 1 in 4 women will have an abortion by age 45 years.1 A critical determinant for access to abortion care is the health workforce. Studies of abortion facilities and clinicians often rely on surveys, which are limited by sample size, or focus on abortion facilities. While these facilities are critical for abortion care in the US, primary care clinicians and others outside of abortion facilities also provide abortions.
The same medications and procedures used for abortion care can be used to manage pregnancy loss. However, abortion and management of pregnancy loss are often treated differently in a policy context, and some clinicians may not provide abortions even if they have the clinical skillset to do so. This cross-sectional study leverages a national medical claims data set to examine the workforce providing abortion care and management of pregnancy loss.
Methods
We used preadjudicated medical claims from a private data company (IQVIA), obtaining full-year 2019 clinician month-level counts of services (Current Procedural Terminology) and indications (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10]). We identified clinicians providing 2 sets of services: medication (misoprostol and mifepristone) and procedural (dilation and curettage, dilation and evacuation, surgical procedures). Services were categorized as induced abortion or management of pregnancy loss based on ICD-10 coding. We analyzed services and clinicians by clinician type/specialty. This study was approved by the George Washington University institutional review board. Informed consent was waived because the research was not regulated by the US Food and Drug Administration and presented no more than minimal risk to participants.
Results
We found 3550 abortion service clinicians and 22 001 clinicians providing management of pregnancy loss (Table). Of induced abortion clinicians, 3119 (88%) were physicians and 431 (12%) were advanced practice clinicians (APCs). The most common clinicians providing induced abortions were obstetrician-gynecologists (OBGYNs; 2565 [72%]), family medicine (310 [9%]), advanced practice registered nurses (282 [8%]), nurse midwives (89 [3%]), physician assistants (52 [1%]), emergency medicine (49 [1%]), internal medicine (37 [1%]), and pediatricians (20 [0.6%]).
Table. Number of Clinicians Providing Induced Abortion and Pregnancy Loss Management by Specialty.
| Specialty | No. (%) | |||||
|---|---|---|---|---|---|---|
| Medication abortiona | Procedural abortionb | Total (medication and/or procedural)c | ||||
| Induced abortion | Pregnancy loss | Induced abortion | Pregnancy loss | Induced abortion | Pregnancy loss | |
| Physicians | ||||||
| OBGYN | 773 (51.1) | 656 (68.8) | 2351 (83.4) | 18 858 (87.1) | 2565 (72.3) | 18 943 (86.1) |
| Emergency medicine | 4 (0.3) | 152 (15.9) | 46 (1.6) | 1107 (5.1) | 49 (1.4) | 1243 (5.6) |
| Family medicine | 251 (16.6) | 49 (5.1) | 210 (7.4) | 480 (2.2) | 310 (8.7) | 515 (2.3) |
| General surgery | 1 (0.1) | 1 (0.1) | 2 (0.1) | 42 (0.2) | 2 (0.1) | 42 (0.2) |
| OBGYN specialty | 13 (0.9) | 10 (1.0) | 58 (2.1) | 550 (2.5) | 67 (1.9) | 555 (2.5) |
| Internal medicine | 24 (1.6) | 12 (1.3) | 20 (0.7) | 119 (0.5) | 37 (1.0) | 131 (0.6) |
| Pediatrics | 17 (1.1) | 3 (0.3) | 15 (0.5) | 21 (0.1) | 20 (0.6) | 24 (0.1) |
| Other physician | 13 (0.9) | 7 (0.7) | 64 (2.3) | 278 (1.3) | 69 (1.9) | 284 (1.3) |
| Total | 1096 (72.4) | 890 (93.4) | 2766 (98.1) | 21 455 (99.1) | 3119 (87.9) | 21 737 (98.8) |
| Advanced practice clinicians | ||||||
| APRN | 273 (18.0) | 37 (3.9) | 36 (1.3) | 79 (0.4) | 282 (7.9) | 113 (0.5) |
| Nurse midwife | 89 (5.9) | 19 (2.0) | 5 (0.2) | 24 (0.1) | 89 (2.5) | 43 (0.2) |
| Physician assistant | 50 (3.3) | 7 (0.7) | 7 (0.2) | 78 (0.4) | 52 (1.5) | 84 (0.4) |
| Other health profession | 5 (0.3) | 0 | 5 (0.2) | 24 (0.1) | 8 (0.2) | 24 (0.1) |
| Total | 417 (27.6) | 63 (6.6) | 53 (1.9) | 205 (0.9) | 431 (12.1) | 264 (1.2) |
| Overall total | 1513 | 953 | 2819 | 21 660 | 3550 | 22 001 |
Abbreviations: APRN, advanced practice registered nurse; OBGYN, obstetrician-gynecologist.
Medication abortion includes mifepristone and misoprostol.
Procedural abortion includes dilation and curettage, dilation and evaluation, and surgical procedures.
Medication and procedural abortion totals do not sum to total because clinicians may perform more than 1 type of service.
Nearly all clinicians providing management of pregnancy loss were physicians (21 737 [99%]); 264 (1%) were APCs. The most common types of clinicians were OBGYNs (18 943 [86%]), followed by emergency medicine (1243 [6%]), OBGYN specialty (555 [3%]), and family medicine (515 [2%]). Advanced practice clinicians included 113 advanced practice registered nurses (43%), 43 nurse midwives (16%), and 84 physician assistants (32%). Of the 23 346 total clinicians, 19 796 (85%) had medical claims only for management of pregnancy loss, 1345 (\6%) had medical claims only for induced abortions, and 2205 (9%) had medical claims for both.
Discussion
This cross-sectional study identifies a small but essential national workforce of clinicians who provide abortions. While most clinicians who provide abortions are OBGYNs, other primary care physicians and advanced practice clinicians are also important providers of these services. Increasing the number of primary care physicians, and others, such as emergency medicine, who provide abortion care can increase access to these services.
We found limited overlap among clinicians who provide abortion and pregnancy loss management. In more favorable policy environments, clinicians who manage pregnancy loss could become abortion clinicians and increase this workforce. In less favorable policy environments, these clinicians may drop out of the workforce because of the fear of retribution associated with providing services that are proximate to abortion care, thus decreasing the abortion workforce.
Abortion coverage is highly restricted under private insurance and Medicaid; therefore, many patients and clinicians cannot or do not bill insurance. Beyond increasingly restrictive payment policies,2 policies that punish clinicians may cause clinicians to stop offering medication and procedural services, reducing access to management of pregnancy loss as well as abortion.
Because of coverage restrictions on abortion services, medical claims data provide an incomplete picture of the abortion clinician workforce. Improving coverage and reimbursement policies, as well as investing in training and removing the restrictive scope of practice policies for APCs, can expand this workforce and increase access to these services.
References
- 1.Jones RK, Witwe, E, Jerman J. 2019. Abortion incidence and service availability in the United States, 2017. Accessed October 19, 2021. https://www.guttmacher.org/report/abortion-incidence-service-availability-us-2017
- 2.Dickman SL, White K, Grossman D. Affordability and access to abortion care in the United States. JAMA Intern Med. 2021;181(9):1157-1158. doi: 10.1001/jamainternmed.2021.3502 [DOI] [PubMed] [Google Scholar]