Abstract
Objective
Our objective was to quantify abortion law and care knowledge among Colorado advanced practice clinicians (APCs).
Methods
We conducted a stratified-random survey of APCs, oversampling women’s health and rural clinicians. We assessed sample characteristics, positions on abortion legality, and abortion law and care knowledge. Mean knowledge scores were compared by sample characteristics. Survey responses were compared by provision of pregnancy options counseling and positions on abortion legality. Linear regression models were used to examine knowledge scores.
Results
A total of 513 participants completed the survey; the response rate was 21%. Abortion law knowledge questions (mean score: 1.7/7) ranged from 12% (physician-only law) to 45% (parental consent law) correct. For five of seven questions, “I don’t know” was the most frequently chosen response. Abortion care knowledge questions (mean score: 2.8/8) ranged from 19% (abortion prevalence) to 60% (no elevated risk of breast cancer) correct. For five of eight questions, “I don’t know” was the most frequently chosen response. Practicing in all other areas (e.g., family practice) was associated with lower abortion law and care knowledge than practicing in women’s health. Providing options counseling was positively associated with abortion knowledge (law: β 0.44; 95% CI: 0.10 - 0.78; care: β 0.52; 95% CI: 0.08 - 0.95). Compared to participants who believe abortion should be legal in all circumstances, those who believe abortion should be illegal in all circumstances had similar abortion law knowledge (β-0.03; 95% CI: −0.65-0.59), but lower abortion care knowledge (β-1.85; 95% CI: −2.34--1.36).
Conclusions
Abortion knowledge is low among Colorado APCs and education is needed.
Induced abortion is a very common healthcare procedure, occurring at a rate of 13.5/1,000 among people assigned female at birth annually in the United States in 2017 (Jones et al., 2019). Unlike most healthcare, abortion care is highly regulated. Laws surrounding abortion provision vary widely state to state and include restrictions such as gestational age limits, mandatory waiting periods, and mandatory parental involvement (Guttmacher Institute, 2021b; National Academies of Sciences, Engineering, and Medicine et al., 2018). Variation in abortion laws can cause confusion for both the public (Bessett et al., 2015; Lara et al., 2015; Swartz et al., 2020; White et al., 2016) and healthcare clinicians alike (Coles et al., 2012; Dodge et al., 2013). Given the recent six-week abortion ban in Texas, implemented in September of 2021, and the potential that Roe v. Wade (410 U.S. 113 [1973]) will be overturned, it is likely we will see more attempts to enact restrictive state-level abortion laws, which may increase confusion about the legal status of abortion (Gallo et al., 2021).
Misinformation regarding the prevalence and safety of abortion is also widespread (Berglas et al., 2017; Swartz et al., 2020), with anti-abortion advocates disseminating misinformation in the clinical setting and on mainstream news (Berglas et al., 2017). With an estimated one in four women having an abortion during their lifetime (Jones et al., 2019), the need for accurate information about abortion is needed within and outside the confines of reproductive health appointments. Clinicians are ethically obligated by their professional organizations to provide accurate and evidence-based information in any type of clinical counseling they provide (Eagen-Torkko & Levi, 2020). Inaccurate or incomplete knowledge about abortion on the part of clinicians may result in a lack of evidence-based counseling and referrals, which can delay abortion care, prevent access entirely, and further stigmatize abortion and people who have abortions (de Moel-Mandel & Shelley, 2017; Waddington et al., 2015). Clinicians are also an important source of trusted information for both their patients and the public at large. As in the current COVID-19 pandemic, clinicians play a special role as arbiters of accurate information in times of crisis (Rozek et al., 2021). Therefore, regardless of whether a clinician routinely provides reproductive healthcare or pregnancy testing, they should have accurate information of abortion laws and care, particularly because legal access to abortion care is in crisis.
There is limited research on knowledge of state-level abortion laws among healthcare clinicians, however. In a 2011 study, scholars assessed the abortion law knowledge of reproductive health clinicians, the majority of whom were physicians and half of whom provided abortion services. Knowledge was generally high but varied on specific laws (Dodge et al., 2013). There is even less research on abortion care knowledge, including abortion prevalence, effectiveness, and safety, among healthcare clinicians. One study explored knowledge of medication abortion among adolescent medicine physicians and found suboptimal knowledge regarding safety, efficacy, and maximum gestational age (Coles et al., 2012).
Despite the growth of advanced practice clinicians (APCs) — nurse practitioners (NPs), certified nurse-midwives(CNMs)/certified midwives, and physician assistants (PAs) — in the U.S. (Pohl et al., 2018), abortion knowledge among APCs remains unknown. APCs are more likely to provide care in rural and low-income communities (Barnes et al., 2018; Pohl et al., 2018), groups that may have unique barriers to accessing abortion (Jerman et al., 2017; Roberts et al., 2014). To address this gap in the literature, we examine abortion law and abortion care knowledge among APCs in Colorado, a state with two abortion restrictions: parental notification for minors and restriction of Medicaid funds for abortion (Guttmacher Institute, 2021a). Further, we identify associations between knowledge and sample characteristics and clinicians’ positions on abortion legality.
Materials and Methods
Sample and procedures
Data are drawn from a larger study assessing reproductive health attitudes, knowledge, practices, and interest in abortion care training among Colorado APCs. Full study procedures were previously published (Coleman-Minahan et al., 2020). We identified APCs using the Colorado Division of Regulatory Agencies’ public database. After excluding those with inactive licenses, out of state addresses, and nurse practitioners with only geriatric, psychiatric/mental health, or neonatal certifications, the target sample was 7,295 APCs. We oversampled CNMs and women’s health nurse practitioners (WHNPs) because they are more likely to provide reproductive healthcare (Hwang et al., 2005), yet comprise less than 10% of practicing APCs in Colorado. Using zip codes, we oversampled rural clinicians given their crucial and understudied role in healthcare. Based on the size of the target population for each group, all licensed CNMs/WHNPs and rural providers were included in the sampling frame.
Sample size was calculated based on clinician interest in abortion training (Hwang et al., 2005), the primary outcome of the larger study (Coleman-Minahan et al., 2020). We randomly selected individuals from each of the six strata (three clinician types [NP, PA, CNM/WHNP] by rural/urban location) to receive a survey invitation. Because email addresses are not publicly available, we mailed a paper letter with an individual survey link through Research Electronic Data Capture (REDCap) (Harris et al., 2009), a secure online data capture and management system hosted by the University of Colorado. Non-responders received a follow-up postcard with a QR code linked to the survey. Inclusion criteria included practicing clinically in Colorado in the last six months. Surveys were collected from June 2018 through June 2019. Informed consent was provided through acknowledgement of a consent form. Participants received a $10 e-gift card for participation. The study was approved by the Colorado Multiple Institutional Review Board.
Measures
We evaluated knowledge of state abortion laws through seven survey questions developed by Dodge and colleagues (2013). Participants were given a list of five laws pertaining to “abortions that are NOT medically necessary” and instructed to “indicate whether the following laws and regulations are present in Colorado, as well as how sure you are.” We additionally asked whether Medicaid is available to fund abortions and if private insurance is allowed to cover abortion. We evaluated abortion care knowledge with eight questions related to abortion prevalence, effectiveness, and safety. Knowledge questions and correct answers are presented in Tables 1 & 2. We created two variables assessing knowledge. First, we created a continuous score based on the number of correct responses for abortion law knowledge (range: 0-7) and abortion care knowledge (range: 0-8); “I don’t know” was considered incorrect (Dodge et al., 2013). Second, because “I don’t know” is qualitatively different than an incorrect response, we created a categorical variable for each knowledge question capturing: (1) the correct response, (2) “I don’t know,” and (3) an incorrect response.
Table 1.
Survey questions for abortion law knowledge (correct answers in bold print)
| Abortion law questions |
|||||
|---|---|---|---|---|---|
| Abortions must be performed by a licensed physician (MD or DO) | Yes, I am very sure | Yes, I am somewhat sure | I don’t know | No, I am somewhat sure | No, I am very sure |
| Parental NOTIFICATION or judicial bypass is required for minors | Yes, I am very sure | Yes, I am somewhat sure | I don’t know | No, I am somewhat sure | No, I am very sure |
| Parental CONSENT or judicial bypass is required for minors | Yes, I am very sure | Yes, I am somewhat sure | I don’t know | No, I am somewhat sure | No, I am very sure |
| There is a mandatory time period that a patient must wait before she can obtain an abortion | Yes, I am very sure | Yes, I am somewhat sure | I don’t know | No, I am somewhat sure | No, I am very sure |
| In Colorado, is there a gestational age limit on abortions that are NOT medically necessary? | Yes, I am very sure | Yes, I am somewhat sure | I don’t know | No, I am somewhat sure | No, I am very sure |
| In Colorado, are Medicaid funds available to assist low-income women seeking abortion services? | Yes, Medicaid can fund any abortion | Yes, but funds are limited to cases of maternal life endangerment, rape, incest | I don’t know | No | |
| In Colorado, is private insurance allowed to cover abortion services? | Yes, private insurance can fund any abortion | Yes, but funds are limited to cases of maternal life endangerment, rape, incest | I don’t know | No |
Table 2.
Survey questions for abortion care knowledge (correct answers in bold print)
| Abortion care questions |
|||||
|---|---|---|---|---|---|
| What percentage of women in the U.S. will have an abortion in her lifetime? | 5-15% | 16-24% | 25-34% | 35-45% | I don’t know |
| What percentage of all abortions occur in the first trimester (<=12 weeks)? | 29% | 52% | 78% | 89% | I don’t know |
| Emergency contraception is an abortifacient (may cause an abortion). | TRUE | FALSE | |||
| The effectiveness of the FDA-approved medication abortion regimen at less than 10 weeks gestation is: | <50% | 50-69% | 70-89% | >=90% | I don’t know |
| The effectiveness of vacuum aspiration abortion at less than 10 weeks gestation is: | <50% | 50-69% | 70-89% | >=90% | I don’t know |
| What percent of women will experience a major complication requiring hospitalization (such as hemorrhage, additional abdominal procedures, or IV antibiotics for infection) for a first-trimester abortion? | 0.50% | 2% | 5% | 10% or more | I don’t know |
| Abortion almost always has negative psychological effects. | Strongly agree | Agree | Neither agree nor disagree | Disagree | Strongly disagree |
| Abortion is linked to an increased risk of breast cancer. | Strongly agree | Agree | Neither agree nor disagree | Disagree | Strongly disagree |
Participants were asked about their gender, age, provider type, years of clinical practice, and practice type. Participants provided the zip code of their practice, which we categorized as rural or urban. We captured if they received didactic or clinical education on abortion during graduate school (Dodge et al., 2013) and if they provide pregnancy testing and pregnancy options counseling in their current practice. We measured participants’ positions on abortion legality by asking if they believe abortion should be legal in all circumstances, legal in certain circumstances, or illegal in all circumstances (Hwang et al., 2005; Shotorbani et al., 2004).
Analysis
Survey weights were created to account for stratified sampling and adjust for non-response (Lumley, 2011). First, we calculated weighted frequencies and percentages of sample characteristics. Second, using the continuous abortion law and abortion care knowledge scores, we calculated mean knowledge scores and standard deviations and compared across sample characteristics using bivariate ordinary least squares regression models. Third, we compared responses to each knowledge question (i.e., correct, “I don’t know,” incorrect) by provision of pregnancy options counseling and by position on abortion legality. Comparisons were tested for significance with logistic and multinomial regression. Finally, we examined continuous knowledge scores using adjusted ordinary least squares linear regression models. We tested each variable for significance, effect size, multicollinearity, confounding, and model fit, presenting the most parsimonious models. Data were analyzed using Stata 13 (StataCorp, 2013).
Results
Sample
As reported previously (Coleman-Minahan et al., 2020), a total of 513 people completed surveys, for a response rate of 21%. Eighty-five percent of the sample identified as women, 39% were between 30 and 39 years of age, and 30% had practiced clinically for 10 - 17 years. Over half (55%) the sample provided primary care (i.e., women’s health, family practice, pediatrics, or internal medicine). Although 78% of the sample provided pregnancy testing and half provided pregnancy options counseling, only 46% received any clinical or didactic education on abortion in graduate school. More than half of participants (58%) believed abortion should be legal under all circumstances (Table 3).
Table 3.
Weighted sample characteristics and mean abortion law and care knowledge scores by sample characteristics
| Full Sample (N=513) | Abortion Law Knowledge (N=513) | Abortion Care Knowledge (N=511) | ||||||
|---|---|---|---|---|---|---|---|---|
|
|
||||||||
| n | % | Mean | (SD) | p-value | Mean | (SD) | p-value | |
|
|
||||||||
| Gender | 0.012 | <0.001 | ||||||
| Woman | 431 | 84.7 | 1.8 | (1.6) | 3.0 | (2.1) | ||
| Man | 78 | 15.3 | 1.3 | (1.1) | 2.0 | (1.4) | ||
| Age | 0.175 | 0.720 | ||||||
| <30 | 31 | 6.0 | 1.9 | (1.1) | 3.3 | (1.9) | ||
| 30-39 | 198 | 38.7 | 1.6 | (1.5) | 2.8 | (1.9) | ||
| 40-49 | 146 | 28.5 | 1.6 | (1.4) | 2.9 | (2.1) | ||
| 50-59 | 71 | 13.8 | 2.1 | (1.8) | 2.7 | (2.0) | ||
| 60+ | 66 | 13.0 | 2.0 | (1.7) | 2.9 | (2.1) | ||
| Provider type | <0.001 | <0.001 | ||||||
| CNM/WHNP | 45 | 8.8 | 3.1 | (3.1) | 4.6 | (3.9) | ||
| NP | 257 | 50.2 | 1.7 | (1.4) | 2.8 | (1.9) | ||
| PA | 210 | 41.0 | 1.5 | (1.1) | 2.5 | (1.5) | ||
| Years in practice | 0.037 | 0.849 | ||||||
| Less than 4 | 115 | 22.5 | 1.8 | (1.6) | 2.8 | (2.0) | ||
| 4-9 years | 152 | 29.7 | 1.5 | (1.3) | 2.8 | (2.0) | ||
| 10-17 years | 154 | 30.1 | 1.7 | (1.4) | 2.9 | (1.9) | ||
| More than 17 years | 90 | 17.7 | 2.1 | (1.8) | 3.0 | (2.3) | ||
| Practice type | <0.001 | <0.001 | ||||||
| Women’s health | 62 | 12.1 | 3.0 | (2.7) | 4.7 | (3.4) | ||
| Family practice | 150 | 29.3 | 1.8 | (1.3) | 2.7 | (1.7) | ||
| Internal medicine/Pediatrics | 69 | 13.4 | 1.8 | (1.4) | 2.8 | (1.7) | ||
| Urgent care | 77 | 15.0 | 1.4 | (1.1) | 2.6 | (1.7) | ||
| Other (non-women’s health) | 155 | 30.2 | 1.3 | (1.2) | 2.4 | (1.6) | ||
| Practice location | 0.077 | 0.035 | ||||||
| Urban or suburban | 469 | 91.3 | 1.7 | (1.4) | 2.8 | (1.9) | ||
| Rural | 44 | 8.7 | 2.0 | (2.4) | 3.3 | (3.3) | ||
| Received abortion training | 0.387 | 0.415 | ||||||
| Yes | 235 | 45.9 | 1.8 | (1.5) | 2.9 | (2.1) | ||
| No | 278 | 54.1 | 1.7 | (1.6) | 2.8 | (2.0) | ||
| Provides pregnancy testing | 0.008 | 0.001 | ||||||
| Yes | 398 | 77.7 | 1.8 | (1.6) | 3.0 | (2.1) | ||
| No | 114 | 22.3 | 1.3 | (1.4) | 2.3 | (1.6) | ||
| Provides pregnancy options counseling | <0.001 | <0.001 | ||||||
| Yes | 258 | 50.5 | 2.1 | (1.7) | 3.3 | (2.3) | ||
| No | 253 | 49.5 | 1.3 | (1.2) | 2.3 | (1.6) | ||
| Position on abortion legality | <0.001 | <0.001 | ||||||
| Legal under all circumstances | 296 | 58.0 | 2.0 | (1.7) | 3.5 | (2.0) | ||
| Legal under certain circumstances | 165 | 32.5 | 1.3 | (1.2) | 2.0 | (1.7) | ||
| Illegal under all circumstances | 49 | 9.6 | 1.9 | (1.5) | 1.6 | (1.2) | ||
Mean abortion law knowledge
The mean score for abortion law knowledge for the full sample was 1.7, standard deviation 1.5, range: 0-7. Mean law knowledge was lower among men than women (1.3 vs. 1.8; p<0.05), among nurse practitioners and physician assistants compared to nurse-midwives/women’s health nurse practitioners (1.7 and 1.5 vs. 3.1, respectively; p<0.001), and among participants practicing in all other specialties compared to those practicing in women’s health (1.8 or lower vs. 3.0 ; p<0.001) (Table 3). Mean abortion law knowledge was higher among participants who provided pregnancy testing (1.8 vs. 1.3; p<0.01) and higher among those who provided options counseling than those who did not (2.1 vs. 1.3; p<0.001). Participants who believed abortion should be legal under certain circumstances had lower knowledge than those who believed it should be legal under all circumstances and those who believe it should illegal under all circumstances (1.3 vs. 2.0 and 1.9, respectively; p<0.001).
Abortion law knowledge survey items
Correct answers for abortion law items ranged from 12% correct (physician-only law) to 45% correct (parental consent law) (Table 4). With the exception of parental consent, greater percentages of participants answered “I don’t know” than answered correctly on all items. Compared to participants who did not provide options counseling, greater proportions of participants who provided options counseling answered correctly and fewer answered “I don’t know” on all items. Position on abortion legality was significantly associated with knowledge on parental consent, mandatory waiting period, gestational age limit, and private insurance to cover abortion; the percentage answering these questions correctly was lowest among participants who believed abortion should be legal under certain circumstances.
Table 4.
Percentage of participants who answered correctly or did not know the answer for abortion law questions among the full sample, by providing pregnancy options counseling, and by abortion attitudes (N=513)
| Abortion law knowledge | Full Sample (%) | Provides options counseling (%) | Does not provide options counseling (%) | p-value | Legal in all circumstances (%) | Legal in certain circumstances (%) | Illegal under all circumstances (%) | p-value |
|---|---|---|---|---|---|---|---|---|
| Abortions must be performed by a licensed physician (MD or DO) | 0.004 | 0.311 | ||||||
| Correct | 12.2 | 15.7 | 8.6 | 14.7 | 8.5 | 8.5 | ||
| Don’t know | 36.7 | 28.9 | 44.3 | 37.9 | 35.9 | 32.2 | ||
| Incorrect | 51.1 | 55.3 | 47.1 | 47.3 | 55.6 | 59.3 | ||
| Parental NOTIFICATION or judicial bypass is required for minors | <0.001 | 0.576 | ||||||
| Correct | 28.5 | 35.5 | 21.6 | 26.8 | 33.0 | 23.2 | ||
| Don’t know | 38.8 | 27.4 | 50.6 | 37.9 | 39.3 | 41.8 | ||
| Incorrect | 32.7 | 37.1 | 27.8 | 35.3 | 27.7 | 35.0 | ||
| Parental CONSENT or judicial bypass is required for minors | <0.001 | 0.037 | ||||||
| Correct | 44.8 | 54.8 | 34.3 | 50.5 | 33.9 | 47.1 | ||
| Don’t know | 40.2 | 29.7 | 51.2 | 37.4 | 44.8 | 40.9 | ||
| Incorrect | 15.0 | 15.6 | 14.6 | 12.0 | 21.3 | 12.0 | ||
| There is a mandatory time period that a patient must wait before she can obtain an abortion | 0.014 | 0.001 | ||||||
| Correct | 37.0 | 42.2 | 31.3 | 45.2 | 22.3 | 36.9 | ||
| Don’t know | 46.7 | 39.2 | 54.7 | 40.5 | 55.8 | 52.9 | ||
| Incorrect | 16.3 | 18.6 | 14.1 | 14.3 | 21.9 | 10.2 | ||
| Is there a gestational age limit on abortions that are NOT medically necessary? | 0.007 | 0.019 | ||||||
| Correct | 15.2 | 16.9 | 13.6 | 16.9 | 8.4 | 27.8 | ||
| Don’t know | 43.5 | 35.1 | 51.7 | 40.6 | 46.3 | 50.8 | ||
| Incorrect | 41.3 | 48.0 | 34.7 | 42.4 | 45.2 | 21.4 | ||
| Are Medicaid funds available to assist low-income women seeking abortion services? | <0.001 | 0.424 | ||||||
| Correct | 16.5 | 20.5 | 12.5 | 17.1 | 14.3 | 20.1 | ||
| Don’t know | 58.9 | 45.2 | 73.3 | 55.4 | 65.6 | 58.5 | ||
| Incorrect | 24.5 | 34.2 | 14.1 | 27.5 | 20.1 | 21.4 | ||
| Is private insurance allowed to cover abortion services? | <0.001 | 0.002 | ||||||
| Correct | 20.2 | 27.5 | 12.6 | 26.1 | 8.6 | 24.1 | ||
| Don’t know | 65.4 | 54.4 | 77.0 | 59.8 | 75.6 | 64.1 | ||
| Incorrect | 14.5 | 18.1 | 10.3 | 14.2 | 15.8 | 11.8 | ||
Mean abortion care knowledge
The mean for abortion care knowledge for the full sample was 2.8, standard deviation 2.0, range: 0-8. Abortion care knowledge was lower among men than women (2.0 vs. 3.0; p<0.001) (Table 3), among nurse practitioners and physician assistants compared to nurse-midwives/women’s health nurse practitioners (2.8 and 2.5 vs. 4.6; p<0.001) and among participants practicing in all other specialties compared to those practicing in women’s health (2.8 or lower vs. 4.7.; p<0.001). Rural clinicians had higher mean abortion care knowledge than urban or suburban clinicians (3.3 vs. 2.8; p<0.05). Mean knowledge was higher among participants who provided pregnancy testing (3.0 vs. 2.3; p<0.01) and higher among those who provided pregnancy options counseling than those who did not (3.3 vs. 2.3; p<0.001). Mean knowledge was lower among those who believed abortion should be legal in certain circumstances and those who believed it should be illegal under all circumstances compared to participants who believed abortion should be legal under all circumstances (2.0 and 1.6 vs. 3.5, respectively; p<0.001).
Abortion care knowledge survey items
Correct answers for abortion care items ranged from 19% correct (abortion prevalence) to 60% correct (breast cancer) (Table 5). Greater percentages of participants answered “I don’t know” than answered correctly for all questions except psychological effects and breast cancer. Compared to participants who did not provide options counseling, greater proportions of participants who provided options counseling answered correctly and fewer answered “I don’t know” on all items except for abortion prevalence, psychological effects, and breast cancer. Position on abortion legality was significantly associated with all eight abortion care questions; fewer participants who believed abortion should be illegal under all circumstances answered correctly than those who believed it should be legal under all circumstances.
Table 5.
Percentage of participants who answered correctly or did not know the answer for abortion care questions among the full sample, by providing pregnancy options counseling, and by abortion attitudes (N=511)
| Abortion care knowledge | Full Sample (%) | Provides options counseling (%) | Does not provide options counseling (%) | p-value | Legal in all circumstances (%) | Legal in certain circumstances (%) | Illegal under all circumstances (%) | p-value |
|---|---|---|---|---|---|---|---|---|
| What percentage of women in the U.S. will have an abortion in her lifetime? | 0.077 | 0.019 | ||||||
| Correct | 19.2 | 21.5 | 16.6 | 20.7 | 16.7 | 19.3 | ||
| Don’t know | 35.7 | 30.3 | 41.4 | 29.8 | 48.2 | 29.5 | ||
| Incorrect | 45.1 | 48.2 | 42.0 | 49.5 | 35.1 | 51.3 | ||
| What percentage of all abortions occur in the first trimester (< =12 weeks)? | 0.003 | 0.014 | ||||||
| Correct | 21.2 | 28.3 | 13.9 | 24.9 | 15.3 | 18.6 | ||
| Don’t know | 40.7 | 35.3 | 46.5 | 33.5 | 52.7 | 43.6 | ||
| Incorrect | 38.1 | 36.4 | 39.6 | 41.6 | 32.0 | 37.8 | ||
| Emergency contraception is an abortifacient (may cause an abortion). (false) | 0.002 | <0.001 | ||||||
| Correct | 56.2 | 64.5 | 48.1 | 69.7 | 41.7 | 23.4 | ||
| Don’t know | NA | NA | NA | NA | NA | NA | ||
| Incorrect | 43.8 | 35.5 | 51.9 | 30.3 | 58.3 | 76.6 | ||
| The effectiveness of the FDA-approved medication abortion regimen at less than 10 weeks gestation is: | <0.001 | 0.008 | ||||||
| Correct | 29.3 | 37.5 | 20.5 | 36.3 | 19.4 | 20.5 | ||
| Don’t know | 55.5 | 43.5 | 68.2 | 47.5 | 66.1 | 67.7 | ||
| Incorrect | 15.2 | 19.1 | 11.3 | 16.2 | 14.4 | 11.8 | ||
| The effectiveness of vacuum aspiration abortion at less than 10 weeks gestation is: | 0.014 | 0.008 | ||||||
| Correct | 43.3 | 50.0 | 36.1 | 51.5 | 31.2 | 34.6 | ||
| Don’t know | 54.2 | 48.7 | 60.1 | 46.7 | 65.4 | 60.8 | ||
| Incorrect | 2.6 | 1.3 | 3.9 | 1.8 | 3.4 | 4.6 | ||
| What percent of women will experience a major complication requiring hospitalization for a first-trimester abortion? | 0.004 | <0.001 | ||||||
| Correct | 24.0 | 29.9 | 17.9 | 32.6 | 13.6 | 6.9 | ||
| Don’t know | 55.2 | 47.1 | 63.9 | 46.8 | 69.0 | 59.5 | ||
| Incorrect | 20.8 | 23.0 | 18.2 | 20.6 | 17.4 | 33.6 | ||
| Abortion almost always has negative psychological effects. | 0.091 | <0.001 | ||||||
| Correct | 32.3 | 37.3 | 27.3 | 46.4 | 14.8 | 6.6 | ||
| Don’t know | 25.3 | 25.2 | 25.6 | 28.0 | 28.0 | 0.0 | ||
| Incorrect | 42.4 | 37.5 | 47.1 | 25.6 | 57.3 | 93.4 | ||
| Abortion is linked to an increased risk of breast cancer. | 0.094 | <0.001 | ||||||
| Correct | 59.9 | 65.1 | 54.3 | 72.3 | 47.3 | 27.1 | ||
| Don’t know | 33.5 | 30.1 | 37.1 | 24.6 | 46.0 | 45.1 | ||
| Incorrect | 6.6 | 4.8 | 8.5 | 3.1 | 6.7 | 27.8 | ||
Adjusted models predicting abortion knowledge
Using linear regression models, we found that after controlling for covariates, practicing in any area outside of women’s health was associated with lower abortion law knowledge than practicing in women’s health (Table 6). Providing pregnancy options counseling was associated with higher abortion law knowledge than not providing options counseling (β 0.44; 95% CI: 0.10-0.78). Compared to participants who believe abortion should be legal in all circumstances, those who believe abortion should be legal in certain circumstances had lower abortion knowledge (β −0.61; 95% CI: −0.88 - −0.33), while those who believe abortion should be illegal in all circumstances had similar abortion law knowledge (β −0.03; 95% CI: −0.65 - 0.59).
Table 6.
Linear regression models [coefficients, 95% confidence intervals] predicting abortion law scores and abortion care scores
| Abortion law score | Abortion care score | |
|---|---|---|
|
|
||
| Practice Type | ||
| Women’s health | Ref. | Ref. |
| Family | −1.11*** | −1.69*** |
| (−1.51 - −0.71) | (−2.21 - −1.17) | |
| Internal medicine/pediatrics | −1.05*** | −1.71*** |
| (−1.59 - −0.51) | (−2.34 - −1.08) | |
| Urgent/emergency care | −1.49*** | −1.95*** |
| (−2.00 - −0.99) | (−2.60 - −1.31) | |
| Other (non-women’s health) | −1.31*** | −1.77*** |
| (−1.79 - −0.83) | (−2.36 - −1.18) | |
| Options counseling | ||
| Does not provide options counseling | Ref. | Ref. |
| Provides options counseling | 0.44* | 0.52* |
| (0.10 - 0.78) | (0.08 - 0.95) | |
| Position on abortion legality | ||
| Legal in all circumstances | Ref. | Ref. |
| Legal in certain circumstances | −0.61*** | −1.44*** |
| (−0.88 - −0.33) | (−1.82 - −1.06) | |
| Illegal in all circumstances | −0.03 | −1.85*** |
| (−0.65 - 0.59) | (−2.34 - −1.36) | |
| Constant | 2.80*** | 4.78*** |
| (2.36 - 3.25) | (4.22 - 5.35) | |
| N | 508 | 508 |
p<0.001,
p<0.01,
p<0.05
After controlling for covariates, practicing in any area outside of women’s health was associated with lower abortion care knowledge than practicing in women’s health. Providing pregnancy options counseling was associated with higher abortion care knowledge than not providing options counseling (β 0.52; 95% CI: 0.08 - 0.95). Compared to participants who believe abortion should be legal in all circumstances, both those who believe abortion should be legal in certain circumstances (β −1.44; 95% CI: −1.82 - −1.06) and those who believe abortion should be illegal in all circumstances (β −1.85; 95% CI: −2.34 - −1.36) had lower abortion care knowledge.
Discussion
Results from this stratified random survey suggest abortion law and care knowledge are low among Colorado APCs. Fewer than half of participants correctly answered any of the abortion law questions and “I don’t know” was the most frequent response for most abortion law and care questions. Abortion knowledge was higher among women’s health clinicians and those who provide pregnancy testing and options counseling. Only among women’s health clinicians did the mean of abortion care knowledge reach 50% correct; the mean for law knowledge was less than 50% correct for all provider characteristics. Clinicians have an obligation to provide patients with accurate and evidence-based information and they are unable to do this if they have incomplete or inaccurate knowledge themselves. Clinician training on abortion laws and care is needed for all Colorado APCs, especially because clinicians must have accurate knowledge in times of crisis (Rozek et al., 2021) and people will come to Colorado for abortion care if Roe v. Wade (410 U.S. 113 [1973]) is overturned.
Abortion law knowledge among Colorado APCs appears to be similar to that of adolescent medicine providers (Coles et al., 2012). Even among women’s health clinicians and those providing pregnancy options counseling, knowledge in our sample was lower than in Dodge et al.’s (2013) sample of clinicians recruited through reproductive health organizations, likely because half of their sample provided abortion care. Compared to reproductive-age women, APCs in our study were only slightly more knowledgeable about abortion laws (Swartz et al., 2020) and were less knowledgeable about the existence of a gestational age limit (Lara et al., 2015; White et al., 2016). Given gestational age limits are one of the most frequent state-level abortion restrictions (Guttmacher Institute, 2021b), it is possible that clinicians assume Colorado also has a gestational age limit.
Regarding abortion care knowledge, APCs in our sample were only slightly more knowledgeable about the absence of elevated breast cancer risk than reproductive-age people and women seeking abortion (Berglas et al., 2017; Kavanaugh et al., 2013; Swartz et al., 2020). Of greater concern is that, similar to the general public (Berglas et al., 2017; Kavanaugh et al., 2013), only one-third of APCs correctly identified that abortion does not have negative psychological effects, demonstrating the pervasiveness of this myth even among clinicians who provide pregnancy options counseling and support abortion rights. Clinicians have a responsibility to stay up to date with their clinical knowledge, but this study suggests that in certain stigmatized areas like abortion, clinicians may not have a depth of knowledge that is greater than that of the public. Clinicians have an ethical obligation to combat stigma and myths with evidence-based information (Hussein & Ferguson, 2019), but must be knowledgeable of laws and clinical care to do so.
In contrast to research showing abortion law knowledge is lower among people who do not support abortion rights (Bessett et al., 2015; Swartz et al., 2020), abortion law knowledge was similar between APCs who believed abortion should be legal and those who believed it should be illegal in all circumstances. Although there are measurement differences across studies, it is possible that clinicians who oppose abortion rights are more engaged in anti-abortion activities and more educated on state-level abortion laws than the public. Moreover, Colorado has relatively few abortion restrictions and the last abortion restriction proposed prior to data collection occurred eight years ago. It is possible that abortion law knowledge varies among APCs based on the state-level abortion policy context of where they practice. Future research to examine abortion law knowledge among APCs in other states and among different types of clinicians is needed.
Consistent with prior research (Bessett et al., 2015; Kavanaugh et al., 2013), we found participants’ positions on abortion legality were positively associated with abortion care knowledge. Clinicians who do not support abortion rights may be less interested in learning about abortion or may be unwilling to accept scientific evidence that conflicts with their values. Incorrect knowledge, particularly about abortion safety, may also shape or reinforce a lack of support for abortion rights. In prior research, APCs who did not support abortion rights were less likely to be willing and able to provide pregnancy options counseling and refer for abortion than those who supported abortion rights (Coleman-Minahan, 2021). Thus, participants who do not support abortion rights and have low abortion care knowledge may not provide abortion counseling to their patients, which can delay or eliminate access to care and reinforce abortion stigma. Even more concerning, it is possible these clinicians share inaccurate information or abortion myths with patients. Existing research suggests that values clarification training can result in more accepting attitudes about abortion among physicians (Turner et al., 2018) and more broadly among key healthcare stakeholders (Guiahi et al., 2021). Our findings suggest such training may be an important component to ensuring accurate knowledge and stigma-free care.
Our findings suggest training on abortion care is needed for APCs. The fact that “I don’t know” was a more common response than an incorrect answer for most knowledge questions suggests that educators can provide accurate knowledge rather than undertake the more difficult task of correcting misinformation (De keersmaecker & Roets, 2017). That said, we did not find an association between education on abortion in graduate school and increased abortion knowledge, perhaps because most of the sample has been out of school for more than four years. Providing reminders about abortion laws is associated with increased abortion law knowledge (Dodge et al., 2013). Thus, in addition to including abortion in graduate program curricula (McLemore & Levi, 2017; Tillman & Levi, 2020), it is important to offer continuing education on abortion to practicing clinicians.
This study is limited by a lower response rate compared to studies using national clinician databases (Desai et al., 2018) and generalizability to practicing APCs in Colorado is reduced by non-response. However, the response rate is comparable to those of other clinician studies (French et al., 2016; Holt et al., 2017; McLemore et al., 2020) and a stratified random design remains more generalizable to APCs in Colorado than a convenience sample despite the low response rate. It is likely that clinicians more interested in reproductive health responded to the survey. Thus, we may be overestimating abortion knowledge among Colorado APCs. Additionally, incorrect answers to some of the abortion knowledge questions reflect a greater knowledge deficit than others that was not captured by the total knowledge score. For example, believing that “abortion almost always has negative psychological effects” is more likely to negatively impact patient care than believing the percentage of abortions that occur in the first trimester is 78% instead of 89%. We further recognize that participants’ positions on abortion legality do not fully capture the complexity of abortion attitudes. Finally, we did not assess the information participants provide to patients about abortion and future research should explore how clinician knowledge is associated with the counseling they provide.
Implications for Practice
Although it is particularly important for clinicians who counsel patients on their pregnancy options to have accurate knowledge about abortion laws and care, recent research suggests that offering information about abortion during contraceptive counseling is acceptable and helpful to patients (Dianat et al., 2020) and a patient in any setting may ask their clinician about abortion. Moreover, clinicians should have accurate information in times of crisis (Rozek et al., 2021). Especially now, as the right to legal abortion care is at risk, APCs, as a trusted source of healthcare information for patients and for the public, have the opportunity and responsibility to combat abortion myths and reduce abortion stigma by having and sharing evidence-based information on abortion to patients, colleagues, friends and family, and stakeholders, including healthcare administrators and policymakers.
Abortion care should be included as part of a comprehensive sexual and reproductive health curriculum for all nurses and physician assistants, not only those who specialize in women’s health. Professional organizations — including family, adult/geriatric, and pediatric healthcare organizations — should provide continuing education programs, as well as clinical practice reminders about abortion laws, to currently practicing APCs. In the meantime, there is a variety of evidence-based sources from which clinicians can educate themselves on federal and state-level abortion laws (Appendix).
Conclusions
Although abortion law and care knowledge were higher among women’s health clinicians and those who provide pregnancy testing and pregnancy options counseling, abortion knowledge is low among Colorado APCs. Abortion care is healthcare. Ensuring adequate knowledge about abortion care among a diverse range of clinicians is critical to providing care in a manner that is accessible and that people find desirable.
Supplementary Material
Acknowledgements
We thank Monica McLemore, Diana Taylor, and Laura Dodge for sharing their survey questions and Jeanelle Sheeder for contributions to the research design.
Funding statement
This project was funded by the University of Colorado College of Nursing. Administrative support was received from The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) funded University of Colorado Population Center (grant R24 HD066613). This project was supported by NIH/NCRR Colorado CTSI Grant Number UL1 RR025780. Its contents are the authors’ sole responsibility and do not necessarily represent official NIH views. The authors have no conflicts of interest to declare.
Biographies
Author Biography
Kate Coleman-Minahan PhD, RN, FNP-BC is an Assistant Professor at the University of Colorado College of Nursing and a CU Population Center Research Affiliate. She is a nurse practitioner and social scientist who studies access to contraception and abortion among oppressed populations.
Amy Alspaugh PhD, CNM is Assistant Professor of Nursing, University of Tennessee, Knoxville College of Nursing and a Certified Nurse-Midwife. Her research interests include reproductive health in people with the capacity for pregnancy age 35 and older, abortion in nursing, and the midwifery workforce.
Footnotes
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