The Future of Medical Abortion Care: an Internal Medicine Obligation

Abstract

Abortion care is an essential part of women’s reproductive health. Due to increasing state restrictions on abortion care and the United States Supreme Court decision to overturn the landmark case of Roe v. Wade, it is becoming ever more important to increase medical abortion access for all women. Internal Medicine (IM) physicians are able to provide reproductive healthcare including medical abortions. As women in over 20 states are at risk of not having any access to abortion, it is our obligation as IM physicians to provide this care and help curb the effects of these restrictive laws and therefore train the next generation of internists to continue doing so.

We believe that abortion care is a fundamental right; i.e., individuals should have access to safe and legal abortion care. On June 24, 2022, the United States Supreme Court overturned the momentous 1973 case of Roe v. Wade to allow individual states to make decisions concerning abortion care.¹ This has already begun to dramatically change the landscape of reproductive healthcare in the USA. So far in 2022, state legislatures have enacted over 80 new restrictions across 16 states to reduce or eliminate access to abortion care.² The already strained healthcare system has already been failing to meet the needs of American women.² In the wake of the ruling, it is paramount that we, as a medical community, move to expand access to this fundamental form of reproductive healthcare and embrace it within our practice in Internal Medicine. Medical abortion can and should be within the scope of internists.

Abortion is culturally thought to be a surgical procedure performed by Obstetrics and Gynecology (Ob/Gyn) specialists. However, with the advent of pregnancy-terminating medications and the US Food and Drug Administration’s (FDA) approval in 2000, medical abortions have become increasingly common. In 2020, 54% of all abortions were medical abortions, according to the Guttmacher Institute, an organization that conducts research and advocates for the expansion of sexual and reproductive health rights.³ Medical abortions are less expensive, less invasive, and safer than surgical abortions.⁴ Medical abortion consists of a two-drug combination, mifepristone, and misoprostol, that can be taken at home or at a clinic in the first 10 weeks of pregnancy. This method is significantly more accessible as patients can obtain the first of the two pills, mifepristone, by visiting an authorized clinic or healthcare provider in person or via telemedicine consultation.

Unfortunately, there are increasing barriers to providing these medications. Many states have tried to limit access to mifepristone under the Risk Evaluation and Mitigation Strategy (REMS), a safety measure required by the FDA for certain drugs to ensure the benefits outweigh the risks.⁵ Among other limitations, mifepristone was only allowed to be prescribed at in-person visits and exclusively by REMS-certified physicians. In 2021, the FDA announced its intention to formally remove the in-person dispensing requirement, though this decision is currently being challenged in court.⁶ Even if the REMS for mifepristone is eliminated, access to mifepristone can still be undermined by state-level restrictions. In at least 20 states, legislators are proposing laws that would place restrictions on abortion medications or make it more difficult to access these medications. For instance, last year about half of all US states outlawed medication disbursement via telehealth appointments and required more in-person visits⁷. Importantly, these restrictions have disproportionately affected women of low socio-economic status and minorities, as greater individual resources will be needed to access abortion care in different states.^{8, 9}

As the ability to provide these medications becomes more complex and restrictive, it is necessary for the pool of providers trained in their use to expand to meet the needs of the populace. The vast majority of medical abortions are currently performed by our Ob/Gyn colleagues, despite an increasing interest in internal medicine–trained physicians to provide this care. Estimates suggest that only about 1% of abortions occur in primary care physician offices, which disproportionally siloes nearly all abortion services to abortion clinics or subspecialty services like obstetrics and gynecology.¹⁰ In 2017, 89% of US counties did not have a clinic facility that provided abortion care, and 38% of women aged 15–44 lived in these counties.¹¹ Due to the time-sensitive nature of abortions, an increasing demand for accessible medical abortion will increase the burden on an already strained health system. The American College of Obstetrics and Gynecology has recognized a shortage of abortion providers and has called for an expansion of non-subspecialty abortion providers.¹² This call to action has been met with an increasing demand for such training in non-Ob/Gyn specialties, especially Internal Medicine. One study surveying Internal Medicine attendings and trainees found that 44% believe medication abortion is within the scope of practice of IM PCPs.¹³ Similarly, 43% endorse an interest in future provision. The most cited barriers to provision included limited training in residency (70%) and low familiarity with abortion medications (57%).¹⁴

Within weeks after the decision, eight states have already banned abortion with a dozen more states soon to follow suit.¹⁵ As such, the need for abortion care has become increasingly more dire. With the FDA relaxing restrictions on medications used for medical abortions and growing evidence to suggest a willingness of internal medicine physicians and trainees to provide these services, it is incumbent upon the American Board of Internal Medicine and the Accreditation Council for Graduate Medical Education to facilitate such education in this critical time. Accrediting and integrating abortion care training into residency programs in the form of tracks and electives, akin to point-of-care ultrasound and medical education tracks, will create a new cadre of prepared physicians to tackle this emerging issue. This will help bridge the ever-widening gap in abortion care and empower both physician and patient alike to make patient-centered decisions. It is time for us to take a more active role and provide the necessary training for the country’s future physician to provide this vital part of reproductive healthcare.

Declarations

Conflict of Interest

The authors declare that they do not have a conflict of interest.